CH.31 Wounds
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? A. Infection of the wound B. Herniation of the wound C. Dehiscence of the wound D. Evisceration of the viscera
c. dehiscence of the wound Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.
The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? A)Desiccation B)Maceration C)Necrosis D) Evisceration
A) Desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? A) "Do you experience incontinence?" B) "How many meals a day do you eat?" C) "Do you use any lotions on your skin?" D) "Have you had any recent illnesses?"
A) "Do you experience any incontinence?" The client's health history is an essential component for assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about skin care regimens, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.
Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis C) Inflammatory phase D) Maturation phase
A) Proliferation phase The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms.
Two nurses are having a disagreement over who will take the next admission to the unit. The nurse manager asks one of the nurses to take the admission and explains that this will be considered a personal favor. Which style of conflict resolution did the nurse manager display? A) Accomodating B) Avoiding C) Competing D) Collaborating
A) accomodating The nurse manager is displaying a conflict resolution style of accommodating by asking one of the nurses to accept the assignment of the admission. If the nurse manager had ignored the situation, this would have been the avoiding style of conflict resolution. With a competing style, the nurse manager would have told the nurse to accept the admission, rather than asking the nurse. If collaborating is the conflict resolution style used, the nurse manager would have discussed the situation with both nurses in order to achieve a solution to this conflict.
A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing? A)Visceral pain B)Referred pain C)Cutaneous pain D)Somatic pain
A) visceral pain Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial. Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix.
A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the client that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement.
B) assist in moving to prevent strain on the suture line The proliferative phase of wound healing begins within two to three days of the injury. Collagen synthesis and accumulation continue, peaking in five to seven days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations.
A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems. Which is an example of a closed wound? A) Abrasion B) Ecchymosis C) Incision D) Puncture wound
B) ecchymosis A closed wound results from a blow, force, or strain caused by trauma (such as a fall, an assault, or a motor vehicle crash). The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas. An open wound occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.
A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention? A. Contact the surgeon. B. Apply sterile dressings with normal saline over the protruding organs and tissue. C. Assess for impaired blood flow to the area of evisceration. D. Monitor for pallor and mottle appearance of the wound.
B. apply sterile dressings w/ normal saline over the protruding organs and tissue The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue, and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.
The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound? A) Stage I pressure ulcer B) Stage II pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer
C) Stage III pressure ulcer Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction associated with full-thickness skin loss is categorized as a stage IV pressure ulcer. A stage I ulcer is a defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in darker pigmented skin. A stage II pressure ulcer is superficial and may present as a blister or abrasion.
A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? A) Epidermis B) Dermis C) Subcutaneous tissue D) Muscle layer
C) Subcutaneous tissue The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.
A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? A) Tearing of the skin and tissue with some type of instrument; tissue not aligned B) Cutting with a sharp instrument with wound edges in close approximation with correct alignment C) Tearing of a structure from its normal position D) Puncture of the skin
C) Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.
The nurse manager for the psychiatric unit sees that there are major conflicts between the day and night shift staff. The nurse manager suggests that each shift put aside their differences for a time and determine a common major goal. Which of the following conflict resolution styles does the nurse manager display? A)Avoiding B)Competing C)Collaborating D)Smoothing
C) collaborating With "collaborating" there is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. With "avoiding" there is awareness of the conflict situation, but the parties involved decide to either ignore the conflict or avoid/postpone its resolution. "Competing" is an approach that results in a win for one party at the expense of the other. "Smoothing" is an effort to complement the other party and focus on agreement rather than disagreement, thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique.
Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following? A) Closing the wound area with Steri-Strips B) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze C) Holding the wound together until the physician arrives D) Covering the wound area with sterile towels moistened with sterile 0.9% saline
D) Covering the wound area with sterile towels moistened with sterile 0.9% saline If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The client should also be placed in the low Fowler's position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone.