NU 136, GALEN COLLEGE OF NURSING, EXAM 2, UNITS 4-
6, CHAPTERS 22, 28, 39, 29, 30, 38 | NEWEST VERSION
| UPDATED ACTUAL QUESTIONS AND VERIFIED
ANSWERS
• what are the characteristics of arterial ulcers -✓✓ANSWER: -severe pain
-minimal drainage
-decreased temperature
-absent or diminished pulses
-cyanosis
-thickened toenails
-gangrene
• what are the locations for venous ulcers -✓✓ANSWER: -medial lower leg
-ankle
-superior to medial melleolus
-seldom, if ever noted on the foot or above the knee
• what are the characteristics of venous ulcers -✓✓ANSWER: -moderate to large
amount of drainage
-pain levels vary
-ankle flare
-lipodermatosclerosis (hard fibrous of surrounding tissue)
-dialated superficial veins
,• what are the location for neuropathic (Diabetic) ulcers -✓✓ANSWER: -plantar
aspect of foot
-over metatarsal heads
-under heel
• what are the characteristics for neuropathic ulcers -✓✓ANSWER: -low to
moderate drainage
-foot deformities
-deminished or absent sensation in foot
-palpable pulses
-osteomyelitis
-usually painless
• what are the phases of wound healing -✓✓ANSWER: hemostatis
inflammation
proliferation
maturation
• what phase is the hemostasis -✓✓ANSWER: phase 1 -the immediate response
the body initiates to heal (blood clotting)
• what phase is the inflammation -✓✓ANSWER: phase 2 - begins immediately and
last 4-5 days, it is the protective response (heat, pain, edema) wbc &
macrophages migrate to the wound & begin the repair
,• what phase is the proliferation -✓✓ANSWER: phase 3 - reconstructive phase -
begins on 3rd or 4th day and lasts 2-3 weeks
• what phase is the maturation phase -✓✓ANSWER: phase 4 - final
phase/remodeling phase - scar maturation, scar slowly thins and becomes paler -
begins about 3 weeks after injury and can last up to 2 years
• what factors affect wound healing -✓✓ANSWER: -age
-nutrition (protein/fluid needed for healing)
-medications (heparin, steroids, antineoplastics interfere
w/healing
-Infection (slows healing) chronic illness (COPD, DM, CV)
slows wound healing due to lack of oxygen & nutrients at
the cellular level
-lifestyle (regular exercise)
-decreased immune system
-decreased liver function
• what is first intention (Primary) -✓✓ANSWER: little tissue loss - edges of wound
approximate and only a slight chance of infection
• what is second intention -✓✓ANSWER: a wound with tissue loss - edges of
wound do not approximate;wound left open & fills with scar tissue
, • what is third intention (Tertiary) -✓✓ANSWER: occurs when there is delayed
suturing of a wound/wound sutured after granulation tissue begins to form.
(Healing.)
• what are the closed wounds and characteristics -✓✓ANSWER: -contusion
(bruise w/out breaking skin)
-hematoma (pooling of blood under unbroken skin)
-sprain (twisting of a joint)
• what are the open wounds and characteristics -✓✓ANSWER: -incision (surgically
made separation of tissues w/clean
even edges)
-laceration (traumatic separation of tissue)
-abrasion (traumatic scraping)
-penetrating (bullet/metal)
-avulsion (tearing away)
-ulceration (excavation of skin
-perforation (internal organ/cavity)
-crush (tissue disrupted or compressed
• list complications of wound healing -✓✓ANSWER: -hemorrhage (uncontrolled
bleeding)
-dehiscence (spontaneous opening of an incision)
-evisceration (protrusion of an internal organ through an
incision)
-infection (redness, edema, pain, purulent drainage)
6, CHAPTERS 22, 28, 39, 29, 30, 38 | NEWEST VERSION
| UPDATED ACTUAL QUESTIONS AND VERIFIED
ANSWERS
• what are the characteristics of arterial ulcers -✓✓ANSWER: -severe pain
-minimal drainage
-decreased temperature
-absent or diminished pulses
-cyanosis
-thickened toenails
-gangrene
• what are the locations for venous ulcers -✓✓ANSWER: -medial lower leg
-ankle
-superior to medial melleolus
-seldom, if ever noted on the foot or above the knee
• what are the characteristics of venous ulcers -✓✓ANSWER: -moderate to large
amount of drainage
-pain levels vary
-ankle flare
-lipodermatosclerosis (hard fibrous of surrounding tissue)
-dialated superficial veins
,• what are the location for neuropathic (Diabetic) ulcers -✓✓ANSWER: -plantar
aspect of foot
-over metatarsal heads
-under heel
• what are the characteristics for neuropathic ulcers -✓✓ANSWER: -low to
moderate drainage
-foot deformities
-deminished or absent sensation in foot
-palpable pulses
-osteomyelitis
-usually painless
• what are the phases of wound healing -✓✓ANSWER: hemostatis
inflammation
proliferation
maturation
• what phase is the hemostasis -✓✓ANSWER: phase 1 -the immediate response
the body initiates to heal (blood clotting)
• what phase is the inflammation -✓✓ANSWER: phase 2 - begins immediately and
last 4-5 days, it is the protective response (heat, pain, edema) wbc &
macrophages migrate to the wound & begin the repair
,• what phase is the proliferation -✓✓ANSWER: phase 3 - reconstructive phase -
begins on 3rd or 4th day and lasts 2-3 weeks
• what phase is the maturation phase -✓✓ANSWER: phase 4 - final
phase/remodeling phase - scar maturation, scar slowly thins and becomes paler -
begins about 3 weeks after injury and can last up to 2 years
• what factors affect wound healing -✓✓ANSWER: -age
-nutrition (protein/fluid needed for healing)
-medications (heparin, steroids, antineoplastics interfere
w/healing
-Infection (slows healing) chronic illness (COPD, DM, CV)
slows wound healing due to lack of oxygen & nutrients at
the cellular level
-lifestyle (regular exercise)
-decreased immune system
-decreased liver function
• what is first intention (Primary) -✓✓ANSWER: little tissue loss - edges of wound
approximate and only a slight chance of infection
• what is second intention -✓✓ANSWER: a wound with tissue loss - edges of
wound do not approximate;wound left open & fills with scar tissue
, • what is third intention (Tertiary) -✓✓ANSWER: occurs when there is delayed
suturing of a wound/wound sutured after granulation tissue begins to form.
(Healing.)
• what are the closed wounds and characteristics -✓✓ANSWER: -contusion
(bruise w/out breaking skin)
-hematoma (pooling of blood under unbroken skin)
-sprain (twisting of a joint)
• what are the open wounds and characteristics -✓✓ANSWER: -incision (surgically
made separation of tissues w/clean
even edges)
-laceration (traumatic separation of tissue)
-abrasion (traumatic scraping)
-penetrating (bullet/metal)
-avulsion (tearing away)
-ulceration (excavation of skin
-perforation (internal organ/cavity)
-crush (tissue disrupted or compressed
• list complications of wound healing -✓✓ANSWER: -hemorrhage (uncontrolled
bleeding)
-dehiscence (spontaneous opening of an incision)
-evisceration (protrusion of an internal organ through an
incision)
-infection (redness, edema, pain, purulent drainage)
