A Review of Real Past Papers Exams |
All 396 Questions With Correct Accurate
Answers With Rationales (New!)
1. Individual risk factors associated with impaired tissue integrity? -
ANSWER-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)
2. What are the three phases of wound healing? - ANSWER-inflammatory
phase
Proliferative phase
Maturation phase
3. What's the inflammatory phase of wound healing? - ANSWER-initiated
immediately after injury and lasts 3-6 days
Hemostasis develops; macrophages remove debris
Wound appears reddened and edematous
4. What's the proliferative phase of wound healing? - ANSWER-lasts from day
3-4 to 21 days
New blood vessels and tissue are formed
Wound contains granulation tissue
Beefy red and bleeds easily
5. What's the maturation phase of wound healing? - ANSWER-lasts from 21
days to months (can extend to 1-2 years)
Collagen fiber is remodeled
Scar formation and contraction occur
6. What are the types of wound healing? - ANSWER-primary intention
Secondary intention
Tertiary intention
,7. What's the primary intention of wound healing? - ANSWER-wound margins
are well approximated (closed)
Most rapid healing due to minimal or no tissue loss
8. Ex) lacerations, surgical incisions
9. What's the secondary intention of wound healing? - ANSWER-wound
margins are not well approximated and involved considerable tissue loss
Larger wound area requires formation of granulation tissue to fill in the gap
Repair time is longer
Scarring is created
Infection risk is greater
Ex) pressure ulcers
10.What's tertiary intention of wound healing? - ANSWER-wound healing is
delayed and occurs when the wound that has previously open is now closed
Process usually associated with large infected and contaminated wounds
Ex) infections
11.During tissue assessment, what should be assessed with health history? -
ANSWER-past and current conditions
Family hx
Allergies
Current and recent meds
Hx of skin diseases
Changes in skin condition/color
New rashes/lesions
Excessive bruising
Loss of hair or excessive hair growth
Wounds slow to heal
12.What should be inspected with tissue? - ANSWER-color and condition of
skin
Lesions
Skinfolds
Areas of frequent moisture (perineum)
Areas of pressure (body prominences)
Condition of skin under medical or assistive devices
,13.What should be palpated with tissue assessment? - ANSWER-skin
temperature, texture
Pinch skin for turgor
Check edema
14.What are the 5 steps to the nursing process? - ANSWER-assessment
Diagnoses
Planning
Implementation
Evaluation
15.What's the assessment phase? - ANSWER-gathering information about pt's
psychological, physiological, sociological, and spiritual status;
Gathered in pt interview; physical exams, hx, etc.
16.What's the diagnosing phase? - ANSWER-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
17.What's the planning phase? - ANSWER-patient and nurse agree on
diagnoses and plan of action can be developed; assigned clear, measurable
goal for expected beneficial outcome
Usually use evidence-based nursing outcome classification
18.What's the evidence-based nursing outcome classification? - ANSWER-set
of standardized terms and measurements for tracking patient wellness; may
be used as a resource for planning
19.What's the implementing phase? - ANSWER-nurse follows through on
decided plan of action' specific to each patient and focuses on achievable
outcomes; can take place over hours, days, weeks, or months
20.What's the evaluation phase? - ANSWER-nurse determines if all goals for
patient wellness have been met; patient's condition improved, patient's
condition stablished, and patient's condition deteriorated, died, or
discharged...
21.What are the functions of the skin? - ANSWER-protection
Temperature regulation
Sensation
, Vitamin d production
Immunologic
Absorption
Elimination
22.What's the epidermis? - ANSWER-top layer of skin
Helps with h20 production
23.What's the dermis? - ANSWER-second layer of skin
Nerves, hair follicles, etc.
24.What's the subcutaneous tissue? - ANSWER-third layer of skin, below
dermis Helps with padding, warmth, etc.
25.Lifespan considerations for infants (tissue) - ANSWER-thinner skin with
less subcutaneous fat
Milia on face
Risk for dehydration
26.Lifespan considerations for children (tissue) - ANSWER-thinner skin
Larger body surface area than adults
27.Lifespan considerations for adolescents (tissue) - ANSWER-increase in
sweat and sebaceous glands
Higher incidence of warts and fungal infections
Acne, hygiene, etc.
28.Lifespan considerations for adults (tissue) - ANSWER-skin thickens to 40-
50s
29.Lifespan considerations for pregnant women (tissue) - ANSWER-hyper
pigmentation
Striae (stretch marks)
Pruritus (itching)
30.Lifespan considerations for elderly (tissue) - ANSWER-decreased skin
thickness
Decreased collagen content (decrease elasticity)
Increase wrinkles, sagging skin
Decreased subcutaneous tissue