ACTUAL Questions and CORRECT
Answers
Which cells located in the dermis produce collagen (dermal building blocks) and elastin (tensile
strength)?
Select one:
a. Leukotrienes.
b. Mast cells.
c. Macrophages.
d. Fibroblasts. - CORRECT ANSWER - d. Fibroblasts.
Fibroblasts' main function is to make connective tissue and the extracellular matrix, specifically
the production of collagen (dermal building blocks) and elastin (tensile strength) and fibronectin,
which binds extracellular matrix proteins.
A patient has an acute full-thickness wound due to trauma. What order of healing would occur
with this wound?
Select one:
a. Inflammatory, hemostatis, granulation tissue formation, re-epithelialization.
b. Re-epithelialization, granulation tissue formation, hemostasis, remodeling.
c. Hemostatis, resurfacing, scar formation, remodeling.
d. Hemostatis, inflammation, proliferation or regeneration, maturation or remodeling phases. -
CORRECT ANSWER - d. Hemostatis, inflammation, proliferation or regeneration,
maturation or remodeling phases.
The deeper the tissue layers affected, the greater number of wound healing mechanisms required.
Full thickness wounds will experience all four phases of wound healing: hemostasis,
,inflammation, proliferation where granulation tissue is formed, re-epithelialization, and finally
the maturational or remodeling phase.
Which statement accurately describes the characteristic and implication of necrotic tissue in a
wound bed?
Select one:
a. Necrosis of muscle tissue typically results in the formation of stringy, yellow slough.
b. Consistency refers to the cohesiveness of the debris; typically more advanced necrosis is thin
and wet.
c. Color varies as necrosis worsens, from white/gray nonviable tissue, to yellow slough, and
finally to black eschar.
d. A soft mushy leather eschar is not attached to the base and edges of wound and is sometimes
mistaken as a scab. - CORRECT ANSWER - c. Color varies as necrosis worsens, from
white/gray nonviable tissue, to yellow slough, and finally to black eschar.
The level and type of tissue death influence the clinical appearance of necrotic tissue. Color
varies as necrosis worsens, from white/gray nonviable tissue to yellow slough, and finally to firm
leathery hard black eschar.
You have a patient in acute care who has multiple risk factors for skin breakdown. Which of the
following statements are true regarding frequency of skin assessments?
Select one:
a. A head to toe skin assessments should be done only upon initial admission.
b. Patients at risk for skin break down should have at least a daily skin inspection.
c. Skin inspection should be performed twice an eight-hour shift for those at risk.
d. Skin inspections should only be done daily if the patient has a wound. - CORRECT
ANSWER - b. Patients at risk for skin break down should have at least a daily skin
inspection.
,At least a daily skin inspection is recommended for patients at risk for skin integrity issues.
Frequency of reassessment is dependent upon many variables i.e. care setting, co-morbidities,
immunosuppression, tissue tolerance, continence status, nutrition, mobility etc. thus frequency of
assessment may change over time.
What is the primary reason for taking the time to perform a comprehensive assessment to
identify protein energy malnutrition as opposed to ordering a simple blood draw to formulate a
diagnosis?
Select one:
a. Blood tests do not provide a 'stand-alone' assessment.
b. None, blood test for malnutrition are completely reliable.
c. There are no blood tests available.
d. There is a high incidence of false-positive results with blood tests. - CORRECT
ANSWER - a. Blood tests do not provide a 'stand-alone' assessment.
It is critical to realize that there is no laboratory test that can provide a "stand-alone" assessment
of an individual's nutritional status.
You are performing a wound assessment on a patient with a plantar foot ulceration. Wound
assessment reveals a full thickness ulcer, with scant amount of serosanguinous drainage. You
note that the wound base is pale pink and there is a tunnel at 3 o'clock. The wound measurements
are unchanged in the last 2 week's wound assessments. The patient denies pain with palpation but
you note mild periwound erythema. What would be your BEST response in the developing the
plan of care for this patient?
Select one:
a. Apply an antimicrobial hydrofiber rope into the tunnel.
b. Apply topical antibiotic ointment with a gauze strip wicked into the tunnel.
c. Apply a silver hydrogel impregnated gauze strip wicked into the tunnel.
d. Call primary care provider for oral antibiotics. - CORRECT ANSWER - c. Apply a
silver hydrogel impregnated gauze strip wicked into the tunnel.
, Goal for this ulcer is to maintain the moist wound environment and add a topical antimicrobial
agent. No progress in this wound in the last 2 weeks plus mild periwound erythema may be a
sign of critical colonization; minimal drainage thus a silver hydrogel to donate moisture to
wound with a wick to accommodate the tunnel is the BEST topical therapy as the primary
dressing.
Which of the following wounds will heal with scar formation?
Select one:
a. Full thickness wound.
b. Partial thickness wound.
c. Classification 2 skin tear.
d. Stage II pressure ulcer. - CORRECT ANSWER - a. Full thickness wound.
Scar tissue formation only occurs when there is full thickness skin loss (remember full thickness
is damage through the epidermis and dermis and into the subcutaneous or lower
layers/structures). Class 2 skin tears and stage 2 pressure ulcers are partial thickness.
When the skin around a wound develops a whitish appearance, it can be described as:
Select one:
a. Desiccated.
b. Excoriated.
c. Indurated.
d. Macerated. - CORRECT ANSWER - d. Macerated.
As you setup a skin care program, you identify the elderly to be at risk for skin tears due to the
effects of aging on: