C HAPTER 48: S KIN I NTEGRITY AND
W OUND C ARE
Fundamentals of Nursing 10th Edition; Pot ter Perry
MULTIPLE CHOICE
1. The nurse uses the Norton scale in the extended care facilit y to determine
the clients risk for pressure ulcer development. Which one of the
following scores, based on this scale, places the clie nt at the highest level
of risk?
A. 6
B. 8
C. 15
D. 19
ANS: A
According to the Norton scale, a lower score indicates a higher risk for
pressure ulcer development. The total score ranges from 5 to 20. The
client at highest risk would be the client with a score of 6.
DIF: A REF: 1288 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Potential for Risk Reduction/Potential for Alterations in Body
Systems
,2. The client requires support, and an abdominal binder is ordered. The nurse
correctl y implements the use of a binder by:
A. Using it as a replacement for underl ying dressings
B. Keeping it loose for client comfort
C. Having the client sit or stand when it is applied
D. Making sure the client has adequate ventilatory capacit y
ANS: D
After appl ying the binder, the nurse should assess the clients abilit y to
ventilate properl y, including deep breathing and coughing. Wounds
should be entirel y covered with dressings; the binder is applied over
the dressing. The binder should not be loose, or it will be i neffective in
providing support. The client should be lying supine with head slightl y
elevated and knees slightl y flexed for application of the abdominal
binder.
DIF: A REF: 1328-1329 OBJ: Comprehension TOP: Nursing
Process: Implementation MSC: NC LEX test plan
designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
3. The client is brought into the emergency department with a knife wound.
The nurse correctl y documents the clients wound as a(n):
A. Contusion wound
B. Clean wound
C. Acute wound
D. Intentional wound
ANS: C
, A client with a knife wound is an example of an acute wound. An acute
wound is caused by trauma from a sharp object. A contusion is a closed
wound caused by a blow to the body by a blunt object, resulting in a
bruise. A clean wound is a wound that contains no pathogenic
organisms, such as a closed surgical wound that does not enter the
gastrointestinal, respiratory, or genitourinary system. An intentional
wound is a wound resulting from therapy, such as a surgical incision.
DIF: A REF: 1294 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Potential for Risk Reduction/Potential for Alterations in Body
Systems
4. The nurse is planning a program on wound healing and includes
information that smok ing influences healing by:
A. Suppressing protein synthesis
B. Creating increased tissue fragilit y
C. Depressing bone marrow function
D. Reducing functional hemoglobin in the blood
ANS: D
Smoking reduces the amount of functional hemoglobin in the blood,
thus decreasing tissue ox ygenation. Antiinflammatory drugs suppress
protein synthesis. Radiation creates tissue fragilit y. Chemotherapeutic
drugs can depress bone marrow function.
W OUND C ARE
Fundamentals of Nursing 10th Edition; Pot ter Perry
MULTIPLE CHOICE
1. The nurse uses the Norton scale in the extended care facilit y to determine
the clients risk for pressure ulcer development. Which one of the
following scores, based on this scale, places the clie nt at the highest level
of risk?
A. 6
B. 8
C. 15
D. 19
ANS: A
According to the Norton scale, a lower score indicates a higher risk for
pressure ulcer development. The total score ranges from 5 to 20. The
client at highest risk would be the client with a score of 6.
DIF: A REF: 1288 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Potential for Risk Reduction/Potential for Alterations in Body
Systems
,2. The client requires support, and an abdominal binder is ordered. The nurse
correctl y implements the use of a binder by:
A. Using it as a replacement for underl ying dressings
B. Keeping it loose for client comfort
C. Having the client sit or stand when it is applied
D. Making sure the client has adequate ventilatory capacit y
ANS: D
After appl ying the binder, the nurse should assess the clients abilit y to
ventilate properl y, including deep breathing and coughing. Wounds
should be entirel y covered with dressings; the binder is applied over
the dressing. The binder should not be loose, or it will be i neffective in
providing support. The client should be lying supine with head slightl y
elevated and knees slightl y flexed for application of the abdominal
binder.
DIF: A REF: 1328-1329 OBJ: Comprehension TOP: Nursing
Process: Implementation MSC: NC LEX test plan
designation: Potential for Risk Reduction/Potential for
Alterations in Body Systems
3. The client is brought into the emergency department with a knife wound.
The nurse correctl y documents the clients wound as a(n):
A. Contusion wound
B. Clean wound
C. Acute wound
D. Intentional wound
ANS: C
, A client with a knife wound is an example of an acute wound. An acute
wound is caused by trauma from a sharp object. A contusion is a closed
wound caused by a blow to the body by a blunt object, resulting in a
bruise. A clean wound is a wound that contains no pathogenic
organisms, such as a closed surgical wound that does not enter the
gastrointestinal, respiratory, or genitourinary system. An intentional
wound is a wound resulting from therapy, such as a surgical incision.
DIF: A REF: 1294 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Potential for Risk Reduction/Potential for Alterations in Body
Systems
4. The nurse is planning a program on wound healing and includes
information that smok ing influences healing by:
A. Suppressing protein synthesis
B. Creating increased tissue fragilit y
C. Depressing bone marrow function
D. Reducing functional hemoglobin in the blood
ANS: D
Smoking reduces the amount of functional hemoglobin in the blood,
thus decreasing tissue ox ygenation. Antiinflammatory drugs suppress
protein synthesis. Radiation creates tissue fragilit y. Chemotherapeutic
drugs can depress bone marrow function.
