Wound Healing

Which of the following systemic factors places a patient at risk for impaired wound healing? A. Low BMI B. Young age C. Vitamin deficiency D. Diabetes mellitus

D. Diabetes mellitus

Which of the following patients is likely to experience the most scarless wound healing? A. A newborn B. A fetus at 22 weeks, gestation C. A teenager D. A young adult

B. A fetus at 22 weeks, gestation

When assessing an abdominal wound, the nurse observes a loop of intestine protruding through the incision. What action should the nurse take? A. Redress the wound and assess it again in 4 hours. B. Leave the wound open and place the patient on bedrest. C. Cover the wound with a moist sterile dressing and call the surgeon. D. Redress the wound and tell the patient to avoid strain on the incision.

C. Cover the wound with a moist sterile dressing and call the surgeon.

The nurse is assessing the wound healing of a patient at his follow up appointment 2 weeks after a total hip replacement. Which of the following wound appearances would the nurse expect to see? A. A gap between the edges of the wound B. Granulation tissue in the wound bed C. Hematoma formation D. Wound edges well approximated

D. Wound edges well approximated

A scar affects joint mobility. Which term should the nurse use to document this​ scar? A. Keloid B. Hypertrophic C. Contracture D. Acne

C. Contracture Rationale: Contracture scars are commonly seen in the healing of severe burns and may compromise the mobility of involved joints. Hypertrophic scars are characterized by an excess of fibrotic​ tissue; they are more likely to be associated with wounds associated with trauma and burns and are raised above the level of the surrounding skin. Keloid scars are characterized by an excess of dermal scar or fibrotic tissue. Acne scars range from deep pits to scars that are angular or wavelike in appearance.

Which statement by the nurse about the relationship between scarless fetal wounds and gestational age is​ accurate? A. ​"Gestational age is positively correlated with the extent of​ scarring." B. ​"Gestational age is negatively correlated with the extent of​ scarring." C. ​"Gestational age is inversely related to​ scarring." D. ​"The gestational age plays no part in scaring—scarring will occur​ regardless."

A. ​"Gestational age is positively correlated with the extent of​ scarring." Rationale: Cutaneous wound healing with minimal or no scarring is related to the gestational age of the fetus and the size of the wound. As the gestational age of the fetus​ increases, healing proceeds from no scar to barely​ visible, to a faint​ mark, to an obvious scar.​ Thus, gestational age is positively correlated with the extent of scarring.

The nurse is assessing the skin of a patient with a sacral pressure injury who was admitted from home. The nurse assesses that the wound is healing by secondary intention when which of the following is observed? A. A large amount of granulation tissue B. Hematoma formation C. A minimal amount of exudate D. Abscess formation

A. A large amount of granulation tissue

The nurse is caring for a chronically ill patient with a long standing wound. The nurse explains to the patient that a diet rich in which of the following vitamins is necessary for wound healing. A. A, C, E, and K B. A, B, C, and E C. A, C, D, and K D. B, C, E, and K

A. A, C, E, and K

The nurse is discussing interventions to prevent​ pressure-related injuries. Which intervention should the nurse​ include? (Select all that​ apply.) A. Ensuring proper hygiene B. Proper nutrition C. Frequent repositioning D. Providing psychological support E. Use of​ pressure-relieving devices

A. Ensuring proper hygiene B. Proper nutrition C. Frequent repositioning E. Use of​ pressure-relieving devices Rationale: One of the most effective means of preventing​ pressure-related injuries is frequent repositioning. Other means are proper​ nutrition, such as adequate vitamin​ intake, ensuring proper​ hygiene, and the use of​ pressure-relieving devices. Providing psychological support will not prevent a​ pressure-related injury.

A client with a wound asks how healing can be facilitated. Which intervention should the nurse include in the​ response? (Select all that​ apply.) A. Maintaining adequate nutritional intake B. Stopping smoking C. Covering the wound with an airtight bandage D. Keeping the wound clean E. Avoiding drug use

A. Maintaining adequate nutritional intake B. Stopping smoking D. Keeping the wound clean E. Avoiding drug use Rationale: Avoiding drug​ use, stopping​ smoking, keeping the wound​ clean, and maintaining adequate nutritional intake will facilitate healing. These actions will promote oxygen delivery to the cells and the vitamins and minerals needed for wound healing. Hypoxia will delay wound​ healing; therefore, an airtight bandage should not be used.

The nurse is listing systemic factors that may impede wound healing. Which factor should the nurse​ include? (Select all that​ apply.) A. Malnutrition B. Excessive edema C. Smoking D. Medication E. Advanced age

A. Malnutrition C. Smoking D. Medication E. Advanced age ​Rationale: Malnutrition, advanced​ age, smoking, and certain medications​ (for example,​ anti-neoplastic agents and​ corticosteroids) are all systemic factors that can impede wound healing. Excessive edema is a local impediment to wound healing.

The nurse is teaching a postoperative patient about wound healing. Which of the following statements made by the patient indicates that the patient requires more education? A. My scar will be stronger than my injured tissue. B. A normal scar is raised above the level of the surrounding skin. C. A maturing scar will be pale white in color. D. It is normal for the wound to be open in the first few weeks of healing.

A. My scar will be stronger than my injured tissue.

The nurse teaches a class about the factors that may impede wound healing. Which participant statement suggests that effective learning has taken​ place? A. ​"Hypoxia can significantly delay or even stop wound​ healing." B. ​"Smoking does not affect wound​ healing." C. ​"Edema will not affect the wound healing​ process." D. ​"Diabetes mellitus is the single biggest deterrent to wound​ healing."

A. ​"Hypoxia can significantly delay or even stop wound​ healing." ​Rationale: Blood flow to the injury site is one of the most important factors affecting the healing process. Hypoxia can significantly delay or even stop the wound healing process. Killing​ bacteria, collagen​ deposition, angiogenesis, and reepithelialization directly depend on the oxygen tension in the wound bed. Diabetes mellitus can impede the wound healing​ process, but it does not impede wound healing more than hypoxia does. Edema and smoking can impede wound healing.

The nurse sees granulation tissue in the wound. Which description should the nurse​ give? A. ​"There is reddish connective tissue on the surface of the​ wound." B. ​"There is dark tissue at the base of the​ wound." C. ​"There is stringy yellow tissue at the base of the​ wound." D. ​"There is fatty tissue on the base of the​ wound."

A. ​"There is reddish connective tissue on the surface of the​ wound." ​Rationale: Granulating tissues are indicated by reddish connective tissue on the surface of the wound. Dark tissue suggests eschar and necrosis. Stringy yellow tissue is slough and fatty tissue is not seen in wounds.

Which should the nurse know are types of​ debridement? (Select all that​ apply.) A. Methodical B. Autolytic C. Surgical D. Mechanical E. Physical

B. Autolytic C. Surgical D. Mechanical ​Rationale: Mechanical debridement is done through the use of wet and dry dressings that are regularly changed throughout the healing process. In autolytic​ debridement, dressings that contain wound​ moisture, such as hydrocolloid and clear absorbent acrylic​ dressings, trap the wound drainage against the eschar. The​ body's own enzymes in the drainage break down the necrotic tissue. Surgical debridement is the cutting away of dead tissue.

The nurse is discussing factors commonly associated with wound dehiscence. Which factor should the nurse​ include? (Select all that​ apply.) A. High blood pressure B. Diabetes mellitus C. ​High-dose corticosteroids D. Infection E. Dehydration

B. Diabetes mellitus C. ​High-dose corticosteroids D. Infection E. Dehydration Rationale: Factors that are commonly associated with wound dehiscence are diabetes​ mellitus, high-dose corticosteroid​ use, and infection. Some additional individual factors that favor dehiscence are increased mechanical strain on the​ wound, age greater than 65​ years, dehydration,​ malnutrition, hypoproteinemia,​ malignancy, and obesity.

The nurse is caring for a client with a stage 3 pressure injury. Which type of tissue does the nurse understand indicates effective wound​ healing? A. Dermal B. Granulating C. Smooth muscle D. Epithelial

B. Granulating ​Rationale: Granulation tissue is a mass of new connective tissue that forms on the surface of a healing wound. Epithelial tissue lines the cavities and surfaces of blood vessel and organs throughout the body. Smooth muscle tissues are found in the walls of internal​ organs, such as the stomach and bladder. Dermal tissues are tissues of the skin not seen in wounds.

The nurse is caring for a patient with a right ischial pressure injury. In which of the following positions should the nurse position the patient? A. On the back in bed B. On either side in bed C. Seated upright in a chair D. Reclining in a chair

B. On either side in bed

The nurse is discussing the phase of the wound healing process when reepithelization occurs. Which phase is the nurse​ describing? A. Remodeling B. Proliferative C. Repairing D. Inflammatory

B. Proliferative ​Rationale: In the proliferative​ phase, wound healing is guided toward tissue​ repair: collagen​ deposition, angiogenesis, and reepithelialization. The goal of the inflammatory phase is to minimize tissue​ damage, prevent additional tissue​ injury, and prepare the wound for healing and regeneration. The goal of the remodelling phase is to restore the structural and functional integrity of the skin. Repairing is not a phase in the wound healing process.

Which purpose does the proliferative phase of wound healing​ serve? A. Restoring structural and functional integrity B. Tissue repair C. Blood clotting D. Minimizing tissue damage

B. Tissue repair ​Rationale: In the proliferative​ phase, wound healing is guided toward tissue repair.​ Fibroblasts, endothelial​ cells, and keratinocytes are the cells responsible for the events of the proliferative​ phase: collagen​ deposition, angiogenesis, and reepithelialization. The goal of the inflammatory phase is to minimize tissue​ damage, prevent additional tissue​ injury, and prepare the wound for healing and regeneration. The goal of the remodelling phase is to restore the structural and functional integrity of the skin. Repairing is not a phase in the wound healing process.

The client asks the nurse how a hypertrophic scar differs from a keloid scar. Which is an accurate response by the​ nurse? A. ​"Hypertrophic scars occur most often in areas of high melanocyte​ concentrations, such as above the​ clavicles, arms, and​ face, whereas keloids appear on​ limbs." B. ​"Keloids usually occur in individuals under the age of 30 and those with​ darker-pigmented skin, while hypertrophic scars usually regress​ spontaneously." C. ​"Keloids are bigger and usually regress​ spontaneously, unlike hypertrophic​ scars." D. ​"Hypertrophic scars usually extend beyond the wound​ borders, while keloids do​ not."

B. ​"Keloids usually occur in individuals under the age of 30 and those with​ darker-pigmented skin, while hypertrophic scars usually regress​ spontaneously." ​Rationale: Hypertrophic scars are characterized by an excess of fibrotic​ tissue; they are more likely to be associated with wounds associated with trauma and burns and are raised above the level of the surrounding skin.​ However, unlike​ keloids, hypertrophic scars grow within the boundaries of the original injury and often regress spontaneously. Keloid scars are characterized by an excess of dermal scar or fibrotic tissue. Keloid scars occur most often in areas of high melanocyte​ concentrations, such as above the​ clavicles, arms, and face.

The nurse is caring for a client with a pressure injury that involves full thickness tissue loss with depth completely obscured by slough or eschar in the wound bed. Which term should the nurse use to document this pressure​ injury? A. Stage 4 B. Stage 2 C. Unstageable D. Stage 3

C. Unstageable ​Rationale: It is unstageable because there is full thickness tissue loss with depth that is completely obscured by slough or eschar in the wound bed. The depth of the wound cannot be determined until the slough or eschar is removed. It is not stage​ 4, because​ fascia, muscle,​ ligament, cartilage,​ tendon, and/or bone are not exposed. Undermining and tunneling and rolled wound edges are usually present. It is not stage​ 3, because adipose tissue is visible within the​ ulcer; granulation and rolled wound edges are​ present; and​ bone, tendon, and muscle are not exposed. It is not stage​ 2, because stage 2 pressure injuries are shallow open ulcers with a viable pink or red moist wound​ bed, with granulation tissue and eschar not present.

Which vitamin deficiency should the nurse suspect to be present in clients with fat​ malabsorption? A. Vitamin C B. Vitamin A C. Vitamin E D. Vitamin K

C. Vitamin E Rationale: Vitamin E deficiency is most common in individuals with fat malabsorption. All other options are incorrect.

A wound is cleansed and left open for several days to drain exudate and ensure no infection is present. The nurse should identify this approach as which type of wound​ healing? A. Delayed secondary intention B. Primary intention C. Secondary intention D. Tertiary intention

D. Tertiary intention ​Rationale: Wound healing by tertiary​ intention, sometimes referred to as delayed primary​ closure, occurs when wound closure is delayed. This type of healing is a combination of primary intention and secondary intention. Wound healing by primary intention​ (primary closure) typically occurs after surgical closure of a wound. It may also occur in wounds that involve minimal loss of​ tissue, that are not infected or​ contaminated, and in which the edges of the wound can be approximated and closed. Wound healing by secondary intention​ (secondary or spontaneous​ closure) occurs when a full thickness wound is allowed to heal without a closure attempt.

Which vitamin deficiency puts clients at risk for poor wound​ healing? A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin C

D. Vitamin C Rationale: Vitamin C deficiency affects all phases of wound healing. It is the only​ water-soluble vitamin listed. It leads to retardation of the inflammatory​ process, resulting in reduction in inflammatory cell function and decrease in proinflammatory complement activity. Vitamin​ A, D, and E deficiencies all delay wound​ healing, but they are​ fat-soluble.

The nurse is teaching a client how corticosteroids affect wound healing. Which statement should the nurse​ include? A. ​"Corticosteroids diminish the production of​ leukocytes, erythrocytes, and​ platelets." B. ​"Corticosteroids help build muscles and aid with wound​ healing." C. ​"Corticosteroids prolong prothrombin and thrombin​ time, hence delaying wound​ healing." D. ​"Corticosteroids promote the breakdown of​ carbohydrates, fats, and​ proteins."

D. ​"Corticosteroids promote the breakdown of​ carbohydrates, fats, and​ proteins." ​Rationale: Prednisone is a corticosteroid. Corticosteroids are hormones that promote the breakdown of​ carbohydrates, fats, and proteins. This nutrient breakdown can impair the anabolic processes needed for cell growth and proliferation during wound healing. Corticosteroids normally affect wound healing only when they are taken in high doses over a prolonged period of time.

The nurse is discussing the difference between stage 3 and stage 4 pressure injuries. Which statement should the nurse​ include? A. ​"In stage​ 3, fascia,​ muscle, ligament,​ cartilage, tendon,​ and/or bone are exposed and directly​ palpable." B. ​"In stage​ 3, the wound is shallow and open with a viable pink or red moist wound​ bed." C. ​"In stage​ 4, the depth of the wound cannot be determined until the slough or eschar is​ removed." D. ​"In stage​ 3, adipose tissue is visible and​ bone, tendon, and muscle are not​ exposed."

D. ​"In stage​ 3, adipose tissue is visible and​ bone, tendon, and muscle are not​ exposed." ​Rationale: Full thickness skin loss with extensive tissue damage and necrosis appear in a stage 4 ulcer.​ Fascia, muscle,​ ligament, cartilage,​ tendon, and/or bone are exposed and directly​ palpable, and slough or eschar may be present. Undermining and tunneling and rolled wound edges are usually present. The depth of a stage 4 pressure injury can vary by anatomic​ location, and injuries can extend into muscle and supporting structures​ (including fascia,​ tendons, or joint​ capsules), increasing the likelihood of osteomyelitis. It is not stage​ 3, because adipose tissue is visible within the​ ulcer; granulation and rolled wound edges are​ present; and​ bone, tendon, and muscle are not exposed. It is not stage​ 2, because stage 2 ulcers are shallow open ulcers with a viable pink or red moist wound​ bed, granulation​ tissue, and eschar is not present. The ulcer is not unstageable because the eschar or slough does not obscure the depth of tissue loss.

A client who has undergone several wound debridements asks why it is necessary to debride the wound again.​ "Doesn't it just prevent healing if you go in and scrape out a bunch of​ tissue?" Which is the​ nurse's best​ response? A. ​"Necrotic tissue promotes healing because it deposits granulation tissue in the​ wound." B. ​"The surgeon is careful not remove all necrotic tissue to facilitate​ healing." C. ​"The surgeon only removes tissue on which bacteria and other organisms are​ growing." D. ​"The dark, necrotic tissue prevents healing because it does not allow new tissue to​ grow."

D. ​"The dark, necrotic tissue prevents healing because it does not allow new tissue to​ grow." ​Rationale: Necrotic tissue prolongs the inflammatory phase and prevents healing. It acts as a mechanical barrier to reepithelization and deposition of granular tissue in the wound. The surgeon will remove all necrotic tissue to facilitate​ healing, and not just the tissue on which bacteria and other organisms are growing. Necrotic tissue does not promote healing.