Chapter 46: Skin Integrity and Wound Care Potter et al: Canadian Fundamentals of Nursing, 6th Edition (Correctly solved questions)

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure injuries. The nurse recognizes that the risk factors that predispose a patient to pressure injury development include which of the following? a. A diet low in calories and fat. b. Alteration in level of consciousness. c. Shortness of breath. d. Muscular pain. correct answers Alteration in level of consciousness. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. What is the major element involved in the development of a pressure injury? correct answers Pressure Which nursing observation would indicate that the patient was at risk for pressure injury formation? correct answers The patient has fecal incontinence. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage 3 pressure injury. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this pressure injury? correct answers Healing stage 3 pressure injury The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open pressure injury without slough on the right heel of the patient. How would this pressure injury be staged? correct answers Stage 2. 6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging a pressure injury on this patient? correct answers Halogen light. 7. The nurse is caring for a patient with a stage 4 pressure injury. The nurse recalls that a pressure injury takes time to heal and that the healing process is an example of which of the following? correct answers Full-thickness wound repair. 8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in how long? correct answers 4 days. 9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? correct answers Granulation. 10. The nurse is caring for a patient who has undergone a laparoscopic appendectomy. The nurse recalls that this type of wound heals by which process? correct answers Primary intention.