Chapter 48: Skin Integrity and Wound Care
ra ra ra ra ra ra ra
MULTIPLE CHOICE ra
1. A nursing attendant participating in a research project associated with pressure ulcers wil
ra ra ra ra ra ra ra ra ra ra ra ra
l assess for what predisposing factor that tends to increase the risk for pressure ulcer dev
ar ra ra ra ra ra ra ra ra ra ra ra ra ra ra
elopment?
a. Decreased level of consciousness ra ra ra
b. Adequate dietary intake ra ra
c. Shortness of breath ra ra
d. Muscular pain ra
ACCURATE ra
ANSWER:-A
Hospital client s who are confused or disoriented or who have changing levels of conscious
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ness are unable to protect themselves. The hospital client may feel the pressure but may not
ra ra ra ra ra ra ra ra r a ra ra ra ar ra ra r
understand what to do to relieve the discomfort or to communicate that he or she is feeling
a ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra ra ra
discomfort.
Impaired sensory perception, impaired mobility, shear, friction, and moisture are other pred
ra ra ra ra ra ra ra ra ra ra ra
isposing factors. Shortness of breath, muscular pain, and an adequate dietary intake are not in
ra ra ra ra ra ra ra ra ra ra ra ra ar ra
cluded among the predisposing factors. ra ra ra ra
DIF:Apply (application) ra
OBJ:Examine risk factors that contribute to pressure ulcer formation. ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Reduction of Risk Potential ra ra ra ra
2. The nursing attendant caring for an unconscious hospital client who was involved in an a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
utomobile accident 2 weeks ago will give priority to which element when planning care
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
t o decrease the development of a decubitus ulcer? a. Resistance
ra ra ra ra ra ra ra
b. Pressure
c. Weight
d. Stress
ACCURATE ar
ANSWER:-B
Pressure is the main element that causes pressure ulcers. Three pressurerelated factors contribut
ra ra ra ra ra ra ra ra ra ra ra ra
e to pressure ulcer development: pressure intensity, pressure dur ation, and tissue tolerance.
ra ra ra ra ra ra ra ra ra ra ra ra
When the intensity of the pressure exerted on the capillary exc
ra ra ra ra ra ra ra ra ra ra
eeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it nor
ra ra ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra
mally feeds. High pressure over a short time and low pressure over a longtime cause skin breakdo
ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra ra
wn.
Resistance, stress, and weight are not the priority causes of pressure ulcers. ra ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Examine risk factors that contribute to pressure ulcer formation. ra ra ra ra ra ra ra ra ar
TOP:Planning MSC: Reduction of Risk Potential ra ra ra ra
3. Which nursing observation will indicate the hospital client is at risk for pressure ulc
ra ra ra ra ra ra ra ra ra ra ra ra ra
er formation? ar
, a. Fecal incontinence ra
b. Ate two thirds of breakfast
ra ra ra ra
c. A raised red rash on the right shin
ra ra ra ra ra ra ra
d. Capillary refill is less than 2 seconds ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
The presence and duration of moisture on the skin increase the risk of ulcer formation by ma
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
king it susceptible to injury. Moisture can originate from wound drainage, excessive perspira
ra ra ra ra ra ra ra ra ra ra ra ra
tion, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the oppo
ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra
rtunity for skin breakdown because the skin is moistened and softened, causing maceration.
ra ra ra ra ra ra ra ra ra ra ra ra ra
Eating a balanced diet is important for nutrition but eating just two thirds of the meal does n
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ot indicate that the individual is at risk. A raised red rash on the leg again is a concern and ca
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
n affect the integrity of the skin, but it is located on the shin, which is not a highrisk area for skin
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
breakdown. Pressure can influence capillary refill, leading to skin breakdo ra ra ra ra ra ra ra ra ra
wn, but this capillary response is within normal limits.
ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Examine risk factors that contribute to pressure ulcer formation. ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Reduction of Risk Potential ra ra ra ra
4. The wound care nursing attendant is monitoring a hospital client
ra ra ra ra ra ra ra ra ra r a
with a Stage III pressur ra ra ra ra
e ulcer whose wound presents with healthy tissue. How should the nursing attendant do
ar ra ra ra ra ra ra ra ra ra ra ra ra
cument this ulcer in the hospital client ’s medical record? a. Stage I pressure ulcer
ra ra ra ra ra ra ra ra ra ra ra ra
b. Healing Stage II pressure ulcer ra ra ra ra
c. Healing Stage III pressure ulcer ra ra ra ra
d. Stage III pressure ulcer ra ra ra
ACCURATE ANSWER:-C ra
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
nd is labeled with the words ―healing stage‖ or healing Stage III pressure ulcer. Once an ulce
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
r has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage III, an
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra
d it cannot return to a previous stage such as Stage I or II. This ulcer is healing, so it is no long
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
er labeled a Stage III.
ra ra ra ra
DIF:Apply (application) ra
OBJ:Explain the pressure ulcer staging system. TOP:Implemen tation ra ra ra ra ra ar MSC:
Physiological Adaptation ra
5. The nursing attendant admitting an older hospital client notes a shallow open reddish, pi
ra ra ra ra ra ra ra ra ra ra ra ra ra
n
k ulcer without slough on the right heel of the hospital client . How will the nursing atte
ar ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nda nt stage this pressure ulcer? a. Stage I
ar ra ra ra ra
b. Stage II ra
c. Stage III ra
d. Stage IV ra
ACCURATE ANSWER:-B ra
This would be a Stage II pressure ulcer because it presents as partial-
ra ra ra ra ra ra ra ra ra ra ra ra
thickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasio
ra ra ra ra ra ra ra ra ra ra ra ra ra
n, blister, or shallow crater. Stage I is intact skin with non-
ra ra ra ra ra ra ra ra ra ra ra
, blanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat
ra ra ra ra ra ar ra ra ra ra ra ra ra ra
may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves fullthickness tis
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
sue loss with exposed bone, tendon, or muscle.
ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Explain the pressure ulcer staging system. TOP:Assessment ra ra ra ra ra ar
MSC: Physiological Adaptation ra ra
6. Which item should the nursing attendant use first to assist in staging an ulcer on th
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e heel of a darkly pigmented skin hospital client ? a. Disposable measuring tape
ar ra ra ra ra ra ra ra ra ra ra
b. Cotton-tipped applicator ra
c. Sterile gloves ra
d. Natural light ra
ACCURATE ANSWER:-D ra
When assessing a hospital client with darkly pigmented skin, proper lighting is essential to a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ccurately complete the first step in assessment—inspection— ra ra ra ra ra ra
and the entire assessment process. Natural light is recommended. Fluorescent light sources c
ra ra ra ra ra ra ra ra ra ra ra ra
an produce blue tones on darkly pigmented skin and can interfere with an accurate assessme
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nt. Other items that could possibly be used during the assessment include gloves for infection
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
control, a disposable measuring device to measure the size of the wound, and a cottontipped app
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
licator to measure the depth of the wound, but these items are not the first items us ed.
ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Explain the pressure ulcer staging system. TOP:Assessment ra ra ra ra ra ar MSC: ra
Health Promotion and Maintenance ra ra ra
7. The nursing attendant is caring for a hospital client with a Stage IV pressure ulcer. Which t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ype of healing will the nursing attendant consider when planning care for this hospital clie
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nt ?
a. Partial thickness wound repair ra ra ra
b. Full thickness wound repair ra ra ra
c. Primary intention ra
d. Tertiary intention ra
ACCURATE ANSWER:-B ra
Stage IV pressure ulcers are full-
ra ra ra ra ra
thickness wounds that extend into the dermis and heal by scar formation because the deeper
ra ra ra ra ra ra ra ra ra ar ra ra ra ra ra
structures do not regenerate, hence the need for full- ra ra ra ra ra ra ra
thickness repair. The fullthickness repair has four phases: hemostasis, inflammatory, prolifer
ra ra ra ra ra ra ra ra ra ra
ative, and maturation. A ra ra ra ra
wound heals by primary intention when wounds such as surgical wounds have little tissue lo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ss; the skin edges are approximated or closed, and the risk for infection is low. Partialthickne
ra ra ra ra ra ra ra ra ra ra ar ra ra ra ra
ss repairs are done on partialthickness wounds that are shallow, involving loss of the epiderm
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
is and maybe partial loss of t
ra ra ra ra ra ra
he dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary in
ra ra ra ra ra ra ra ra ra ra ra ra
tention is seen when a wound is left open for several days, and then the wound edges are appr
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
oximated. Wound closure is delayed until risk of infection is resolved.
ra ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Discuss the normal process of wound healing. TOP:Planning ra ra ra ra ra ra ar
MSC: Physiological Adaptation ra ra
, 8. The nursing attendant is caring for a group of hospital client s. Which hospital client wil
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
l the nursing attendant see first?
ra ar ra ra ra
a. A hospital client with a Stage IV pressure ulcer
ra ra ra ra ra ra ra ra
b. A hospital client with a Braden Scale score of 18
ra ra ra ra ra ra ra ra ra
c. A hospital client with appendicitis using a heating pad
ra ra r a ra ra ra ra ra
d. A hospital client with an incision that is approximated
ra ra r a ra ra ra ra ra
ACCURATE ANSWER:-C ra
The nursing attendant should see the hospital client with an appendicitis first. Warm applica
ra ra ra ra ra ra ra ra ra ra ra ra ra
tions are contraindicated when the hospital client has an acute, localized inflammation such a
ra ra ra ra ra ra ra ra ra ra ra ar ra
s appendicitis because the heat could cause the appendix to rupture. Although a Stage IV pre
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ssure ulcer is deep, it is not as critical as the appendicitis hospital client . The total Braden sco
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
re ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer developme
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
nt. A score of 18 can be assessed later. A healing incision is approximated (closed); this is a no
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
rmal finding and does not need to be seen first.
ra ra ra ra ra ra ra ra ra
DIF:Analyze (analysis) OBJ:Assess a hospital client with impaired skin integrity. TOP:Assessment
ra ra ra ra ra ra ra ra
MSC: Management of Care ra ra ra
9. The nursing attendant is caring for a hospital client who is experiencing a full thickness
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
wound repair. Which type of tissue will the nursing attendant expect to observe when t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
he wound is healing? a. Eschar
ar ra ra
b. Slough
c. Granulation
d. Purulent drainage ra
ACCURATE ANSWER:-C ra
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which in
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
dicates progression toward healing. Soft yellow or white tissue is characteristic of slough—
ra ra ra ra ra ra ra ra ra ra ra ra
a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is c
ar ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
alled eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicativ
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e of an infection and will need to be resolved for the wound to heal.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Discuss the normal process of wound healing. TOP:Assessment ra ra ra ra ra ra ar
MSC: Physiological Adaptation ra ra
10. The nursing attendant is caring for a hospital client who has experienced a laparoscopi
ra ra ra ra ra ra ra ra ra ra ra ra ra
c appendectomy. For which type of healing will the nursing attendant focus the care pl
ar ra ra ra ra ra ra ra ra ra ra ra ra ra
an?
a. Partial-thickness repair ra
b. Secondary intention ra
c. Tertiary intention ra
d. Primary intention ra
ACCURATE ANSWER:-D ra
A clean surgical incision is an example of a wound with little loss of tissue that heals with pri
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
mary intention. The skin edges are approximated or closed, and the risk for infection is low. P
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
artial-
thickness repairs are done on partialthickness wounds that are shallow, involving loss of the epi
ra ra ra ra ra ra ra ra ra ra ar ra ra ra
dermis and maybe partial loss of the ra ra ra ra ra ra r
dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intent
a ra ra ra ra ra ar ra ra ra ra ra
ra ra ra ra ra ra ra
MULTIPLE CHOICE ra
1. A nursing attendant participating in a research project associated with pressure ulcers wil
ra ra ra ra ra ra ra ra ra ra ra ra
l assess for what predisposing factor that tends to increase the risk for pressure ulcer dev
ar ra ra ra ra ra ra ra ra ra ra ra ra ra ra
elopment?
a. Decreased level of consciousness ra ra ra
b. Adequate dietary intake ra ra
c. Shortness of breath ra ra
d. Muscular pain ra
ACCURATE ra
ANSWER:-A
Hospital client s who are confused or disoriented or who have changing levels of conscious
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ness are unable to protect themselves. The hospital client may feel the pressure but may not
ra ra ra ra ra ra ra ra r a ra ra ra ar ra ra r
understand what to do to relieve the discomfort or to communicate that he or she is feeling
a ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra ra ra
discomfort.
Impaired sensory perception, impaired mobility, shear, friction, and moisture are other pred
ra ra ra ra ra ra ra ra ra ra ra
isposing factors. Shortness of breath, muscular pain, and an adequate dietary intake are not in
ra ra ra ra ra ra ra ra ra ra ra ra ar ra
cluded among the predisposing factors. ra ra ra ra
DIF:Apply (application) ra
OBJ:Examine risk factors that contribute to pressure ulcer formation. ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Reduction of Risk Potential ra ra ra ra
2. The nursing attendant caring for an unconscious hospital client who was involved in an a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
utomobile accident 2 weeks ago will give priority to which element when planning care
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
t o decrease the development of a decubitus ulcer? a. Resistance
ra ra ra ra ra ra ra
b. Pressure
c. Weight
d. Stress
ACCURATE ar
ANSWER:-B
Pressure is the main element that causes pressure ulcers. Three pressurerelated factors contribut
ra ra ra ra ra ra ra ra ra ra ra ra
e to pressure ulcer development: pressure intensity, pressure dur ation, and tissue tolerance.
ra ra ra ra ra ra ra ra ra ra ra ra
When the intensity of the pressure exerted on the capillary exc
ra ra ra ra ra ra ra ra ra ra
eeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it nor
ra ra ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra
mally feeds. High pressure over a short time and low pressure over a longtime cause skin breakdo
ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra ra
wn.
Resistance, stress, and weight are not the priority causes of pressure ulcers. ra ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Examine risk factors that contribute to pressure ulcer formation. ra ra ra ra ra ra ra ra ar
TOP:Planning MSC: Reduction of Risk Potential ra ra ra ra
3. Which nursing observation will indicate the hospital client is at risk for pressure ulc
ra ra ra ra ra ra ra ra ra ra ra ra ra
er formation? ar
, a. Fecal incontinence ra
b. Ate two thirds of breakfast
ra ra ra ra
c. A raised red rash on the right shin
ra ra ra ra ra ra ra
d. Capillary refill is less than 2 seconds ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
The presence and duration of moisture on the skin increase the risk of ulcer formation by ma
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
king it susceptible to injury. Moisture can originate from wound drainage, excessive perspira
ra ra ra ra ra ra ra ra ra ra ra ra
tion, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the oppo
ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra
rtunity for skin breakdown because the skin is moistened and softened, causing maceration.
ra ra ra ra ra ra ra ra ra ra ra ra ra
Eating a balanced diet is important for nutrition but eating just two thirds of the meal does n
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ot indicate that the individual is at risk. A raised red rash on the leg again is a concern and ca
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
n affect the integrity of the skin, but it is located on the shin, which is not a highrisk area for skin
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
breakdown. Pressure can influence capillary refill, leading to skin breakdo ra ra ra ra ra ra ra ra ra
wn, but this capillary response is within normal limits.
ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Examine risk factors that contribute to pressure ulcer formation. ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Reduction of Risk Potential ra ra ra ra
4. The wound care nursing attendant is monitoring a hospital client
ra ra ra ra ra ra ra ra ra r a
with a Stage III pressur ra ra ra ra
e ulcer whose wound presents with healthy tissue. How should the nursing attendant do
ar ra ra ra ra ra ra ra ra ra ra ra ra
cument this ulcer in the hospital client ’s medical record? a. Stage I pressure ulcer
ra ra ra ra ra ra ra ra ra ra ra ra
b. Healing Stage II pressure ulcer ra ra ra ra
c. Healing Stage III pressure ulcer ra ra ra ra
d. Stage III pressure ulcer ra ra ra
ACCURATE ANSWER:-C ra
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
nd is labeled with the words ―healing stage‖ or healing Stage III pressure ulcer. Once an ulce
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
r has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage III, an
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra
d it cannot return to a previous stage such as Stage I or II. This ulcer is healing, so it is no long
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
er labeled a Stage III.
ra ra ra ra
DIF:Apply (application) ra
OBJ:Explain the pressure ulcer staging system. TOP:Implemen tation ra ra ra ra ra ar MSC:
Physiological Adaptation ra
5. The nursing attendant admitting an older hospital client notes a shallow open reddish, pi
ra ra ra ra ra ra ra ra ra ra ra ra ra
n
k ulcer without slough on the right heel of the hospital client . How will the nursing atte
ar ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nda nt stage this pressure ulcer? a. Stage I
ar ra ra ra ra
b. Stage II ra
c. Stage III ra
d. Stage IV ra
ACCURATE ANSWER:-B ra
This would be a Stage II pressure ulcer because it presents as partial-
ra ra ra ra ra ra ra ra ra ra ra ra
thickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasio
ra ra ra ra ra ra ra ra ra ra ra ra ra
n, blister, or shallow crater. Stage I is intact skin with non-
ra ra ra ra ra ra ra ra ra ra ra
, blanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat
ra ra ra ra ra ar ra ra ra ra ra ra ra ra
may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves fullthickness tis
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
sue loss with exposed bone, tendon, or muscle.
ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Explain the pressure ulcer staging system. TOP:Assessment ra ra ra ra ra ar
MSC: Physiological Adaptation ra ra
6. Which item should the nursing attendant use first to assist in staging an ulcer on th
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e heel of a darkly pigmented skin hospital client ? a. Disposable measuring tape
ar ra ra ra ra ra ra ra ra ra ra
b. Cotton-tipped applicator ra
c. Sterile gloves ra
d. Natural light ra
ACCURATE ANSWER:-D ra
When assessing a hospital client with darkly pigmented skin, proper lighting is essential to a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ccurately complete the first step in assessment—inspection— ra ra ra ra ra ra
and the entire assessment process. Natural light is recommended. Fluorescent light sources c
ra ra ra ra ra ra ra ra ra ra ra ra
an produce blue tones on darkly pigmented skin and can interfere with an accurate assessme
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nt. Other items that could possibly be used during the assessment include gloves for infection
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
control, a disposable measuring device to measure the size of the wound, and a cottontipped app
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
licator to measure the depth of the wound, but these items are not the first items us ed.
ra ra ar ra ra ra ra ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Explain the pressure ulcer staging system. TOP:Assessment ra ra ra ra ra ar MSC: ra
Health Promotion and Maintenance ra ra ra
7. The nursing attendant is caring for a hospital client with a Stage IV pressure ulcer. Which t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ype of healing will the nursing attendant consider when planning care for this hospital clie
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
nt ?
a. Partial thickness wound repair ra ra ra
b. Full thickness wound repair ra ra ra
c. Primary intention ra
d. Tertiary intention ra
ACCURATE ANSWER:-B ra
Stage IV pressure ulcers are full-
ra ra ra ra ra
thickness wounds that extend into the dermis and heal by scar formation because the deeper
ra ra ra ra ra ra ra ra ra ar ra ra ra ra ra
structures do not regenerate, hence the need for full- ra ra ra ra ra ra ra
thickness repair. The fullthickness repair has four phases: hemostasis, inflammatory, prolifer
ra ra ra ra ra ra ra ra ra ra
ative, and maturation. A ra ra ra ra
wound heals by primary intention when wounds such as surgical wounds have little tissue lo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ss; the skin edges are approximated or closed, and the risk for infection is low. Partialthickne
ra ra ra ra ra ra ra ra ra ra ar ra ra ra ra
ss repairs are done on partialthickness wounds that are shallow, involving loss of the epiderm
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
is and maybe partial loss of t
ra ra ra ra ra ra
he dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary in
ra ra ra ra ra ra ra ra ra ra ra ra
tention is seen when a wound is left open for several days, and then the wound edges are appr
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
oximated. Wound closure is delayed until risk of infection is resolved.
ra ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Discuss the normal process of wound healing. TOP:Planning ra ra ra ra ra ra ar
MSC: Physiological Adaptation ra ra
, 8. The nursing attendant is caring for a group of hospital client s. Which hospital client wil
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
l the nursing attendant see first?
ra ar ra ra ra
a. A hospital client with a Stage IV pressure ulcer
ra ra ra ra ra ra ra ra
b. A hospital client with a Braden Scale score of 18
ra ra ra ra ra ra ra ra ra
c. A hospital client with appendicitis using a heating pad
ra ra r a ra ra ra ra ra
d. A hospital client with an incision that is approximated
ra ra r a ra ra ra ra ra
ACCURATE ANSWER:-C ra
The nursing attendant should see the hospital client with an appendicitis first. Warm applica
ra ra ra ra ra ra ra ra ra ra ra ra ra
tions are contraindicated when the hospital client has an acute, localized inflammation such a
ra ra ra ra ra ra ra ra ra ra ra ar ra
s appendicitis because the heat could cause the appendix to rupture. Although a Stage IV pre
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ssure ulcer is deep, it is not as critical as the appendicitis hospital client . The total Braden sco
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
re ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer developme
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
nt. A score of 18 can be assessed later. A healing incision is approximated (closed); this is a no
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
rmal finding and does not need to be seen first.
ra ra ra ra ra ra ra ra ra
DIF:Analyze (analysis) OBJ:Assess a hospital client with impaired skin integrity. TOP:Assessment
ra ra ra ra ra ra ra ra
MSC: Management of Care ra ra ra
9. The nursing attendant is caring for a hospital client who is experiencing a full thickness
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
wound repair. Which type of tissue will the nursing attendant expect to observe when t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
he wound is healing? a. Eschar
ar ra ra
b. Slough
c. Granulation
d. Purulent drainage ra
ACCURATE ANSWER:-C ra
Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which in
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
dicates progression toward healing. Soft yellow or white tissue is characteristic of slough—
ra ra ra ra ra ra ra ra ra ra ra ra
a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is c
ar ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
alled eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicativ
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
e of an infection and will need to be resolved for the wound to heal.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
DIF:Apply (application) ra
OBJ:Discuss the normal process of wound healing. TOP:Assessment ra ra ra ra ra ra ar
MSC: Physiological Adaptation ra ra
10. The nursing attendant is caring for a hospital client who has experienced a laparoscopi
ra ra ra ra ra ra ra ra ra ra ra ra ra
c appendectomy. For which type of healing will the nursing attendant focus the care pl
ar ra ra ra ra ra ra ra ra ra ra ra ra ra
an?
a. Partial-thickness repair ra
b. Secondary intention ra
c. Tertiary intention ra
d. Primary intention ra
ACCURATE ANSWER:-D ra
A clean surgical incision is an example of a wound with little loss of tissue that heals with pri
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
mary intention. The skin edges are approximated or closed, and the risk for infection is low. P
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
artial-
thickness repairs are done on partialthickness wounds that are shallow, involving loss of the epi
ra ra ra ra ra ra ra ra ra ra ar ra ra ra
dermis and maybe partial loss of the ra ra ra ra ra ra r
dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intent
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