NURC 324 Ch. 12 Sherpath

Match each stage of pressure injury stage to its description.

Partial-thickness skin loss with exposed dermis Stage 2 Full-thickness tissue loss, in which subcutaneous fat may be visible Stage 3 Non-blanchable erythema of intact skin Stage 1 Full-thickness skin and tissue loss, with involvement of underlying tissue Stage 4

The patient who is 2 days postoperative from appendectomy reports incisional pain of 4/10, and the nurse notes erythema at the margins of the wound, temperature of 100.4°F orally, and serosanguinous drainage on the dressing. Based on this assessment, which conclusion would the nurse make?

The incision is showing signs of infection and the surgeon should be notified.

Place the stages of wound healing in order.

Vasoconstriction Vasodilation Formation of new blood vessels Formation of mature scar tissue

Which statement by a patient indicates an understanding of the role of nutrition in wound healing? Select all that apply. One, some, or all responses may be correct.

"A high fluid intake is needed to replace fluid loss from perspiration." "Protein is necessary to make the building blocks needed for healing." "Vitamin C is good for wound healing."

Which information about pressure injury formation would the nurse provide to a patient with decreased mobility? Select all that apply. One, some, or all responses may be correct.

"Ambulate to the restroom frequently." "Place pillows between your legs when sleeping." "Shift your weight every 60 minutes while sitting down."

Which statement by a healthy adult patient indicates effective teaching about managing fever at home?

"I can treat fevers under 103°F (39.4°C) with comfort measures."

Which statement indicates that the patient understands the role of inflammation in wound healing? Select all that apply. One, some, or all responses may be correct.

"The inflammatory response works to clean the wound of organisms and debris." "Inflammation is responsible for the redness, heat, and swelling of my wound."

Which statement would the nurse include in a discussion on pressure injuries? Select all that apply. One, some, or all responses may be correct.

"The risk is influenced by nutrition and activity." "People with an inability to communicate are at higher risk." "They can be prevented by relieving pressure on the affected areas."

Which patient would the nurse expect to be at the highest risk for skin breakdown?

A 65-year-old patient who has bowel and bladder incontinence

Which meal choice would indicate that a patient understands about dietary changes needed to promote wound granulation?

A ham and cheese sandwich with an orange and milk

Which statement about wet-to-damp dressings is accurate?

A wet-to-damp dressing protects the wound bed from trauma during dressing changes.

Which action by a student nurse performing a dressing change requires intervention by the registered nurse?

Applying debridement enzyme ointment to the healthy tissue

Which condition is a common cause of acute inflammation?

Anaphylaxis

Which patient population is most likely to have a blunted response to infection?

Older adults

Which condition puts a patient at risk for pressure injury development? Select all that apply. One, some, or all responses may be correct.

Complete bed rest Poor nutrition

Primary and secondary intention healing differ in which aspect?

Healing and granulation take place from the bottom of the wound upward in secondary intention.

Match each cell type to its description.

Damage leads to permanent loss. Tissue is replaced by glial cells. Permanent cells (central nervous system) Retain their ability to regenerate but only do so if the organ is injured. Stable cells Cells divide constantly. Injury is followed by rapid regeneration. Labile cells Healing will occur by repair with scar tissue. Permanent cells (cardiac muscle)

Match each factor to its effect on wound healing.

Delays formation of collagen fibers and capillary development Vitamin C deficiency Impairs phagocytosis by WBCs; depresses formation of granulation tissue Corticosteroid use Destroys granulation tissue; prevents apposition of wound edges Mechanical friction on wound Increases inflammatory response and tissue destruction Infection

The nurse understands that which tissue is involved in a partial-thickness wound? Select all that apply. One, some, or all responses may be correct.

Dermis Epidermis

Which characteristic would the nurse expect in an unstageable wound?

Eschar is covering wound bed.

During which time frame would antipyretics be given to prevent acute swings in temperature in a patient who is febrile?

Every 2 to 4 hours

Which complication of the healing process occurs when wound edges separate to the extent that intestines protrude?

Evisceration

Which finding is a systemic manifestation of inflammation?

Fever

Which process of healing would the nurse expect in a patient with an uninfected surgical wound?

First intention

Which secondary step occurs during primary intention healing?

Granulation

Which action is the result of fever during the inflammatory process? Select all that apply. One, some, or all responses may be correct.

Increased killing of microorganisms Increased phagocytosis by neutrophils Enhanced activity of interferon

Which cellular response occurs with a shift to the left in the presence of infection?

Increased release of white blood cells (WBCs) from the bone marrow

Which white blood cell (WBC) is the first to arrive at the injury site?

Neutrophil

Which patient is at greatest risk for developing a pressure injury?

Patient with a spinal cord injury

Which finding indicates that a patient with a full-thickness pressure injury to the sacrum may likely require surgical intervention for the wound?

Patient with paraplegia sits in a wheelchair all day.

Which information would the nurse note when performing a focused wound assessment? Select all that apply. One, some, or all responses may be correct.

Presence of exudate in the wound base Measurement of the greatest depth of the wound Presence of erythema for 1 cm around the wound edges

Which condition is a common cause of chronic inflammation? Select all that apply. One, some, or all responses may be correct.

Psoriasis Multiple sclerosis Osteoarthritis Tuberculosis Rheumatoid arthritis

Which type of inflammatory exudate consists of white blood cells (WBCs), microorganisms, liquified dead cells, and other debris?

Purulent 9pus)

The nurse is caring for a patient who has had a pressure injury for 3 days. When assessing the wound, which finding causes greatest concern for the nurse?

Purulent, draining wound

Which complication is the most common in patients with a pressure injury?

Recurrence

Which local manifestation would the nurse expect to observe in an infected wound? Select all that apply. One, some, or all responses may be correct.

Redness Swelling of the arm Inability to move the arm

Which component would be included in the plan of care for a patient who is at high risk for a pressure injury?

Reduce exposure to moisture.

In which way does negative-pressure wound therapy (NPWT) promote wound healing?

Reduces bacterial load

Which technique would the nurse use when obtaining wound cultures?

Rotate a culture swab over a cleansed 1-cm2 area near the center of the wound.

Which area of the body is the most at risk for the development of a pressure injury?

Sacrum

Which stage of a pressure injury acquired after admission to a health care setting is a serious reportable event (SRE)?

Stage 3

Match each mediator of inflammation to its mechanism of action.

Stimulate histamine release Complement components Cause vasodilation Prostaglandins Cause contraction of smooth muscle and stimulates pain Kinins Stimulate chemotaxis Leukotrienes

Which data is missing from the documentation entry for a patient with a stage 2 pressure injury: "Wound bed is pink with noticeable slough. It measures 2 cm × 2 cm. Packed with normal saline wet-to-damp dressing and covered with dry sterile dressing"?

Type of drainage

Which intervention would the nurse implement for a patient who is at risk for skin breakdown who is sitting in the chair?

Use a chair seat cushion.

Which technique would the nurse use when cleansing a pressure injury?

Use enough irrigation pressure (4-15 psi) to clean the pressure injury.