Quiz week three wound
Mrs. Anderson has dependent rubor and elevation pallor of her right lower extremity. The systolic pressure in her R. arm is 170 mmHg; L arm is 165 mmHg, R. dorsal pedis systolic pressure was 100 mmHg and the posterior tibial pressure was 95 mmHg. What is Mrs. Anderson's ABI for the RLE?
0.59
You were called to the Cancer Center to evaluate a patient receiving daily radiation to his R. neck region. You note primarily dry desquamation with small patches of weeping skin, redness and edema. Which treatment modality would NOT be appropriate for this patient?
A moisture retentive adhesive dressing.
Which of the following assessments is most indicative of an arterial ulcer?
An ABI of 0.7.
Patients undergoing myocutaneous flap closure of a pressure injury are BEST managed in the initial postoperative period on what type of support surface?
An air-fluidized bed with non-shear surface.
Mr. Benn's venous ulcers have now resolved completely. You have fitted him with proper below the knee compression stockings. Your discharge instructions include which of the following?
Apply stocking upon rising in the morning.
As you examine a patient's lower extremity you observe a thin leg with dry skin and very little hair; the ABI is 0.5. From this data, what condition would you assess to be present?
Arterial insufficiency.
Mrs. Jones has an ulcer located on the dorsal surface of the third toe on the left foot. The ulcer is 1 cm in diameter, with a dry, pale pink wound bed. She reports significant pain in the ulcer and denies any history of diabetes. What is the MOST likely cause of this ulcer?
Arterial insufficiency.
You are providing some patient education for a patient at risk for a neuropathic foot ulcer in obtaining proper footwear, which of the following is NOT an important factor when selecting proper footwear?
Both feet should be measured, and shoes sized to the smaller foot.
What is Mrs. Lang's foot deformity called when there is a rocker bottom appearance to her foot?
Charcot's joint
Mr. Best has been diagnosed with lower extremity arterial disease (LEAD). What risk factor for arterial disease may have played the greatest role in atherosclerosis development?
Diabetes mellitus
What diagnostic test is considered the "Gold Standard" for diagnosing LEVD (lower extremity venous disease)?
Duplex ultrasound.
Which of the following statements concerning the management of a mixed venous/arterial ulcer with an ABI of .75 is TRUE?
Graduated compression can be provided at a modified level of support.
An elderly female developed a dehisced wound following abdominal surgery for a bowel obstruction. Which of the following conditions BEST explains what placed her at risk for developing a wound dehiscence?
History of radiation in the surgical field.
The wound care nurse is investigating why modalities and treatments used in the management of wounds are less effective with spinal cord-injured (SCI) patients. What is one reason to consider is:
Lack of spasticity management & AD (autonomic dysreflexia) trigger identification
A patient in the outpatient wound clinic has a venous ulcer and with palpation, the skin around the ulcer feels firm and woody or hardened. This describes what condition?
Lipodermatosclerosis.
You are observing the limbs of a new patient and note that one limb has brawny non-pitting edema from the toes to groin and positive Stemmer sign while the other is without edema and no distortion in the leg shape. What type of disorder is this patient most likely suffering from?
Lymphedema.
The wound nurse is providing discharge education to a patient who suffered a deep partial thickness burn to their lower extremity. What intervention would be most appropriate in the plan of care?
Moisturizers and OTC antihistamines
An ambulatory patient with insulin dependent diabetes has an ulcer located on the plantar surface of the left foot over the third metatarsal head. The ulcer is 1 cm in diameter, with a dry red surface. The patient denies any pain in the ulcer. What type of wound does this most likely represent?
Neuropathic Ulcer
While you are educating the staff at the NICU, one of the staff members wanted your recommendations on treating a pre-mature infant's skin stripping injury. Which of the following interventions would be the BEST choice to manage the skin stripping?
Non-adherent absorptive dressing held in place with stretch netting
Which single risk factor is MOST likely to lead to SSI (surgical site infection)?
Obesity
Your 80 y/o patient with diabetes is scheduled to have surgery to repair a hip fracture. What is the BEST POST-OP intervention to minimize her Surgical Site Infection (SSI) risk.
Prevent hyperglycemia
Lymphedema is the accumulation of:
Protein rich fluid in the soft tissue.
The nursing staff calls you because a patient suffered an extravasation of Vancomycin at a peripheral IV site, your immediate instructions are to:
Recommend topical wound therapy once residual drug is aspirated
You are called into a care conference to help the Skin Care Team determine a plan of care to promote bariatric skin integrity. What characteristic listed is NOT a risk factor for alteration in skin integrity for those who suffer obesity?
Reduced bacterial load on skin
A routine baseline assessment of the lower leg in a patient with diabetes and neuropathy should include:
Sensory testing with a monofilament.
You are called to the neonatal intensive care unit regarding appropriate products to use on the skin of neonates. Which of the following products would be considered safe to use on the neonates skin?
Silicone.
You are evaluating a palliative care patient with a lower extremity arterial ulcer. What is the primary goal and treatment focus in developing a plan of care?
Symptom control and prevention of pressure injuries.
Mrs. James has an eschar covered heel ulcer and you decide that the best approach to management is NOT to debride but to keep the eschar covered, dry and intact. The rationale for your decision is that the:
TcPO2 (transcutaneous oxygen) is 15 mmHg.
Which of the following statements about contact casting is correct?
The contact cast redistributes the weight of the diabetic foot.
Which of the following statements about inelastic compression bandages is accurate?
They are only effective in the ambulatory patient.
Which of the following causes of massive tissue loss is most commonly associated with a severe drug reaction?
Toxic Epidermal Necrolysis (TEN).
A patient has pyoderma gangrenosum with a LE ulceration. It is acutely painful and typically breaks down to form a progressively larger ulceration with a bright red "halo" on the ulcer border. It also typically has a purple (violaceous) border and may have undermining at the wound edges, inflamed, necrotic base, boggy tissue, purulent drainage. The treatment for this problem is to:
Treat the underlying disease
You have a preterm neonate patient with a large surgical abdominal wound draining a large amount of exudate. What will you need to consider in wound management for this age patient
Weigh dressings and eliminate the use of adhesives
Intermittent claudication leg pain is characterized as pain that occurs:
With activity and is relieved by rest.
Which of the following statements is TRUE? Venous dermatitis:
results in erythema, crusting, scaling skin of the leg.
