2
NUR 204 exam 3 with verified detailed solutions || || || || || || ||
on initial assessment of a patient the nurse notices an area of redness over the right
|| || || || || || || || || || || || || || || ||
trochanter that when pressed lightly does not blanch. what does this assessment cue
|| || || || || || || || || || || || ||
indicate to the nurse? || || ||
the presence of a stage 1 pressure injury
|| || || || || || ||
Four days after abdominal surgery, the patient is getting out of bed and feels something
|| || || || || || || || || || || || || || ||
"pop" in his abdominal wound. An increase in amount of drainage from the wound is seen,
|| || || || || || || || || || || || || || || ||
and further examination shows that the sutured incision is now partially open, with tissue
|| || || || || || || || || || || || || ||
protruding from the wound. What is the nurse's next action? || || || || || || || || ||
cover the wound with saline moistened gauze
|| || || || || ||
Which features are characteristic of a closed drainage system such as a Jackson-Pratt (JP)
|| || || || || || || || || || || || || ||
drain? (Select all that apply.) || || || ||
- usually is inserted in surgery
|| || || || ||
- allows for accurate measurement of wound drainage
|| || || || || || ||
Based on knowledge of areas at greatest risk for development of a pressure ulcer in the
|| || || || || || || || || || || || || || || ||
bedridden patient, the nurse identifies which position to minimize this risk?
|| || || || || || || || || ||
30 degree side lying
|| || ||
,2
A patient who has suffered a stroke is unable to maintain his position while seated in a
|| || || || || || || || || || || || || || || || ||
chair without sliding down. His physician has ordered him to be up in a chair for part of the
|| || || || || || || || || || || || || || || || || ||
day. What does the nurse recognize as the patient's greatest risk factor for development of
|| || || || || || || || || || || || || || || ||
pressure ulcers? ||
pressure and shear || ||
A patient has a stage III pressure ulcer on the coccyx. Which food will be most beneficial in
|| || || || || || || || || || || || || || || || || ||
improving the healing process? || || ||
high calorie high protein drink
|| || || ||
Which technique is used to collect an aerobic culture specimen from a wound?
|| || || || || || || || || || || ||
irrigate the wound before collecting the culture material
|| || || || || || ||
which patient is at highest risk for impaired wound healing
|| || || || || || || || ||
a 72 year old with diabetes and cardiovascular disease who has surgical repair of a broken
|| || || || || || || || || || || || || || || ||
hip
which best describes a fresh surgical wound that has been closed with sutures or staples
|| || || || || || || || || || || || || || ||
making the two edges of the wound meet || || || || || || ||
approximated
cognition
,2
knowing influenced by awareness and judgement it comprises skills that include language
|| || || || || || || || || || || ||
calculation memory and attention || || ||
sensation
is a feeling within or outside the body of conditions resulting from stimulation of sensory
|| || || || || || || || || || || || || || ||
receptors
stimulus
a change in the environment sufficient to evoke a responce
|| || || || || || || || ||
perception
the way the brain perceives the information
|| || || || || ||
decussate
The cross-over of sensory pathways as they ascend the spinal cord before reaching the brain
|| || || || || || || || || || || || || ||
stratum corneum ||
outermost layer of the epidermis, which consists of flattened, keratinized cells
|| || || || || || || || || ||
stratum germinativum ||
, 2
innermost layer or basal layer only single layer of cells
|| || || || || || || || ||
rete ridges
||
papillary dermis ||
irregular interconnected projections that extend from the dermis and link with the
|| || || || || || || || || || || ||
epidermis
subcutaneous layer ||
layer of adipose tissue or fat
|| || || || ||
wounds
disruptions that may occur in the skin's integrity, leading to a loss of the skin's normal
|| || || || || || || || || || || || || || || ||
functioning
factors that lead to the development of wounds and decay in wounds are
|| || || || || || || || || || || ||
-vascular disease ||
- diabetes
||
-malnutrition
-medication
tactile receptors
||
NUR 204 exam 3 with verified detailed solutions || || || || || || ||
on initial assessment of a patient the nurse notices an area of redness over the right
|| || || || || || || || || || || || || || || ||
trochanter that when pressed lightly does not blanch. what does this assessment cue
|| || || || || || || || || || || || ||
indicate to the nurse? || || ||
the presence of a stage 1 pressure injury
|| || || || || || ||
Four days after abdominal surgery, the patient is getting out of bed and feels something
|| || || || || || || || || || || || || || ||
"pop" in his abdominal wound. An increase in amount of drainage from the wound is seen,
|| || || || || || || || || || || || || || || ||
and further examination shows that the sutured incision is now partially open, with tissue
|| || || || || || || || || || || || || ||
protruding from the wound. What is the nurse's next action? || || || || || || || || ||
cover the wound with saline moistened gauze
|| || || || || ||
Which features are characteristic of a closed drainage system such as a Jackson-Pratt (JP)
|| || || || || || || || || || || || || ||
drain? (Select all that apply.) || || || ||
- usually is inserted in surgery
|| || || || ||
- allows for accurate measurement of wound drainage
|| || || || || || ||
Based on knowledge of areas at greatest risk for development of a pressure ulcer in the
|| || || || || || || || || || || || || || || ||
bedridden patient, the nurse identifies which position to minimize this risk?
|| || || || || || || || || ||
30 degree side lying
|| || ||
,2
A patient who has suffered a stroke is unable to maintain his position while seated in a
|| || || || || || || || || || || || || || || || ||
chair without sliding down. His physician has ordered him to be up in a chair for part of the
|| || || || || || || || || || || || || || || || || ||
day. What does the nurse recognize as the patient's greatest risk factor for development of
|| || || || || || || || || || || || || || || ||
pressure ulcers? ||
pressure and shear || ||
A patient has a stage III pressure ulcer on the coccyx. Which food will be most beneficial in
|| || || || || || || || || || || || || || || || || ||
improving the healing process? || || ||
high calorie high protein drink
|| || || ||
Which technique is used to collect an aerobic culture specimen from a wound?
|| || || || || || || || || || || ||
irrigate the wound before collecting the culture material
|| || || || || || ||
which patient is at highest risk for impaired wound healing
|| || || || || || || || ||
a 72 year old with diabetes and cardiovascular disease who has surgical repair of a broken
|| || || || || || || || || || || || || || || ||
hip
which best describes a fresh surgical wound that has been closed with sutures or staples
|| || || || || || || || || || || || || || ||
making the two edges of the wound meet || || || || || || ||
approximated
cognition
,2
knowing influenced by awareness and judgement it comprises skills that include language
|| || || || || || || || || || || ||
calculation memory and attention || || ||
sensation
is a feeling within or outside the body of conditions resulting from stimulation of sensory
|| || || || || || || || || || || || || || ||
receptors
stimulus
a change in the environment sufficient to evoke a responce
|| || || || || || || || ||
perception
the way the brain perceives the information
|| || || || || ||
decussate
The cross-over of sensory pathways as they ascend the spinal cord before reaching the brain
|| || || || || || || || || || || || || ||
stratum corneum ||
outermost layer of the epidermis, which consists of flattened, keratinized cells
|| || || || || || || || || ||
stratum germinativum ||
, 2
innermost layer or basal layer only single layer of cells
|| || || || || || || || ||
rete ridges
||
papillary dermis ||
irregular interconnected projections that extend from the dermis and link with the
|| || || || || || || || || || || ||
epidermis
subcutaneous layer ||
layer of adipose tissue or fat
|| || || || ||
wounds
disruptions that may occur in the skin's integrity, leading to a loss of the skin's normal
|| || || || || || || || || || || || || || || ||
functioning
factors that lead to the development of wounds and decay in wounds are
|| || || || || || || || || || || ||
-vascular disease ||
- diabetes
||
-malnutrition
-medication
tactile receptors
||
