Tissue Integrity Practice Questions

Mechanical __________ on the wound destroys granulation tissue and prevents apposition of wound edges.

friction

The final phase of the inflammatory response is ________.

healing

Poor general _______ causes generalized absence of factors necessary to promote wound healing.

health

Bleeding is normal immediately after tissue injury and ceases with clot formation. ___________ occurs as abnormal internal or external blood loss caused by suture failure,, clotting abnormalities, dislodged clot, infection, or erosion of a blood vessel by a foreign object or infection process.

hemorrhage

____________ blood supply decreases supply of nutrients to injured area, decreases removal of exudative debris and inhibits inflammatory response.

inadequate

A nutritional deficit of _________ decreases supply of amino acids for tissue repair.

protein

____________ is the replacement of lost cells and tissues with cells of the same type.

regeneration

What are the two major components of healing?

regeneration and repair

_______ is healing as a result of lost cells being replaced by connective tissue.

repair

_______ is the more common type of healing and usually results in scar formation.

repair

It takes longer for a wound to heal by ___________ intention thus the chance of infection is greater.

secondary

A wound involving loss of tissue such as a burn, pressure ulcer, or severe laceration heals by _________ _________.

secondary intention

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temp, tissue consistency (firm or soft), and or pain?

stage 1

When providing discharge teaching for a client who had an excisional biopsy of a skin lesion, what should the nurse include? "Keep the dressing in place for at least 24 hours." "Clean the incisional site daily after the dressing is removed." "Use hydrogen peroxide to clean the incisional site." "The sutures will be removed in 2 weeks."

"Clean the incisional site daily after the dressing is removed." The nurse should instruct the client to clean the incisional site daily after the dressing is removed. "Use hydrogen peroxide to clean the incisional site." The nurse should instruct the client to clean the incisional site with tap water or saline to remove any dried blood or crusts. "The sutures will be removed in 2 weeks." The nurse should instruct the client that suture removal will take place in 7 to 10 days. "Keep the dressing in place for at least 24 hours." The nurse should instruct the client to keep the dressing dry and in place for at least 8 hr.

With a client who has DM and reports foot pain, what are signs of infection? (SATA) Bradycardia An increase in neutrophils An increase in RBCs An increase in platelets Localized edema

An increase in neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms. Localized edema is correct. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema. An increase in platelets is incorrect. An increase in the platelet count can reflect malignancies, not infection. An increase in RBCs is incorrect. An increase in the RBC count reflects polycythemia, not infection. Bradycardia is incorrect. Tachycardia, not bradycardia, is an indication of infection.

Working on an orthopedic unit and you have four clients, who is more at risk for skin breakdown? An adolescent who has a cervical fracture and is in a halo brace A young adult who has a femur fracture and is in skeletal balanced suspension traction A middle adult who has a fractured radius and an arm cast An older adult who has a hip fracture and is in Buck's traction

An older adult who has a hip fracture and is in Buck's traction. According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown. An adolescent who has a cervical fracture and is in a halo brace. The halo brace is a risk factor for skin breakdown in the area of the brace; however, the client will be able to ambulate, which minimizes the risk for skin breakdown. Evidence-based practice indicates that another client is at greater risk. A young adult who has a femur fracture and is in skeletal balanced suspension traction. The skeletal traction is a risk factor for skin breakdown; however, the client will be able to shift his weight while immobile, which minimizes the risk for skin breakdown. Evidence-based practice indicates that another client is at greater risk. A middle adult who has a fractured radius and an arm cast. The arm cast is a risk factor for skin breakdown in the area of the cast; however, the client will be able to ambulate with an arm cast, which minimizes the risk for skin breakdown. Evidence-based practice indicates that another client is at greater risk.

________ supplies less oxygen at tissue level.

Anemia

The nurse assessing a pt with a chronic leg wound finds local signs of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? A. serum protein analysis B. WBC count with differential C. punch biopsy of center of wound D. culture and sensitivity of the wound

B. WBC count and differential

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

The ________ ________ evaluates risk factors that place the pt at risk for skin breakdown.

Braden Scale

After surgery the pt with a closed abdominal wound reports a sudden pop after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now opened wound. Which corrective intervention should the nurse do first?

Cover the area with sterile, saline soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration

_________ decreases collagen synthesis, retards early capillary growth, impairs phagocytosis, reduces supply of oxygen and nutrients secondary to vascular disease.

Diabetes

_________ increases inflammatory response and tissue destruction.

Infection

A leg wound: full thickness with jagged edges and muscle tissue visible. How should this be documented by the nurse? Abrasion Contusion Laceration Puncture

Laceration Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged and irregular. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound. Puncture. A puncture is an open wound usually caused by a sharp object that penetrates the skin leaving a small surface opening. Contusion. A contusion is a closed wound; the result of a blunt force impact. The wound appears ecchymotic (bruised) as a result of trauma to the vascular system. Abrasion. An abrasion is an open wound that occurs when the skin is scraped or rubbed off, such as an injury resulting from a fall in which the knees are scraped.

When assessing a pressure ulcer, which one should be recognized as a stage 3 pressure ulcer? Exposed bone Blood filled blisters Partial-thickness skin loss Necrotic subcutaneous tissue

Necrotic subcutaneous tissue. Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic subcutaneous tissue. Exposed bone. Manifestations of a stage 4 pressure ulcer can include full-thickness skin loss with exposed or palpable bone or muscle. Blood filled blisters. Manifestations of a stage 1 pressure ulcer can include reddened intact skin and blood filled blisters. Partial-thickness skin loss. Manifestations of a stage 2 pressure ulcer can include partial-thickness skin loss and a superficial ulcer.

For someone who is confined to bed, which is an action to be included in the plan? Massage the client's red bony prominences. Assess the client's skin for increased coolness. Reposition the client every 2 hr. Keep the client's skin moist.

Reposition the client every 2 hr. The nurse should change the client's position every 2 hr to stimulate circulation and prevent pressure ulcers. Massage the client's red bony prominences. The nurse may cause deep tissue trauma by massaging red bony prominences. Assess the client's skin for increased coolness. The nurse should asses the client's skin for increased warmth. Keep the client's skin moist. The nurse should use moisturizers on dry skin but should keep the client's skin dry and free of prolonged moisture or drainage to prevent skin breakdown.

Pediculosis capitis: what instructions should be given to parents? Soak all combs and hairbrushes in alcohol. Inspect any dogs or cats at home for lice. Seal nonwashable items in airtight plastic bags. Spray countertops and sinks with insecticide.

Seal nonwashable items in airtight plastic bags. Parents should seal items they cannot wash, vacuum, or dry clean in airtight plastic bags for 14 days to kill any lice on them. Spray countertops and sinks with insecticide. Parents should not spray insecticides in the home because they can pose a hazard to children and pets. Cleaning hard surfaces with household cleaners or disinfectants is appropriate. Soak all combs and hairbrushes in alcohol. Parents should soak all combs, brushes, and hair clips in a commercial pediculicide (lice-killing product) for 1 hr or in boiling water for 10 min. Inspect any dogs or cats at home for lice. Pets do not carry or transmit lice.

__________impedes blood flow to healing areas because nicotine is a potent vasoconstrictor.

Smoking

When planning care for an older adult client who is at risk for developing pressure ulcers, what is the best option? Use a transfer device to lift the client up in bed. Apply cornstarch to keep sensitive skin areas dry. Massage the skin over the client's bony prominences. Elevate the head of the bed no more than 45°.

Use a transfer device to lift the client up in bed. Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions. Apply cornstarch to keep sensitive skin areas dry. Cornstarch and baby powder can create dry, gritty debris that can abrade sensitive skin. Massage the skin over the client's bony prominences. Massaging the skin over bony prominences has no preventive value, and it can traumatize deep tissues. Elevate the head of the bed no more than 45°. Keeping the head of the bed no higher than 30° helps minimize shearing forces. Higher elevations can cause the skin to stick to the bed linens while deeper tissues slide downward.

Advanced ______ slows collagen synthesis by fibroblasts, impairs circulation, requires longer time for epithelialization of skin, alters phagocytic and immune responses.

age

___________ drugs impair phagocytosis by WBCs, inhibit fibroblast proliferation and function, depress formation of granulation tissue and inhibit wound contraction.

corticosteroids

There is an increased risk of __________ when wound contains necrotic tissue or blood supply is decreased, patient's immune function is decreased, undernutrition, multiple stressors, and hyperglycemia in diabetes.

infection

_________ decreases blood supply in fatty tissue.

obesity

_______ ________ healing takes place when wound margins are neatly approximated, as in a surgical incision or a paper cut.

primary intention

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer.

unstageable

Which skin care measures are used to manage a pt who is experiencing fecal and urinary incontinence?

using an incontinence cleaner, followed by application of a moisture barrier ointment

A nutritional deficit of _________ __ delays formation of collagen fibers and capillary development.

vitamin C

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

wound after it has first been cleaned with normal saline

A nutritional deficit of ________ impairs epithelialization.

zinc