NUR 2206 midterm Questions and All
Correct Answers.
intentional wound - Answer planned incision
unintentional wound - Answer fall and scrape knee, etc
open wound - Answer skin surface is broken
closed wound - Answer skin surface intact
acute wound - Answer heals quickly, edges approximated, low risk of infection
chronic wound - Answer do not heal as expected, remain in inflammatory phase
--> could be due to arterial or venous inssufficiency
phases of wound healing - Answer 1. hemostasis
2. inflammatory phase
3. proliferation phase
4. materation phase
inflammatory phase - Answer 4-6 days; phagocytosis and WBC, generalized body response to
hemostasis, growth factor released
-acute inflammation (pain, heat, redness, swelling)
proliferation phase - Answer lasts several weeks;
granulation tissue develops to fill in wounds; fibroblastic, regenerative, connective tissue
-new blood cell formation
-oxygen and nutrients needed to heal
maturation phase - Answer begins ~ day 21;
can last months of years; *collagen* remodeled;
blood vessels compressed
-scar
,types of wound healing - Answer primary, secondary, tertiary intention
primary intention - Answer wound edges well approximated
secondary intention - Answer wound edge not well approximated; heals by granulation
tissue formation
tertiary intention - Answer delayed primary intention
desiccation - Answer drying up of wound; cells die and rust over wound site
maceration - Answer overhydration of cells due to moisture somewhere on skin;
--> leads to softening and breakdown of skin
dehiscence - Answer partial or total separation of wound layers due to excessive stress on
wounds that are not healed;
sutures holding wound together pop
--> pts. with a lot of fat, diabetic, or elderly
--> cannot be closed the same way due to bacteria
evisceration - Answer complete separation of wound with protrusion of viscera through
incision (intestines/organs coming out that happens 2-7 days after surgery)
fistula - Answer abnormal passage from internal organ to outside the body or from one
internal organ to another
--> skin doesnt heal well or suture slips
--> caused by abscess
granulation tissue - Answer During a dressing change, inspection of the wound reveals what
appears to be reddish-pink tissue in the wound. The nurse interprets this as most likely
indicating
area of maceration - Answer A patient has a wound caused by exposure to moisture. This
wound is considered to be
friction - Answer damaging superficial blood vessels when 2 surfaces rub together (elbows
when patients try to lift themselves in bed)
, ischemia - Answer paleness in area where pressure was applied; deficiency of blood in a
particular area
reactive hyperemia - Answer blanchable reddening of the skin when pressure is removed
stage 1 pressure ulcer - Answer area of intact skin with nonblanchable redness of localized
area usually over bony prominence;
may be painful, firm/soft, warm/cool
stage 2 pressure ulcer - Answer skin loss involving epidermis/dermis (partial-thickness), may
present as blister;
shallow, open ulcer
stage 3 pressure ulcer - Answer full thickness skin loss; subcutaneous fat may be visible, but
bone,tendon,muscle are NOT;
slough doesn't obscure depth of tissue
-may have undermining and tunneling
stage 4 pressure ulcer - Answer bone, tendon, muscle visible (full-thickness tissue loss)
unstageable pressure ulcer - Answer full thickness skin loss, base of ulcer covered by slough
or eschar
purpose of wound dressings - Answer Control infection
Absorb drainage
Maintain moist wound environment
Protect wound from injury
Protect peri-wound skin
Remove necrotic tissue
penrose drain - Answer -open drainage system
-soft flexible tube
-passive drainage into absorptive dressing
JP (jackson-pratt) drain - Answer closed drainage system
Correct Answers.
intentional wound - Answer planned incision
unintentional wound - Answer fall and scrape knee, etc
open wound - Answer skin surface is broken
closed wound - Answer skin surface intact
acute wound - Answer heals quickly, edges approximated, low risk of infection
chronic wound - Answer do not heal as expected, remain in inflammatory phase
--> could be due to arterial or venous inssufficiency
phases of wound healing - Answer 1. hemostasis
2. inflammatory phase
3. proliferation phase
4. materation phase
inflammatory phase - Answer 4-6 days; phagocytosis and WBC, generalized body response to
hemostasis, growth factor released
-acute inflammation (pain, heat, redness, swelling)
proliferation phase - Answer lasts several weeks;
granulation tissue develops to fill in wounds; fibroblastic, regenerative, connective tissue
-new blood cell formation
-oxygen and nutrients needed to heal
maturation phase - Answer begins ~ day 21;
can last months of years; *collagen* remodeled;
blood vessels compressed
-scar
,types of wound healing - Answer primary, secondary, tertiary intention
primary intention - Answer wound edges well approximated
secondary intention - Answer wound edge not well approximated; heals by granulation
tissue formation
tertiary intention - Answer delayed primary intention
desiccation - Answer drying up of wound; cells die and rust over wound site
maceration - Answer overhydration of cells due to moisture somewhere on skin;
--> leads to softening and breakdown of skin
dehiscence - Answer partial or total separation of wound layers due to excessive stress on
wounds that are not healed;
sutures holding wound together pop
--> pts. with a lot of fat, diabetic, or elderly
--> cannot be closed the same way due to bacteria
evisceration - Answer complete separation of wound with protrusion of viscera through
incision (intestines/organs coming out that happens 2-7 days after surgery)
fistula - Answer abnormal passage from internal organ to outside the body or from one
internal organ to another
--> skin doesnt heal well or suture slips
--> caused by abscess
granulation tissue - Answer During a dressing change, inspection of the wound reveals what
appears to be reddish-pink tissue in the wound. The nurse interprets this as most likely
indicating
area of maceration - Answer A patient has a wound caused by exposure to moisture. This
wound is considered to be
friction - Answer damaging superficial blood vessels when 2 surfaces rub together (elbows
when patients try to lift themselves in bed)
, ischemia - Answer paleness in area where pressure was applied; deficiency of blood in a
particular area
reactive hyperemia - Answer blanchable reddening of the skin when pressure is removed
stage 1 pressure ulcer - Answer area of intact skin with nonblanchable redness of localized
area usually over bony prominence;
may be painful, firm/soft, warm/cool
stage 2 pressure ulcer - Answer skin loss involving epidermis/dermis (partial-thickness), may
present as blister;
shallow, open ulcer
stage 3 pressure ulcer - Answer full thickness skin loss; subcutaneous fat may be visible, but
bone,tendon,muscle are NOT;
slough doesn't obscure depth of tissue
-may have undermining and tunneling
stage 4 pressure ulcer - Answer bone, tendon, muscle visible (full-thickness tissue loss)
unstageable pressure ulcer - Answer full thickness skin loss, base of ulcer covered by slough
or eschar
purpose of wound dressings - Answer Control infection
Absorb drainage
Maintain moist wound environment
Protect wound from injury
Protect peri-wound skin
Remove necrotic tissue
penrose drain - Answer -open drainage system
-soft flexible tube
-passive drainage into absorptive dressing
JP (jackson-pratt) drain - Answer closed drainage system
