GOODQUESTIONS-Medical Surgical Nursing Chapter 12 Inflammation and Wound Healing

3, 4, 5 The nurse should teach the patient's caregiver to provide the patient with adequate nutrition to speed up the healing process. Exposure to excessive moisture from incontinence can cause pressure ulcers. The caregiver should cleanse skin after soiling and use absorbent pads or briefs to help keep the patient dry. The patient should be assisted in lifting himself or herself when repositioning in bed because sliding can cause friction and sheer. A wheelchair-bound patient should be repositioned every hour, whereas a patient confined to bed should be repositioned every two hours. Text Reference - p. 187

A 65-year-old diabetic patient is treated for a fractured fibula and is discharged from the health care facility. Which instructions should the nurse give the patient's caregiver to prevent occurrence of pressure ulcers in the patient? Select all that apply. 1 Reposition the patient in wheelchair every two hours. 2 Reposition the patient in bed every six hours. 3 Provide the patient with adequate nutrition. 4 Provide the patient absorbent pads or briefs. 5 Assist the patient to lift self and reposition on bed.

2 Impaired tissue integrity would be a priority nursing diagnosis for this patient. Interventions to prevent further damage and other areas of impaired tissue would be essential. Acute pain, imbalanced nutrition, and risk for infection may be appropriate nursing diagnoses but are not a priority at this time. Text Reference - p. 186

A 75-year-old stroke patient with limited mobility and altered mental status has a black area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnosis is most appropriate for this patient? 1 Acute pain related to tissue damage and inflammation. 2 Impaired tissue integrity related to inadequate circulation secondary to pressure. 3 Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke. 4 Imbalanced nutrition: less than body requirements related to inability to consume sufficient calories and nutrients secondary to stroke.

2 Characteristics of a stage II ulcer include partial-thickness loss of dermis manifesting as a shallow open ulcer with a red-pink wound bed, without slough. Stage II ulcers also may manifest an intact or open/ruptured serum-filled blister. See Table 12-13 for descriptions of Stage I, III, and IV ulcers. STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend seven hours sleeping and three hours studying than to cut sleep to six hours and study four hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency. Text Reference - p. 185

A 90-year-old patient is being cared for at home by the family. A pressure ulcer on the right trochantor area measures 1 × 2 × 0.2 cm in depth, with a red-pink wound bed without slough. Which stage would the home health nurse document on the wound assessment form? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

1, 3, 4 Pressure ulcers develop in patients who are nonambulatory and who do not change their positions often. Patients who have quadriplegia, are disoriented, are nonambulatory, or have had a brain injury are at high risk of developing pressure ulcers. These patients cannot move by themselves and need help to change position. Therefore, they are at high risk of developing pressure ulcers. The patient who had myocardial infarction has moderate ambulation and can change positions in bed, so the risk of pressure ulcers is low. Similarly, the patient with fractures of the right humerus and rib is ambulatory and is at low risk for pressure ulcer. Text Reference - p. 184

A nurse is assessing the risks of patients for developing pressure ulcers. Which patients are at high risk for developing pressure ulcers? Select all that apply. 1 A 65-year-old female patient with quadriplegia; nonambulatory 2 A 52-year-old male patient who had suffered myocardial ischemia; moderate ambulation 3 A 49-year-old male patient with sepsis; responds in grunts; disoriented 4 A 58-year-old female patient with stroke and incontinence of urine and stool; ambulates with a wheelchair 5 A 67-year-old male patient with a history of falls and current fractures of the right humerus and one rib

1, 2, 4 Cultures can be obtained by needle aspiration, tissue culture, or swab technique. Concurrent swab specimens are obtained from wounds using wound exudates, Z-technique, and Levine's technique. A wound exudate swab is collected from the exudates before cleaning the wound. In the Z-technique, the nurse rotates a culture swab over the cleansed wound bed surface in a 10-point Z-track fashion. In Levine's technique, the nurse rotates a culture swab over a cleansed 1-cm2 area near the center of the wound using sufficient pressure to extract wound fluid from deep tissue layers. A health care provider will obtain needle and tissue punch biopsy samples. As a nurse, you can obtain cultures using the swab technique. STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover. Text Reference - p. 184

A nurse is caring for a patient suffering from a deep wound. What are the techniques by which a nurse can obtain a specimen for culture studies? Select all that apply. 1 Wound exudate swab 2 Swab using Z-technique 3 Sample by tissue punch biopsy 4 Swab using Levine's technique 5 Tissue sample using needle aspiration

1, 4, 5 Increasing the amount of protein in the diet will help to increase the synthesis of collagen, leukocytes, and fibroblasts, all of which are necessary for healing. Vitamin A helps in epithelialization, so its intake should be increased. Including a moderate amount of fats will help healing because the fats help in the synthesis of fatty acids, which are part of the cell membrane. Fluid intake should not be limited, but rather should be increased because it helps replace the fluid that is lost from perspiration and exudate formation. Vitamin C, not vitamin D, is responsible for capillary synthesis. Text Reference - p. 183

A nurse is caring for a patient who has been admitted to the trauma unit after an injury to the chest. After taking a detailed history, the nurse finds that the patient is undernourished, which might delay healing of the wound. How should the nurse plan the diet of the patient to ensure proper nutrition for adequate wound healing? Select all that apply. 1 Increase the protein intake to promote synthesis of collagen. 2 Limit fluid intake, because it may result in increased exudate. 3 Increase the intake of vitamin D to promote capillary synthesis. 4 Increase the intake of vitamin A, because it helps in epithelialization. 5 Include a moderate amount of fats to help in synthesis of fatty acids.

1, 2, 4

A nurse is caring for a patient who is receiving negative-pressure wound therapy. Which parameters should be monitored for a patient on negative-pressure wound therapy? Select all that apply. 1 Platelet count 2 Prothrombin time 3 Serum creatinine level 4 Partial prothrombin time 5 Fasting blood glucose level

3 An injured extremity may become engorged with blood. Elevation of the injured extremity above the level of the heart helps to reduce pain associated with swelling by increasing the venous and lymphatic return. Compression helps to reduce vasodilation and edema. However, distal pulses should be assessed before and after a compression bandage is applied, to evaluate whether the extremity has compromised circulation. If the circulation is not compromised, a compression bandage can be used. The injured extremity should be immobilized and allowed to rest, because immobilization promotes healing by decreasing the metabolic needs of the patient. At the time of initial trauma, cold fomentation should be used to promote vasoconstriction and decrease pain, swelling, and congestion. Heat may be used 24 to 48 hours after injury to promote healing by increasing circulation at the inflamed site. Text Reference - p. 177

A nurse is designing a plan of care for a patient with a soft tissue injury and related inflammation as a result of a motor vehicle accident. Which nursing intervention should be included in the plan? 1 Avoid compression bandages, because they may compromise circulation. 2 Keep the injured extremity moving for proper blood circulation. 3 Elevate the injured extremity above the level of the heart to reduce pain. 4 Use hot fomentation to increase the circulation at the inflamed site during initial trauma care.

1, 3, 5 Signs of inflammation are pain, swelling, and redness. Pain is caused by the change in pH, nerve stimulation by chemicals, and pressure from fluid exudate. Swelling is caused by fluid shift to interstitial spaces and accumulation of fluid exudate. Redness is a result of hyperemia from vasodilation. Blackish discoloration and ulcers are not indicative of inflammation. Text Reference - p. 175

A nurse is examining an intravenous site and confirms that inflammation is present at the site. What signs of inflammation may be present in the patient? Select all that apply. 1 Pain at the site 2 Ulcers at the site 3 Swelling of the site 4 Black discoloration 5 Redness at the site

2

A nurse is examining the pressure ulcer of a patient and observes that subcutaneous fat is visible in the ulcer, but bones, muscle, and tendon are not visible. Slough is present and there is tunneling of the ulcer. From this observation, what stage of the ulcer should the nurse record in the patient's medical record? 1 Stage II 2 Stage III 3 Stage IV 4 Unstageable

1, 2, 5 Deficiency of zinc impairs epithelialization, delaying the wound healing process. Protein deficiency decreases the supply of amino acids available for tissue repair. Deficiency of vitamin C delays formation of collagen fibers and capillary development. Sodium and copper are not strongly related to wound healing. Text Reference - p. 183

A nurse is explaining to a patient about the common nutritional deficiencies that cause delayed wound healing. Which are the most common elements whose deficiency delays wound healing? Select all that apply. 1 Zinc 2 Protein 3 Sodium 4 Copper 5 Vitamin C

4 It is important to practice the "no touch" technique when changing the dressing to avoid wound contamination. Repositioning the patient every 20 minutes would be too frequent. However, the caregiver should reposition the patient at least every 2 hours. The skin of the patient should be inspected daily for pressure ulcers. The caregiver should be taught the proper way of disposing of contaminated dressings; they should not be disposed of with other garbage, because they can spread infection. Text Reference - p. 187

A nurse is preparing for the discharge of a patient with a pressure ulcer and includes the caregiver in the education. What should the nurse include in the home care instructions? 1 Instruct the caregiver to reposition the patient every 20 minutes. 2 Teach the caregiver to inspect the skin of the patient every 15 days. 3 Instruct the caregiver to dispose of contaminated dressings along with other garbage. 4 Teach the caregiver the "no touch" technique for changing the dressing

3, 4, 5 There are four types of debridement: surgical, mechanical, autolytic, and enzymatic. Mechanical debridement has three methods: wet-to-dry dressings, wound irrigation, and whirlpool. Whirlpool is used when minimal debris is present. Wound irrigation involves debriding the wound with high irrigation pressure. Wet-to-dry dressings involve application of open-mesh gauze moistened with normal saline. It is packed on or into a wound surface and allowed to dry. Autolytic and enzymatic are different types of debridement and are not methods of mechanical debridement. Text Reference - p. 183

A nurse is providing care to a patient who is scheduled for mechanical debridement. What are methods of mechanical debridement? Select all that apply. 1 Autolytic 2 Enzymatic 3 Whirlpool 4 Wound irrigation 5 Wet-to-dry dressings

4 Tertiary intention healing is a delayed suturing of a wound after the infection has been controlled. Because it is associated with delayed healing, the scar is larger and deeper than the scar that results from primary and secondary intention healing. The process of repair is more complex than the process of regeneration, because repair occurs by primary, secondary, and tertiary intention. Secondary intention healing is the healing of wounds whose edges cannot be approximated. Delayed closure with sutures is a form of tertiary intention healing. Primary healing takes place when wound margins are clear and concise. Text Reference - p. 177

A nursing student is learning about inflammation and wound healing. Which statement describing the process of wound healing conveys that the nursing student understands the process? 1 "Regeneration is more complex than the process of repair." 2 "Delayed closure with sutures is a secondary intention healing." 3 "Primary intention healing takes place when wound margins are irregular." 4 "Tertiary intention healing results in a larger and deeper scar."

3 With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason. Text Reference - p. 178

A patient asks the nurse what the surgeon meant by "the wound will be allowed to heal by secondary intention." How should the nurse explain this to the patient? 1 The wound will be stapled together until it heals. 2 The healing will contract the area to close the wound. 3 The wound will be left open and heal from the edges inward. 4 The wound will be sutured after the current infection is controlled.

2, 3, 5 Hyperbaric oxygen therapy involves delivering oxygen at increased atmospheric pressure. The therapy kills anaerobic bacteria in the wound, preventing further infection. It increases the killing power of WBCs and certain antibiotics. The therapy also promotes angiogenesis (growth of new blood vessels) to facilitate wound healing. Hyperbaric oxygen therapy accelerates formation of granulation tissue, which in turn accelerates the wound healing process. Text Reference - p. 182

A patient has been advised to receive hyperbaric oxygen therapy for wound healing. How does this therapy promote wound healing? Select all that apply. 1 It prevents formation of new blood vessels. 2 It kills anaerobic bacteria. 3 It increases the killing power of white blood cells (WBCs). 4 It slows down formation of granulation tissue. 5 It increases the effectiveness of certain antibiotics

3 Any compression dressing requires vigilant assessment of the circulation distal to the dressing site, because tissue and nerve damage are significant risks. Exudate and infection normally would not accompany a soft tissue injury such as a sprain. Assessment of the circulation distal to the dressing site supersedes the importance of assessing the patient's mobility. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question. Text Reference - p. 177

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? 1 Frequent examination of the character and quantity of exudate 2 Monitoring for signs and symptoms of local or systemic infections 3 Assessment of the patient's circulation distal to the location of the dressing 4 Assessment of the range of motion of the ankle and the patient's activity tolerance

4 Acetaminophen is an antipyretic drug that inhibits the synthesis of prostaglandins. Acetaminophen lowers body temperature by acting on the heat-regulating center in the hypothalamus. This drug should be administered around the clock to prevent acute swings in temperature. Vitamin A supplements are used to increase collagen synthesis. Corticosteroids prevent liberation of lysosomes. Hyperbaric oxygen therapy increases the power of white blood cells. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Text Reference - p. 176

A patient has fever associated with inflammation at an injury site. The nurse administers acetaminophen to the patient around the clock. What is the rationale behind this nursing intervention? 1 To increase collagen synthesis 2 To prevent liberation of lysosomes 3 To increase power of white blood cells 4 To prevent acute swings in temperature

4 White blood cells play an important role in the body's defense and they facilitate the response to inflammation. A decreased white blood cell count causes neutropenia; a neutropenic patient is unable to mount an inflammatory response. Zinc deficiency impairs epithelialization in the wound-healing process. Protein deficiency decreases the supply of amino acids for tissue repair. Decreased red blood cell count causes anemia. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 172

A patient has sustained an injury, but has no signs or symptoms of inflammation at the site of injury. Which laboratory finding does the nurse correlate with this finding? 1 Zinc deficiency 2 Protein deficiency 3 Decreased red blood cell count 4 Decreased white blood cell count

1, 2, 5 In cases of soft tissue injuries, RICE treatment (rest, ice, compression, and elevation) is given. The affected part is immobilized and given rest. Ice or cold is applied to reduce pain and inflammation. Hot applications can be given after 24 to 48 hours. The affected part is compressed with bandages to provide support and prevent edema. The affected part should be elevated above the heart level to prevent edema and pain. Making the patient walk would increase pain and discomfort, so it is not advisable. Text Reference - p. 177

A patient is admitted to the hospital two hours following an ankle injury. A soft tissue injury is suspected. There is no external bleeding. What measures can the nurse take for this patient to help relieve the inflammation? Select all that apply. 1 Immobilize the affected part and encourage rest. 2 Provide cold application to the affected part. 3 Make the patient lie down and keep the ankle below the level of heart. 4 Make the patient walk a little distance to increase circulation in the affected area. 5 Apply a compression bandage to the ankle and check the distal pulse.

3 The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function. Typical drainage from a surgical tube is serosanguionous; purulent drainage would indicate an infection. The response is normal, not a sign of infection or of impending dehiscence. The symptoms do not necessarily indicate the hernia repair was not successful. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress. Text Reference - p. 177

A patient is one day postoperative after having a hernia repair. During the morning assessment, the nurse notes that the patient has incisional pain, a 99.2° F temperature, slight redness at the incision margins, and 20 mL of serosanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make? 1 The abdominal incision is showing signs of an infection. 2 The patient's abdominal hernia repair was not successful. 3 The patient is experiencing a normal inflammatory response. 4 The abdominal incision is showing signs of impending dehiscence.

1, 2, 5 Foam dressings, alginate dressings, and hydrocolloidal dressings are best suited for moderate to heavy drainage or exudates. These dressings provide protection from infection and can also hold large amount of exudates. Gauze and nonwoven dressings are used for maintaining a moist wound surface and are not suitable for wounds that have drainage or exudates. Nonadherent dressings are used for minor wounds or as a second dressing. Text Reference - p. 182

A patient is suffering from moderate to heavy drainage (exudates) from his wound. What are the types of wound dressings that the nurse should use for this patient? Select all that apply. 1 Foam dressing 2 Alginate dressing 3 Gauze and nonwoven dressings 4 Nonadherent dressing 5 Hydrocolloidal dressing

1, 4, 5 Vitamin C is a very important nutrient that helps in wound healing. Deficiency of vitamin C delays formation of collagen fibers and capillary development. The nurse should encourage the patient to eat guava, strawberries, and kiwi, because these fruits are rich in vitamin C. Apples and bananas are not rich sources of vitamin C. Text Reference - p. 181

A patient is suffering from multiple lacerations and wounds. Which food items should be encouraged to promote healing in the patient? Select all that apply. 1 Guava 2 Apple 3 Banana 4 Strawberry 5 Kiwi fruits

1, 2, 5 Persistent hyperglycemia (steroid diabetes) can occur because of altered glucose metabolism. Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of patients receiving long-term corticosteroid therapy tend to heal slowly. Because of the depressed immune system, fever may be blunted in this patient. Corticosteroid therapy does not affect the risk of bleeding from the wound or the risk of bone infection. Text Reference - p. 181

A patient receiving long-term corticosteroid therapy for rheumatoid arthritis is admitted to the hospital with a wound of the left upper extremity. What should the nurse expect while assessing this patient? Select all that apply. 1 The patient is at risk of hyperglycemia. 2 The wound of this patient will heal slowly. 3 There will be reduced bleeding from the wound. 4 The patient is at a risk of developing bone infection. 5 The symptom of fever may be blunted in this patient.

2 Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. An apple, popsicle, or potato chips do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid is also are needed for healing. Text Reference - p. 184

A postoperative patient now is able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? 1 Apple 2 Custard 3 Popsicle 4 Potato chips

4 A patient with a total Braden score of 16 or less is considered to be at risk for pressure ulcers. Pressure ulcers can be prevented by using an established risk assessment tool; repositioning frequently (every one to two hours); using devices to reduce pressure and shearing force (e.g., alternating pressure mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots [foam, air], lift sheets); removing excessive moisture on the skin; avoiding massage over bony prominences; positioning with pillows; and assisting the patient in maintaining a healthy weight. Moist gauze dressings are appropriate for yellow pressure ulcers, not for patients who are assessed at risk for pressure ulcers. Text Reference - p. 186

An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, the nurse will plan which intervention for this patient? 1 Massage the pressure points every shift. 2 Apply moist gauze dressings over the bony prominences. 3 Elevate the head of bed to 90 degrees when the patient is supine. 4 Implement an every two hours turning schedule with skin assessment.

2 Cigarettes contain nicotine, which is a potent vasoconstrictor, and thus impedes blood flow to healing areas and delays wound healing. A decreased blood supply in fatty tissue is a consequence of obesity. Advanced age may result in slow collagen synthesis by fibroblasts. A decreased supply of nutrients to the injured area occurs due to inadequate blood supply. Text Reference - p. 181

The nurse is caring for a patient who has a pressure ulcer. The patient has a 20-year history of smoking. What effect does smoking have on wound healing? 1 It decreases the blood supply in fatty tissue. 2 It impedes blood flow to healing areas. 3 It slows collagen synthesis by fibroblasts. 4 It decreases the supply of nutrients to the injured area.

2, 4, 5 The diet should be high in proteins to promote wound healing. High carbohydrate intake should be encouraged to help meet the high metabolic rate associated with burns. Fluid intake should be increased to compensate for the fluid loss. Sodium and potassium are restricted during the acute phase of a burn injury, not two weeks after the injury. Text Reference - p. 183

The nurse is caring for a patient who sustained full-thickness burns two weeks ago. The nurse weighs the patient and documents the weight. The nurse finds that the patient is losing weight. What adjustments should be made in the diet to ensure the metabolic requirements of the patient are being met? Select all that apply. 1 Low-sodium diet 2 High-protein intake 3 Low-potassium diet 4 High-carbohydrate intake 5 Adequate intake of water

1, 5, 6 The nurse should assess this patient's vital signs; increase in temperature, pulse, and respiratory rates indicate the presence of infection. It is important for the nurse to note vital signs when an inflammation is present. Older adults have a blunted febrile response to infection, and body temperature may not rise as expected. Loss of function occurs due to pain and edema. Edema, erythema, and pain are local manifestations of inflammation. Text Reference - p. 176

The nurse is caring for an older adult who has a compound fracture of the radius. The nurse observes manifestations of inflammation. Which symptoms should the nurse note as signs of infection in this older patient? Select all that apply. 1 Fever 2 Pain 3 Presence of edema 4 Presence of erythema 5 Increased pulse 6 Increased respiratory rate

1, 2, 6 Skin, bone marrow, and mucous membranes have labile cells that divide constantly. Injury to these organs is followed by rapid regeneration. Pancreas and kidney have stable cells that retain their ability to regenerate only if the organ is injured; the regeneration is slow. Cardiac muscle cells are permanent cells that do not divide; healing occurs by repair with scar tissue. Text Reference - p. 177

The nurse is dressing a laceration on the palmar aspect of the hand on the patient. Which tissues have labile cells that regenerate rapidly? Select all that apply. 1 Skin 2 Bone marrow 3 Pancreas 4 Cardiac muscle cells 5 Kidney 6 Mucous membranes

1 A patient with rheumatoid arthritis who is being treated with a nonsteroidal antiinflammatory drug (such as piroxicam) may show a blunted febrile response to infection. Prednisone is a corticosteroid and is used to treat inflammation associated with asthma; a decreased synthesis of lymphocytes is a side effect of the drug. Chlorhexidine is an antiseptic used to clean the wound; this drug may not result in blunted febrile response. Becaplermin is not a nonsteroidal antiinflammatory drug and does not blunt febrile response to infection. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the patient in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking. In a clinical exam, you may be expected to select instruments, arrange instruments, and/or perform some other task. Acquaint yourself with the physical facility. If the required procedures are not clear to you, ask for clarification. Text Reference - p. 176

The nurse is reviewing the medical reports of four patients. Which patient may show a blunted febrile response to infection? 1 Patient A 2 Patient B 3 Patient C 4 Patient D

7, 5, 8, 3, 1, 6, 4, 2 During the initial phase of wound healing, which is during the first three to five days, there is approximation of wound edges. Next, epithelial cells migrate to the site and clots form, serving as a meshwork for starting capillary growth. After the initial phase, the granulation phase starts, which lasts from five days to four weeks. It includes migration of fibroblasts at the site, secretion of collagen, and an abundance of capillary buds at the site. This makes the wound fragile. The next phase is the maturation and scar contraction phase, which includes remodeling of collagen and strengthening of the scar. This may last from seven days to several months, depending on wound size. Text Reference - p. 177

The nurse recalls that a surgical wound heals by primary intention. What is the order of the phases of primary intention healing? 1. Secretion of collagen 2. Strengthening of scar 3. Migration of fibroblasts 4. Remodeling of collagen 5. Migration of epithelial cells 6. Abundance of capillary buds 7. Approximation of incision edges 8. Clot serving as meshwork for starting capillary growth

2 The migration of fibroblasts occurs in the granulation phase which lasts from five days to four weeks. In this phase collagen is secreted and there is an abundance of capillary buds in the wound making it fragile. The initial phase lasts from three to five days. In this phase, the migration of epithelial cells takes place. The clot serves as a meshwork for starting capillary growth. The maturation phase lasts from seven days to several months. In this phase, remodeling of collagen and strengthening of the scar occurs. Regeneration is not the phase of primary intention healing. Text Reference - p. 178

The nurse recalls that primary intention healing takes place in various phases. Which phase best describes the migration of fibroblasts? 1 Initial phase 2 Granulation phase 3 Maturation phase 4 Regeneration phase

3 Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage I ulcers have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage II ulcers are partial-thickness with a red-pink wound bed. Stage IV ulcers involve extensive destruction of tissue with exposed bone, tendon, or muscle. Text Reference - p. 185

The patient is admitted with a pressure ulcer with full-thickness skin loss involving damage to subcutaneous tissue. How should the nurse document it? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

4 Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable. Text Reference - p. 180

The patient previously had a breast reduction. She has come to the surgeon's office complaining about excess soft pink tissue where a scar should be forming. What complication of wound healing does the nurse recognize this to be? 1 Adhesion 2 Contractions 3 Keloid formation 4 Excess granulation tissue

3 Elevation of an extremity above the level of the heart increases venous and lymphatic return. To reduce the risk of compromised perfusion, the nurse should check the patient's reports for reduced arterial circulation before elevating the injured extremity. Diabetes does not cause complications due to elevation of an injured extremity. The nurse should check the patient's history for cancer and other wounds before administering becaplermin. Taking a nonsteroidal antiinflammatory drug may blunt the febrile response, but it does not cause complications while elevating an injured extremity. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason. Text Reference - p. 177

The primary health care provider instructs the nurse to elevate a patient's injured extremity. What should the nurse check for in the patient's reports before elevating the patient's extremity? 1 Diabetes 2 Cancer and other wounds 3 Reduced arterial circulation 4 Nonsteroidal antiinflammatory drug treatment

3 With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse first should assess the patient and the drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care prescribed, provide care prescribed, and document the care and patient response. Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence. Text Reference - p. 179

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What should the nurse do about this situation? 1 Notify the health care provider 2 Document the fistula formation 3 Assess the patient and vaginal drainage 4 Have the UAP apply a dressing to the vagina

2 Turning and repositioning the patient every one to two hours will keep pressure areas from developing and help prevent other pulmonary and vascular complications. Repositioning the patient every half hour is unrealistic. Keeping the patient supine as much as possible does not support the turning schedule. Turning the patient from one side to the other every four to eight hours is too much time between turning and repositioning. Text Reference - p. 188

To prevent complications, what turning schedule should the nurse implement for a patient who spends most of the day in bed? 1 Repositioning the patient every half hour 2 Repositioning the patient every one to two hours 3 Keeping the patient supine as much as possible 4 Turning the patient from one side to the other once every four to eight hours

1, 2, 5 Inflammation increases the permeability of the blood vessels by causing vasodilation, resulting in redness at the site. Inflammation causes a shifting of fluids to the interstitial spaces and fluid accumulation, resulting in swelling at the site. Swelling and pain can result in loss of cellular function at the inflammatory site. Characteristic odor and purulent exudate at the site are signs of infection. Text Reference - p. 173

What are the symptoms of inflammation at an injury site? Select all that apply. 1 Swelling at the site 2 Redness at the site 3 Characteristic odor at the site 4 Purulent exudate from the site 5 Loss of function of cells at the site

4 Prednisone is a corticosteroid drug that interferes with the synthesis of lymphocytes, resulting in a decreased white blood cell count. Prednisone does not interfere with prothrombin time. Prednisone does not increase red blood cell count because it does not stimulate erythropoiesis. Serum protein levels are not affected by prednisone. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. Text Reference - p. 176

What does the nurse expect to find in the laboratory report of a patient taking prednisone for rheumatoid arthritis? 1 Increased prothrombin time 2 Increased red blood cell count 3 Decreased serum protein levels 4 Decreased white blood cell count

1 Surgical removal is the best treatment for inflammation of the appendix to prevent further complications. Antipyretics are used to reduce fever that may be associated with appendicitis, but will not promote healing. Antimicrobials are used to kill bacteria that may be involved but in a life-threatening situation, surgery is required. Corticosteroids reduce inflammation but cause immunosuppression, reducing the body's ability to fight infection. Text Reference - p. 179

What is the best choice of treatment for a patient who has acute, life-threatening inflammation of the appendix? 1 Surgery 2 Antipyretics 3 Antimicrobials 4 Corticosteroids

1 The complement system causes cell lysis by creating holes in the cell membranes, causing those cells to rupture. The complement system increases vascular permeability. Thromboxane promotes clot formation during healing. Macrophages clean the injured area before healing. Text Reference - p. 174

What is the function of the complement system during an immune response? 1 Cellular lysis 2 Promoting clot formation 3 Decrease in vascular permeability 4 Cleaning the injured area before healing

4 Lymphocytes stimulate cell-mediated immunity by releasing various cytokines in response to an antigen at the injury site. Neutrophils arrive at the injury site first and engulf bacteria. A giant cell made of a group of macrophages forms a granuloma. Macrophages clean the injury site before healing by engulfing dead cells and foreign particles. Text Reference - p. 174

What is the primary role of lymphocytes? 1 Engulfing bacteria 2 Forming granuloma 3 Cleaning the area before healing 4 Stimulating cell-mediated immunity

4 Heat application is used to localize the inflammatory agents and promote healing by increasing the circulation to the inflamed site and subsequent removal of debris. Cold application decreases congestion and promotes vasoconstriction at the site of inflammation. Immobilizing the inflamed area with a cast prevents further tissue injury. Text Reference - p. 177

What is the purpose of applying heat at the site of inflammation? 1 To decrease congestion 2 To promote vasoconstriction 3 To prevent further tissue injury 4 To localize the inflammatory agents

3 Macrophages act like a clean-up crew. They phagocytize the leftover debris, bacteria, and dead cells at the injury site essentially clean the area before healing. Prostaglandins cause vasodilation. Complement components stimulate histamine release. Serotonin stimulates smooth muscle contraction. Text Reference - p. 173

What is the role of macrophages in the body? 1 To cause vasodilation 2 To stimulate histamine release 3 To clean the area before healing 4 To stimulate smooth muscle contraction

1 The vitamin B complex acts as coenzymes. Vitamin A accelerates epithelialization. Vitamin D facilitates calcium absorption. Vitamin C assists in the synthesis of collagen. Text Reference - p. 176

What is the role of the vitamin B complex? 1 Acts as coenzymes 2 Accelerates epithelialization 3 Facilitates calcium absorption 4 Assists in synthesis of collagen

3 A WBC count of 8500/μL and a temperature of 98.4° F are within the normal range. A normal WBC is 4000 to 11,000/μL. An elevated WBC count and elevated temperature are indicators of infection. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur. Text Reference - p. 174

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? 1 White blood cell (WBC) count 8000/μL, temperature 101° F 2 WBC count 4000/μL, temperature 101° F 3 WBC count 8500/μL, temperature 98.4° F 4 WBC count 16,500/μL, temperature 98.8° F

3 Prednisone is an antiinflammatory drug that interferes with tissue granulation and induces immunosuppressive effects; thus, this drug prevents the liberation of lysosomes. Ibuprofen inhibits the synthesis of prostaglandins. Piroxicam is an antiinflammatory drug that inhibits the synthesis of prostaglandins. Acetaminophen is an antipyretic drug that lowers body temperature by acting on the heat-regulating center in the hypothalamus. Text Reference - p. 176

Which drug prevents the liberation of lysosomes? 1 Ibuprofen 2 Piroxicam 3 Prednisone 4 Acetaminophen

1, 2 Applying a compression bandage may compromise the patient's blood circulation. Therefore, the nurse should assess the distal pulses to evaluate blood circulation before and after applying a compression bandage. The nurse should check capillary refill before and after applying a compression bandage to ensure adequate blood circulation. Serum protein levels should be monitored after performing negative-pressure wound therapy. Partial thromboplastin time should be checked after performing negative-pressure wound therapy. The patient's fluid and electrolyte balance should be checked after applying negative-pressure wound therapy because fluid and electrolyte loss may occur. Text Reference - p. 177

Which factors should the nurse check in a patient before applying a compression bandage? Select all that apply. 1 Distal pulses 2 Capillary refill 3 Serum protein levels 4 Partial thromboplastin time 5 Fluid and electrolyte balance

4 Prostaglandins are a group of lipids produced at sites of tissue damage or infection and are involved in injury response. Prostaglandins are derived from arachidonic acid by sequential oxidation. Kinins are peptides that are produced and act at the site of tissue injury or inflammation. Kinins are produced from precursor factor kininogen as a result of activation of Hageman factor. Histamine is an organic nitrogenous compound involved in local immune responses. It is stored in granules of basophils, mast cells, and platelets. Serotonin is stored in platelets, mast cells, and enterochromaffin cells of the gastrointestinal (GI) tract. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 174

Which inflammatory mediator is produced from arachidonic acid? 1 Kinin 2 Histamine 3 Serotonin 4 Prostaglandin

1 The release of cytokines initiates metabolic changes in the temperature-regulating center of the hypothalamus. Thus, cytokines trigger fever during inflammation. Serotonin stimulates smooth muscle contraction. Bradykinin causes vasodilation and contraction of smooth muscle. Leukotriene stimulates chemotaxis. Text Reference - p. 174

Which inflammatory mediator may trigger fever during inflammation? 1 Cytokines 2 Serotonin 3 Bradykinin 4 Leukotrienes

1 Histamine is released by the cells in response to inflammation; this chemical causes vasodilation and increases capillary permeability at the injury site. Leukotrienes stimulate chemotaxis and cause smooth muscle constriction along with capillary permeability. Complement components such as C4a and C3a stimulate histamine release and chemotaxis. Text Reference - p. 174

Which mediator of inflammation causes vasodilation and increases capillary permeability at the injury site? 1 Histamine 2 Leukotrienes 3 Complement component C4a 4 Complement component C3a

1 Kinins are produced by the activation of the Hageman factor. They cause contraction of smooth muscle and vasodilation. Enterochromaffin cells of the gastrointestinal tract store serotonin. Arachidonic acid produces leukotrienes. Anaphylatoxic agents generated from complement pathway activation produce complement component C5a. Text Reference - p. 174

Which mediator of inflammation is produced by activation of the Hageman factor? 1 Kinins 2 Serotonin 3 Leukotrienes 4 Complement component C5a

1 Serotonin is stored in the enterochromaffin cells of the gastrointestinal tract. Histamine is stored in the granules of basophils, mast cells, and platelets. Bradykinin is produced after activation of the Hageman factor of the clotting system. Prostaglandin is produced from arachidonic acid. Text Reference - p. 174

Which mediator of inflammation is stored in the enterochromaffin cells of the gastrointestinal tract? 1 Serotonin 2 Histamine 3 Bradykinin 4 Prostaglandin

1 Aspirin is an antiinflammatory drug that reduces capillary permeability in the body. Ibuprofen is a nonsteroidal antiinflammatory drug that inhibits prostaglandin synthesis. Piroxicam is a nonsteroidal antiinflammatory drug that inhibits the synthesis of prostaglandin. Acetaminophen helps maintain thermoregulation by acting on the heat-regulating center in the hypothalamus. Text Reference - p. 176

Which medication may reduce capillary permeability? 1 Aspirin 2 Piroxicam 3 Ibuprofen 4 Acetaminophen

4 A turning schedule including proper documentation is the best way to ensure that the patient is repositioned every one to two hours. Sliding instead of lifting the patient causes friction and may result in skin tears. Placing a patient on a doughnut ring is contraindicated because it results in an area of pressure; three to four hours is too long between changes of position. Lotion applied to the skin does provide moisture, but vigorous massage may cause tissue damage. Text Reference - p. 187

Which nursing intervention should be included on a plan of care to prevent the development of pressure ulcers in a bedridden patient? 1 Sliding the patient instead of lifting when turning 2 Repositioning the patient on a doughnut ring every three to four hours 3 Applying lotion after the patient bathes and vigorously massaging the skin 4 Implementing a turning schedule calling for position changes every one to two hours

3 Fever is mediated by a host macrophage product called endogenous pyrogen (EP) that stimulates the proliferation of T cells. Fever increases the action of neutrophils and promotes phagocytosis. Vasodilators increase blood flow rate. Fever increases destruction of microorganisms by enhancing the activity of interferon. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Text Reference - p. 175

Which physiologic change is associated with fever during inflammatory conditions? 1 Increased blood flow rate 2 Decreased neutrophil action 3 Increased proliferation of T cells 4 Suppressed activity of interferon

2 Alginates form a nonsticky gel on contact with a draining wound. They are easy to use over irregularly shaped wounds and generally require a secondary dressing. Foams are sheets that hold large amounts of exudates and mostly require gauze wrapping. Hydrogels donate moisture to a dry wound and maintain a moist environment that rehydrates wound tissue. Semipermeable transparent films allow visualization of the wound and are minimally absorbent. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. Text Reference - p. 182

Which type of wound dressing is easy to use over irregularly shaped wounds and forms a nonsticky gel on contact with a draining wound? 1 Foam 2 Alginate 3 Hydrogel 4 Semipermeable transparent film

2 In tuberculosis, the Mycobacterium bacillus is walled off, and the macrophages accumulate and fuse to form a multinucleated giant cell that engulfs the bacterial particle. This giant cell is encapsulated by collagen and forms granuloma. Tuberculosis causes chronic inflammation. Ivory to yellow-green exudate indicates infection, but is not seen in tuberculosis. Tissue damage by complement activation can occur in rheumatoid arthritis. Text Reference - p. 174

While reviewing a patient's laboratory reports, the nurse finds Mycobacterium strains in the patient's sputum. Which physiologic change does the nurse expect in this patient? 1 Acute inflammation 2 Granuloma formation 3 Ivory to yellow-green exudate 4 Tissue damage by complement activation