NSG 100 Final Exam V2
1. what's noted with dehiscence?: wound opening unintentionallyoften seen with c-section
patients
2. what's seen in evisceration?: when wound contents burst out of site
3. serous exudate: Clear or straw colored Occurs as a normal part of the healing process
4. purulent exudate: thick, milky appearance, green or yellow coloredmay be a sign of
infection
5. sanguineous exudate: bloody drainage
6. serosanguineous exudate: mixture of light pink to blood tinged, can appearyellow or
orange with a pink ting
7. partial-thickness wound?: shallow in depthmoist and painful
base appears red
loss of epidermis and dermis
8. full-thickness wound?: involves dermis, epidermis, and subcutaneous tissue;may involve
muscle and bone
requires connective tissue repairusually deep wound
usually see yellow and red in the wound
9. partial-thickness wound repar?: inflammatory responseepithelial proliferation and
migration
reestablishment of epidermal layersred and swollen
10. full-thickness wound repair?: homeostasisinflammatory
proliferative maturation (scarring)
beefy red, granulation tissue
11. T/F Moisture helps the healing process?: true
12. factors influencing pressure injury formation and wound healing?: nutritiontissue perfusion
infectionage
psychosocial impact of wounds
13. eschar?: black/brown discoloration
14. slough?: stringy, sticks to wound
15. necrosis?: tissue death
,16. who are at greatest risk for impaired tissue integrity?: infantschildren
elderly
17. individual risk factors associated with impaired tissue integrity?: health conditions (poor
peripheral perfusion, malnutrition or obesity, dehydration or edema,impaired mobility,
immunosuppression)
exposure to irritants (radiation, temp extremes, chemical or mechanical trauma)tissue trauma
(friction, shearing, moisture, pressure)
18. what are the three phases of wound healing?: inflammatory phaseproliferative phase
maturation phase
19. what's the inflammatory phase of wound healing?: initiated immediatelyafter injury and
lasts 3-6 days
hemostasis develops; macrophages remove debriswound appears reddened and edematous
20. what's the proliferative phase of wound healing?: lasts from day 3-4 to 21days
new blood vessels and tissue are formedwound contains granulation tissue
beefy red and bleeds easily
21. what's the maturation phase of wound healing?: lasts from 21 days tomonths (can extend
to 1-2 years)
collagen fiber is remodeled
scar formation and contraction occur
22. what are the types of wound healing?: primary intentionsecondary intention
tertiary intention
23. what's the primary intention of wound healing?: wound margins are wellapproximated
(closed)
most rapid healing due to minimal or no tissue loss
ex) lacerations, surgical incisions
24. what's the secondary intention of wound healing?: wound margins are notwell
approximated and involved considerable tissue loss
larger wound area requires formation of granulation tissue to fill in the gaprepair time is
longer
scarring is created
, infection risk is greater
ex) pressure ulcers
25. what's tertiary intention of wound healing?: wound healing is delayed andoccurs when the
wound that has previously open is now closed
process usually associated with large infected and contaminated wounds
ex) infections
26. during tissue assessment, what should be assessed with health history?-
: past and current conditionsfamily hx
allergies
current and recent medshx of skin diseases
changes in skin condition/colornew rashes/lesions
excessive bruising
loss of hair or excessive hair growthwounds slow to heal
27. what should be inspected with tissue?: color and condition of skinlesions
skinfolds
areas of frequent moisture (perineum)areas of pressure (body prominences)
condition of skin under medical or assistive devices
28. what should be palpated with tissue assessment?: skin temperature, texturepinch skin for
turgor
check edema
29. what is blanchable?: Pressing the cappilaries to check and see if they go fromwhite back to
red
30. what are the 5 steps to the nursing process?: assessmentdiagnoses
planning implementation evaluation
31. what's the assessment phase?: gathering information about pt's psychological,
physiological, sociological, and spiritual status;
gathered in pt interview; physical exams, hx, etc.
32. what's the diagnosing phase?: nurse makes an educated judgement about potential or
actual health problem; include actual description and whether or not patient is at risk for
further issues
1. what's noted with dehiscence?: wound opening unintentionallyoften seen with c-section
patients
2. what's seen in evisceration?: when wound contents burst out of site
3. serous exudate: Clear or straw colored Occurs as a normal part of the healing process
4. purulent exudate: thick, milky appearance, green or yellow coloredmay be a sign of
infection
5. sanguineous exudate: bloody drainage
6. serosanguineous exudate: mixture of light pink to blood tinged, can appearyellow or
orange with a pink ting
7. partial-thickness wound?: shallow in depthmoist and painful
base appears red
loss of epidermis and dermis
8. full-thickness wound?: involves dermis, epidermis, and subcutaneous tissue;may involve
muscle and bone
requires connective tissue repairusually deep wound
usually see yellow and red in the wound
9. partial-thickness wound repar?: inflammatory responseepithelial proliferation and
migration
reestablishment of epidermal layersred and swollen
10. full-thickness wound repair?: homeostasisinflammatory
proliferative maturation (scarring)
beefy red, granulation tissue
11. T/F Moisture helps the healing process?: true
12. factors influencing pressure injury formation and wound healing?: nutritiontissue perfusion
infectionage
psychosocial impact of wounds
13. eschar?: black/brown discoloration
14. slough?: stringy, sticks to wound
15. necrosis?: tissue death
,16. who are at greatest risk for impaired tissue integrity?: infantschildren
elderly
17. individual risk factors associated with impaired tissue integrity?: health conditions (poor
peripheral perfusion, malnutrition or obesity, dehydration or edema,impaired mobility,
immunosuppression)
exposure to irritants (radiation, temp extremes, chemical or mechanical trauma)tissue trauma
(friction, shearing, moisture, pressure)
18. what are the three phases of wound healing?: inflammatory phaseproliferative phase
maturation phase
19. what's the inflammatory phase of wound healing?: initiated immediatelyafter injury and
lasts 3-6 days
hemostasis develops; macrophages remove debriswound appears reddened and edematous
20. what's the proliferative phase of wound healing?: lasts from day 3-4 to 21days
new blood vessels and tissue are formedwound contains granulation tissue
beefy red and bleeds easily
21. what's the maturation phase of wound healing?: lasts from 21 days tomonths (can extend
to 1-2 years)
collagen fiber is remodeled
scar formation and contraction occur
22. what are the types of wound healing?: primary intentionsecondary intention
tertiary intention
23. what's the primary intention of wound healing?: wound margins are wellapproximated
(closed)
most rapid healing due to minimal or no tissue loss
ex) lacerations, surgical incisions
24. what's the secondary intention of wound healing?: wound margins are notwell
approximated and involved considerable tissue loss
larger wound area requires formation of granulation tissue to fill in the gaprepair time is
longer
scarring is created
, infection risk is greater
ex) pressure ulcers
25. what's tertiary intention of wound healing?: wound healing is delayed andoccurs when the
wound that has previously open is now closed
process usually associated with large infected and contaminated wounds
ex) infections
26. during tissue assessment, what should be assessed with health history?-
: past and current conditionsfamily hx
allergies
current and recent medshx of skin diseases
changes in skin condition/colornew rashes/lesions
excessive bruising
loss of hair or excessive hair growthwounds slow to heal
27. what should be inspected with tissue?: color and condition of skinlesions
skinfolds
areas of frequent moisture (perineum)areas of pressure (body prominences)
condition of skin under medical or assistive devices
28. what should be palpated with tissue assessment?: skin temperature, texturepinch skin for
turgor
check edema
29. what is blanchable?: Pressing the cappilaries to check and see if they go fromwhite back to
red
30. what are the 5 steps to the nursing process?: assessmentdiagnoses
planning implementation evaluation
31. what's the assessment phase?: gathering information about pt's psychological,
physiological, sociological, and spiritual status;
gathered in pt interview; physical exams, hx, etc.
32. what's the diagnosing phase?: nurse makes an educated judgement about potential or
actual health problem; include actual description and whether or not patient is at risk for
further issues
