Chapter 33: Skin Integrity and Wound Care

A student nurse studying anatomy and physiology learns that the largest organ of the body is the:

A) heart

B) lungs

C) skin

D) intestines

C) skin

Which of the following are functions of the skin? Select all that apply.

A) protection

B) temperature regulation

C) psychosocial, sensation

D) vitamin C production

E) immunological

F) lipid reduction

A) protection

B) temperature regulation

C) psychosocial, sensation

E) immunological

Which of the following patients would be considered at risk for skin alterations? Select all that apply.

A) a teenager with multiple body piercings

B) a homosexual in a monogamous relationship

C) a patient receiving radiation therapy

D) a patient undergoing cardiac monitoring

E) a patient with diabetes mellitus

F) a patient with a respiratory disorder

A) a teenager with multiple body piercings

C) a patient receiving radiation therapy

E) a patient with diabetes mellitus

Which of the following statements accurately describes a developmental consideration when assessing skin integrity of patients?

A) In children younger than 2 years, the skin is thicker and stronger than it is in adults.

B) An infants skin and mucous membranes are injured easily and are subject to infection.

C) A childs skin becomes increasingly at risk for injury and infection.

D) In the older adult, circulation and collagen formation are increased.

B) An infants skin and mucous membranes are injured easily and are subject to infection.

A nurse assessing the skin of patients knows that the following are health states that may predispose patients to skin alterations. Select all that apply.

A) obesity

B) excessive perspiration

C) cataracts

D) hypertension

E) low BMI

F) Jaundice

A) obesity

B) excessive perspiration

E) low BMI

F) Jaundice

What is the most accurate definition of a wound?

A) a disruption in normal skin and tissue integrity

B) a change in the function of internal organs

C) any injury that results in changes in nervous tissue

D) any trauma resulting in serious damage and pain

A) a disruption in normal skin and tissue integrity

Which of the following best describes an unintentional wound?

A) clean wound edges, controlled bleeding

B) jagged wound edges, uncontrolled bleeding

C) little risk for infection, shorter healing time

D) the result of surgery, intravenous therapy

B) jagged wound edges, uncontrolled bleeding

A nurse documents a closed wound on a patient chart. Which of the following is an example of a closed wound?

A) abrasion

B) ecchymosis

C) incision

D) puncture wound

B) ecchymosis

What are the two major processes involved in the inflammatory phase of wound healing?

A) bleeding is stimulated, epithelial cells are deposited

B) granulation tissue is formed, collagen is deposited

C) collagen is remodeled, avascular scar forms

D) blood clotting is initiated, WBCs move into the wound

D) blood clotting is initiated, WBCs move into the wound

A nurse is caring for a patient who is 2 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 patient 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.

A home health nurse has a caseload of several postoperative patients. Which one would be most likely to require a longer period of care?

A) an infant

B) a young adult

C) a middle adult

D) an older adult

D) an older adult

A nurse is teaching a postoperative patient about essential nutrition for healing. What statement by the patient would indicate a need for more information?

A) I will drink a lot of orange juice and drink milk too.

B) I will take the zinc supplement the doctor recommended.

C) I will restrict my diet to fats and carbohydrates.

D) I will drink 8 to 10 glasses of water every day.

C) I will restrict my diet to fats and carbohydrates.

What nursing diagnosis would be a priority for a patient who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?

A) Self-care Deficit

B) Risk for Imbalanced Nutrition

C) Anxiety

D) Risk for Infection

D) Risk for Infection

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk?

A) an 83-year-old who is mobile

B) a 92-year-old who uses a walker

C) a 75-year-old who uses a cane

D) an 86-year-old who is bedfast

D) an 86-year-old who is bedfast

When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

A) friction

B) necrosis of tissue

C) ischemia

D) shearing force

D) shearing force

What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings?

A) Change position at least once each shift.

B) Implement a turning schedule every 2 hours.

C) Use ring cushions for heels and elbows.

D) Do not turn, use pressure-relieving support surface.

B) Implement a turning schedule every 2 hours.

A nurse assesses an area of pale white skin over a patients coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

A) Immediately report to the physician that the patient has a pressure ulcer.

B) Recognize that this is ischemia, followed by reactive hyperemia.

C) Document the presence of a pressure ulcer and develop a care plan.

D) Implement nursing interventions for Altered Skin Integrity.

B) Recognize that this is ischemia, followed by reactive hyperemia.

A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected?

A) full-thickness skin loss

B) skin pallor

C) blister formation

D) eschar formation

A) full-thickness skin loss

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

A) Document the assessments and intervention.

B) Reinforce the dressing with additional layers.

C) Administer pain medications intramuscularly.

D) Notify the physician and prepare for surgery.

D) Notify the physician and prepare for surgery.

A nurse is assessing wound drainage during the immediate postoperative period for apatient who has had a breast removed. In addition to assessing the dressing, where would the nurse also check for drainage?

A) under the skin

B) under the patient

C) on the output sheet

D) in the axilla

B) under the patient

A nurse assessing a patients wound documents the finding of purulent drainage. What is the composition of this type of drainage?

A) clear, watery blood

B) large numbers of red blood cells

C) mixture of serum and red blood cells

D) white blood cells, debris, bacteria

D) white blood cells, debris, bacteria

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?

A) evisceration

B) infection

C) dehiscence

D) fistula

B) infection

The plan of care for a postoperative patient specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information?

A) Question the physician about the accuracy of this agent.

B) Refuse to use 0.9% normal saline on a wound.

C) Document the rationale for not changing the dressing.

D) Continue with the dressing change as planned.

D) Continue with the dressing change as planned.

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

A) Oh, for gosh sakesit doesnt look that bad!

B) I understand, but you are going to have to look someday.

C) I respect your wish not to look at it right now.

D) You wont be able to go home until you look at it.

C) I respect your wish not to look at it right now.

A nurse is teaching a patient on home care how to apply hot packs to an infected leg ulcer. What statement by the patient indicates the need for further teaching?

A) I understand the rebound effect of heat.

B) I will put the heat packs only on the sore on my leg.

C) I will only leave the heat packs on for 20 minutes.

D) I will leave the heat packs on for an hour.

D) I will leave the heat packs on for an hour.

Of the many topics that may be taught to patients or caregivers about home wound care, which one is the most significant in preventing wound infections?

A) taking medications as prescribed

B) proper intake of food and fluids

C) thorough hand hygiene

D) adequate sleep and rest

C) thorough hand hygiene

Heat applications are often used to promote tissue healing. What is the rationale for this type of treatment?

A) Physiologic effects of heat accelerate the inflammatory response.

B) Local heat increases cardiac output and pulse rate.

C) Heat reduces blood flow to tissues resulting in decreased edema.

D) Heat reduces muscle tension to promote relaxation.

A nurse is applying cold therapy to a patient with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply.

A) constricts peripheral blood vessels

B) reduces muscle spasms

C) increases blood flow to tissues

D) increases the local release of pain-producing substances

E) reduces the formation of edema and inflammation.

F) alters tissue sensitivity (producing numbness)

A) constricts peripheral blood vessels

B) reduces muscle spasms

E) reduces the formation of edema and inflammation.

F) alters tissue sensitivity (producing numbness)

Which of the following considerations should be made when assessing a patient for the application of cold or heat therapy?

A) prolonged exposure decreases tolerance

B) the neck and perineum are less sensitive to thermal change

C) open tissue or abraded skin is less sensitive to thermal changes

D) applications of heat or cold to large areas of the body cause systemic responses

D) applications of heat or cold to large areas of the body cause systemic responses

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a patient?

A) Secure the heating pad to the patients clothing with safety pins.

B) Place a heavy towel or blanket over the heating pad to maximize heat effects.

C) Use a heating pad with a selector switch that can be turned up by the patient if needed.

D) Place a heating pad anteriorly or laterally to, not under, the body part.

D) Place a heating pad anteriorly or laterally to, not under, the body part.