Med Surg Exam 2 - Inflammation and Wound Healing Practice Questions
Nutrients that are important for wound healing
-Protein -Vitamin A, C, B, K -Increase in water intake -Copper, Zn, Mg
What "players" are involved in inflammation
-neutrophils -macrophages -eosinophils -basophils
Risk factors for altered wound healing
-poor nutrition -smoking -diabetes -poor hygiene
Example of second-intentional wound healing
A larger wound, such as a burn
A client asks the nurse about the function of acute inflammation. The nurse correctly explains that: A) "Acute inflammation serves a protective function by removing harmful agents and promoting healing." B) "Acute inflammation lasts for several months and leads to scarring." C) "The purpose of acute inflammation is to cause permanent tissue damage." D) "Acute inflammation occurs when chronic inflammation fails to resolve."
A) "Acute inflammation serves a protective function by removing harmful agents and promoting healing." Acute inflammation is an immediate response to injury, aiming to remove the causative agent and promote tissue repair.
A nurse is applying a wound dressing but notices the previous dressing was too small. What is the most appropriate nursing intervention? A) Apply a larger dressing that fully covers the wound B) Leave the wound uncovered to allow air circulation C) Apply an occlusive dressing to trap moisture D) Secure the old dressing with additional tape
A) Apply a larger dressing that fully covers the wound
A nurse is caring for a patient with delayed wound healing due to protein-calorie depletion. What intervention should the nurse implement? A) Correct nutritional deficits, which may require parenteral nutrition B) Encourage a high-fat diet to promote tissue repair C) Restrict carbohydrate intake to maintain stable blood glucose levels D) Reduce fluid intake to prevent swelling around the wound
A) Correct nutritional deficits, which may require parenteral nutrition Adequate protein and calorie intake are necessary for tissue repair, and parenteral nutrition may be needed in cases of severe depletion.
A nurse is caring for a patient with edema at a wound site. Which of the following is the most appropriate intervention? A) Elevate the affected part and apply cool compresses B) Apply warm compresses to increase blood flow C) Keep the extremity in a dependent position to improve circulation D) Massage the edematous area to reduce swelling
A) Elevate the affected part and apply cool compresses
A nurse is reviewing immune function with a patient. Which of the following factors can affect immune system integrity? A) Emotional status and dietary patterns B) Blood pressure regulation and hormone secretion C) Sleep cycles and skin integrity alone D) Vision changes and pulmonary function
A) Emotional status and dietary patterns The immune system is influenced by central nervous system integrity, physical and emotional status, medications, dietary habits, and stress from illness, trauma, or surgery.
A patient recovering from surgery has signs of inadequate oxygenation. What is the most appropriate nursing intervention? A) Encourage deep breathing, turning, and controlled coughing B) Keep the patient in a supine position to conserve energy C) Restrict fluid intake to prevent pulmonary congestion D) Limit physical activity to reduce oxygen demand
A) Encourage deep breathing, turning, and controlled coughing These interventions promote lung expansion, oxygenation, and secretion clearance, improving tissue oxygenation.
A nurse is caring for a patient with edema at a wound site. The nurse understands that edema can delay healing by: A) Increasing interstitial pressure and reducing blood supply to tissues B) Preventing bacterial invasion and enhancing immune function C) Promoting increased oxygen delivery to the wound D) Encouraging nutrient absorption through capillaries
A) Increasing interstitial pressure and reducing blood supply to tissues Edema increases pressure on blood vessels, which reduces the supply of oxygen and nutrients to the tissues, thereby delaying healing.
A client experiences an inflammatory response with blood vessel dilation. Which of the following best explains why vasodilation occurs? A) It allows increased delivery of oxygen and immune cells to the site of injury. B) It prevents fluid from leaking into the surrounding tissues. C) It causes platelet aggregation to prevent further bleeding. D) It reduces local temperature to slow the inflammatory process.
A) It allows increased delivery of oxygen and immune cells to the site of injury. Vasodilation, caused by histamine, kinins, and prostaglandins, increases blood flow to the injured area, ensuring oxygen and immune cells reach the site to promote healing.
A nurse is explaining the role of histamine in the inflammatory response to a group of nursing students. Which of the following statements best describes the function of histamine? A) It increases vascular permeability and causes vasodilation. B) It stimulates platelet aggregation to form a clot. C) It decreases blood flow to the site of injury to prevent swelling. D) It enhances red blood cell migration to the area of inflammation.
A) It increases vascular permeability and causes vasodilation. Histamine, released from mast cells, is responsible for early vasodilation and increased vascular permeability, allowing plasma proteins and fluids to leak into tissues and contribute to swelling.
A nurse is caring for a patient with a wound containing foreign material. What is the priority nursing intervention? A) Keep the wound free of dressing threads and ensure sterility of implanted items B) Allow small debris to remain in the wound to stimulate immune response C) Apply an occlusive dressing to trap foreign material inside the wound D) Delay cleaning the wound until the next dressing change
A) Keep the wound free of dressing threads and ensure sterility of implanted items
A patient's dressing is applied too tightly. What is the best nursing action? A) Loosen or replace the dressing to restore blood flow B) Apply additional bandages to secure the dressing C) Elevate the affected limb to improve circulation D) Document the finding and continue to monitor
A) Loosen or replace the dressing to restore blood flow
A patient recovering from surgery has elevated blood glucose levels. What intervention should the nurse implement? A) Monitor blood glucose levels and administer insulin as prescribed B) Increase carbohydrate intake to boost energy levels C) Discontinue wound dressings to allow for better healing D) Reduce protein intake to lower blood glucose
A) Monitor blood glucose levels and administer insulin as prescribed
A nurse is monitoring a patient's closed drainage system. Which intervention ensures proper wound healing? A) Monitor the system for proper functioning and drainage output B) Clamp the drainage tube intermittently to control fluid loss C) Remove the drainage system as soon as output is noted D) Leave the system unmonitored as long as it is draining
A) Monitor the system for proper functioning and drainage output
A nurse is educating a client about inflammation. Which statement requires further teaching? A) "Acute inflammation lasts less than two weeks and promotes healing." B) "Chronic inflammation is always preceded by an acute phase." C) "Chronic inflammation can be debilitating and cause permanent tissue damage." D) "The inflammatory process can become chronic if the causative agent is not removed."
B) "Chronic inflammation is always preceded by an acute phase." Chronic inflammation can develop without an initial acute phase, beginning insidiously and persisting without resolution.
A patient asks the nurse why they have swelling at an injury site. What is the best response? A) "Your body is sending additional red blood cells to the injury site." B) "The increased permeability of blood vessels allows fluid and proteins to move into the tissue." C) "The clotting process has been activated, which traps excess fluid at the site." D) "The body is producing extra connective tissue to protect the wound."
B) "The increased permeability of blood vessels allows fluid and proteins to move into the tissue." Swelling occurs due to increased vascular permeability, which allows plasma proteins and fluids to leak into the tissues during the inflammatory response.
A patient's wound dressing is too small. The nurse recognizes that this increases the risk of: A) Increased oxygenation and faster healing B) Bacterial invasion and contamination C) Decreased drainage accumulation D) Improved wound protection
B) Bacterial invasion and contamination A dressing that is too small may not fully cover the wound, increasing the risk of bacterial contamination and infection.
A client with an inflammatory response following an injury asks the nurse why swelling occurs. The nurse correctly explains that: A) Vasoconstriction prevents excessive blood flow to the area. B) Chemical mediators cause increased vascular permeability, leading to fluid leakage. C) White blood cells multiply in the bloodstream, causing fluid accumulation. D) Platelets aggregate at the site, forming a barrier that holds in excess fluid.
B) Chemical mediators cause increased vascular permeability, leading to fluid leakage. Histamine, kinins, and prostaglandins increase vascular permeability, allowing plasma proteins and fluids to move into the surrounding tissue, causing swelling.
A patient presents with redness and warmth at the site of an injury. The nurse understands that this response is primarily due to which chemical mediator? A) Kinins B) Histamine C) Bradykinin D) Fibrinogen
B) Histamine Histamine causes vasodilation, increasing blood flow to the affected area, which leads to redness and warmth.
A nurse is assessing a patient with an acute injury. Which chemical mediator is primarily responsible for the early vascular changes of vasodilation and increased permeability? A) Prostaglandins B) Histamine C) Kinins D) Neutrophils
B) Histamine Histamine is released from mast cells when injury occurs and is responsible for the initial vasodilation and increased vascular permeability that characterize the early inflammatory response.
A client asks the nurse why they feel pain at the site of an injury. Which of the following best explains the cause of pain? A) Decreased oxygen delivery to the site of injury B) Increased vascular permeability and irritation of nerve endings C) Formation of a fibrin clot in the blood vessels D) Migration of red blood cells to the site of injury
B) Increased vascular permeability and irritation of nerve endings Pain occurs due to the pressure exerted by the accumulation of fluids in the inflamed tissues and irritation of nerve endings by chemical mediators such as bradykinin.
A nurse is assessing a client with an acute inflammatory response. Which of the following chemical mediators is responsible for attracting neutrophils to the site of injury? A) Histamine B) Kinins C) Prostaglandins D) Fibrinogen
B) Kinins Kinins, particularly bradykinin, contribute to vasodilation, increased vascular permeability, and the recruitment of neutrophils to the injury site.
Which of the following best describes the cellular response (Stage 2) of inflammation? A) Histamine is released to initiate vasodilation B) Leukocytes, particularly neutrophils, migrate to the injury site C) Granulation tissue forms, leading to scar development D) The inflammatory debris is removed, allowing for tissue regeneration
B) Leukocytes, particularly neutrophils, migrate to the injury site In the cellular stage of inflammation, neutrophils and other leukocytes move from the bloodstream into the injured tissues to engulf debris and pathogens.
The nurse is reviewing the stages of the inflammatory response. Which event occurs during the vascular stage (Stage 1)? A) Neutrophils migrate to the injury site to perform phagocytosis B) Plasma proteins leak into tissues, causing edema C) Granulation tissue begins to form, leading to scar development D) Epithelial cells multiply to replace damaged cells
B) Plasma proteins leak into tissues, causing edema The vascular stage of inflammation involves increased vascular permeability, allowing plasma proteins and fluids to leak into the tissues, leading to swelling.
A nurse is assessing a patient with an immune deficiency. Which statement best differentiates primary and secondary immune deficiencies? A) Primary immune deficiencies are always inherited, while secondary immune deficiencies result from genetic mutations. B) Primary immune deficiencies result from improper immune cell development, while secondary immune deficiencies develop later in life due to external factors. C) Both primary and secondary immune deficiencies are congenital and cannot be acquired later in life. D) Secondary immune deficiencies occur due to overproduction of immunoglobulins, while primary immune deficiencies result from cellular mutations.
B) Primary immune deficiencies result from improper immune cell development, while secondary immune deficiencies develop later in life due to external factors.
A patient's dressing is too tight. The nurse understands that this can: A) Improve circulation by keeping the wound compressed B) Reduce blood supply and oxygen delivery to tissues C) Promote tissue healing by restricting edema formation D) Prevent bacterial invasion by sealing the wound
B) Reduce blood supply and oxygen delivery to tissues A tight dressing can compress blood vessels, reducing circulation and oxygen delivery, which can impair wound healing.
A patient is diagnosed with an autoimmune disorder. The nurse understands that this means: A) The immune system is underactive and fails to respond to infections B) The immune system attacks the body's own tissues, leading to damage C) The body has an excessive immune response to harmless substances D) The patient has a congenital deficiency in immune cell development
B) The immune system attacks the body's own tissues, leading to damage
A nurse is educating a patient about the immune system. Which of the following best describes immunity? A) The body's ability to recognize and attack any foreign or self-antigen B) The specific protective response of the body against a foreign agent C) A nonspecific mechanism that eliminates all antigens indiscriminately D) The function of the central nervous system in regulating metabolism
B) The specific protective response of the body against a foreign agent Immunity is the body's specific protective response to foreign agents, allowing for a rapid and targeted defense against microbial invaders.
What is the primary purpose of fibrin formation during the inflammatory response? A) To reduce blood viscosity and improve circulation B) To form a clot that walls off the injured area and prevents infection spread C) To stimulate vasodilation and promote leukocyte migration D) To decrease swelling and facilitate rapid tissue healing
B) To form a clot that walls off the injured area and prevents infection spread
The nurse is educating a student nurse about the inflammatory process. Which of the following statements by the student indicates a correct understanding? A) "Plasma proteins remain in the bloodstream during inflammation to prevent fluid loss." B) "Leukocytes migrate to the site of injury to engulf debris and pathogens." C) "Vasoconstriction is the primary mechanism that causes redness and warmth at the injury site." D) "Platelets migrate into tissues to remove cellular debris and initiate clot formation."
B)"Leukocytes migrate to the site of injury to engulf debris and pathogens." Leukocytes (white blood cells) migrate through the endothelium to the injury site, where they perform phagocytosis to remove pathogens and debris. Vasodilation, not vasoconstriction, causes redness and warmth
When should bladder distention and the urge to void of a patient be assessed?
Bladder distention and the urge to void should be assessed at the time of the patient's arrival at the unit ad frequently thereafter
Which of the following statements made by a nursing student requires further teaching about the inflammatory process? A) "Histamine is released early in the inflammatory response to cause vasodilation." B) "Kinins increase vascular permeability and help attract neutrophils." C) "Bradykinin is primarily responsible for clot formation at the injury site." D) "Prostaglandins contribute to pain, fever, and increased vascular permeability."
C) "Bradykinin is primarily responsible for clot formation at the injury site." Bradykinin is primarily involved in vasodilation, increased vascular permeability, and pain sensation. Clot formation is facilitated by fibrinogen and platelets.
A nurse is educating a patient about the difference between acute and chronic inflammation. Which statement by the patient indicates a correct understanding? A) "Acute inflammation can last for many months or years." B) "Chronic inflammation always begins with an acute phase." C) "Chronic inflammation can lead to permanent tissue damage and scarring." D) "Acute inflammation does not have a protective function."
C) "Chronic inflammation can lead to permanent tissue damage and scarring." Chronic inflammation can persist for months or years, leading to cellular infiltration, necrosis, fibrosis, and permanent tissue damage.
A nurse is educating a patient about wound care. Which statement by the patient indicates the need for further teaching? A) "I should monitor my wound drainage for any changes in color or amount." B) "If my drainage increases suddenly, I should contact my healthcare provider." C) "If my dressing is full of drainage, I should leave it on until my next scheduled change." D) "Keeping my drainage system functioning properly will help my wound heal faster."
C) "If my dressing is full of drainage, I should leave it on until my next scheduled change." A dressing saturated with drainage should be changed to prevent bacterial growth and maintain a clean healing environment.
A nurse is reviewing immune system function with a student nurse. Which of the following statements by the student requires further teaching? A) "The immune system remains in a state of surveillance, screening and rejecting foreign invaders." B) "Immune tolerance allows the body to distinguish between self and non-self antigens." C) "Primary immune deficiencies are acquired later in life due to infections and stress." D) "Emotional and physical health can influence immune function."
C) "Primary immune deficiencies are acquired later in life due to infections and stress." Primary immune deficiencies are congenital or inherited, while secondary immune deficiencies develop later in life due to infections, medications, or other external factors.
A nurse is reviewing the inflammatory response with a group of nursing students. Which statement requires further teaching? A) "Inflammation is initiated by vasodilation and increased vascular permeability." B) "Bradykinin is a chemical mediator suspected of causing pain." C) "Red blood cells actively migrate to the site of injury to help fight infection." D) "Fibrinogen leaks from the plasma and forms a clot to wall off the injured area."
C) "Red blood cells actively migrate to the site of injury to help fight infection."
The nurse explains to a student that chronic inflammation differs from acute inflammation in which key way? A) Chronic inflammation occurs immediately and has a protective function. B) Acute inflammation leads to fibrosis, while chronic inflammation resolves quickly. C) Chronic inflammation persists and can cause permanent structural changes. D) Acute inflammation does not involve vascular changes or exudate production.
C) Chronic inflammation persists and can cause permanent structural changes. Chronic inflammation is ongoing and can lead to fibrosis, necrosis, and scarring, causing long-term structural changes in the affected tissues.
A nurse explains to a client that swelling at an injury site is caused by: A) Decreased blood viscosity B) Accumulation of red blood cells at the site C) Leakage of plasma fluids, proteins, and solutes into the tissues D) Immediate vasoconstriction of blood vessels
C) Leakage of plasma fluids, proteins, and solutes into the tissues
A nurse is caring for a client with chronic inflammation. Which of the following should the nurse anticipate? A) The injury site will heal quickly after the causative agent is removed. B) The inflammatory process will be self-limiting and resolve within two weeks. C) The client may experience ongoing tissue damage, necrosis, and scarring. D) The primary symptom will be localized swelling without systemic effects.
C) The client may experience ongoing tissue damage, necrosis, and scarring. Chronic inflammation involves ongoing tissue destruction and repair, often resulting in fibrosis and scarring, with symptoms persisting for months or years
A nurse is caring for a patient with a healing wound. Which statement best describes the tissue repair and replacement stage (Stage 3)? A) The inflammatory response is activated, releasing chemical mediators B) Neutrophils and monocytes engulf pathogens and cellular debris C) The defect is repaired through regeneration or replacement with scar tissue D) Blood vessels constrict to prevent further plasma loss
C) The defect is repaired through regeneration or replacement with scar tissue Stage 3 of the inflammatory response involves tissue repair, which occurs either by regeneration (with the same cell type) or by replacement (with connective tissue, leading to scar formation)
A nurse is assessing a client with inflammation. Which finding suggests a chronic inflammatory response rather than an acute one? A) Localized warmth, redness, and swelling lasting less than two weeks B) Rapid resolution of symptoms after the causative agent is removed C) The presence of proliferative exudate and fibrosis at the injury site D) A temporary increase in vascular permeability with immediate symptom relief
C) The presence of proliferative exudate and fibrosis at the injury site
The nurse is reviewing a client's inflammatory response. Which of the following best describes how prostaglandins contribute to inflammation? A) They reduce vascular permeability to limit swelling. B) They increase blood viscosity, preventing white blood cells from leaving circulation. C) They increase vascular permeability and contribute to pain and fever. D) They decrease leukocyte migration to minimize immune response.
C) They increase vascular permeability and contribute to pain and fever. Prostaglandins increase vascular permeability, allowing fluid to leak into tissues, and they also play a role in fever and pain perception.
A client presents with warmth, redness, and swelling at the site of an injury. The nurse understands that these symptoms occur due to which physiological response? A) Decreased capillary permeability B) Vasoconstriction and platelet aggregation C) Vasodilation and increased vascular permeability D) Decreased blood flow and fibrin clot formation
C) Vasodilation and increased vascular permeability After an injury, transient vasoconstriction is followed by vasodilation, increasing blood flow to the area. This, along with increased vascular permeability, allows plasma proteins and fluids to leak into the tissues, leading to redness, warmth, and swelling.
A nurse is explaining the difference between primary and secondary intention healing. Which statement by the patient requires further teaching? A) "Primary intention healing occurs when wound edges are brought together." B) "In secondary intention healing, wounds take longer to heal due to tissue loss." C) "Secondary intention healing results in granulation tissue formation." D) "Primary intention healing leads to a large scar and loss of function."
D) "Primary intention healing leads to a large scar and loss of function." In primary intention healing, wound edges are approximated, resulting in minimal scar formation. Large scars and loss of function are more common with secondary intention healing.
A client reports pain at the site of inflammation. The nurse understands that which of the following chemical mediators is most likely responsible for pain? A) Histamine B) Prostaglandins C) Kinins D) Both B and C
D) Both B and C Both prostaglandins and kinins, especially bradykinin, are involved in the sensation of pain by irritating nerve endings.
Infection
Exists when the infectious agent is living, growing, and multiplying in the tissues and is able to overcome the body's normal defenses
What is the first stage of would healing
Inflammatory phase -occurs at time of injury with formation of a blood clot and migration of phagocytic white blood cells into the wound site. First cell to arrive (neutrophils) are joined by macrophages
Inflammation
Localized reaction intended to neutralize, control, or eliminate the offending agent to prepare the site for repair
True or False: Inflammation is proportional to the degree of tissue injury
The inflammatory response is often confined to the site, causing only local signs and symptoms. Systemic responses (like a fever) can sometimes occur
What is a patient at risk for in postoperative period?
The patient is at risk for malignant hyperthermia and hypothermia in the post op period
What is not a cardinal sign of inflammation a. fever b. loss of function c. redness d. swelling
a. fever the 5 cardinal signs of inflammation are redness, warmth, swelling, pain, and loss of function
What is the second phase of wound healing
proliferation phase -Focuses on building new tissue to fill the wound space. Fibroblasts, proteoglycans, and glycoproteins are needed for wound healing. Final phase is epithelialization phase which form a new surface layer that is similar to what was destroyed.
When does granulation tissue form and angiogenesis occur in the 3 phases of wound healing?
regeneration phase.
Example of first intention wound healing
sutured surgical incision
what is the third (and last) phase of wound healing
wound contraction/remodeling phase -occurs 3 weeks after injury and develops fibrous scarring. Decreased vascularity and remodeling of scar tissue by simultaneous synthesis of collagen by fibroblasts and lysis.
What is a serious surgical complication the nurse should be cautious of when performing a wound assessment?
wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents). Patient may report that "something gave away"
