Chapter 60 Osborn,_2e

Question 1 Type: MCSA A patient injured in an accident has a large open leg wound that will require hospitalization for several days. The patient states he has just completed a course of steroid therapy. The nurse will include additional monitoring for which condition in the plan of care? 1. Delayed wound healing 2. Increased risk of thromboembolism 3. Increased tendency to bleed excessively 4. Increased pain at the wound site Correct Answer: 1 Rationale 1: Steroids suppress the inflammatory phase and thus contribute to a delay in wound healing. Chronic use of steroids results in decreased production of histamines, which are needed for the inflammatory response. Rationale 2: There is no increase in the risk of thromboembolism specifically associated with the use of steroids. Rationale 3: There is no increase in bleeding specifically associated with the use of steroids. Rationale 4: Steroid use does not increase pain from wounds. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 60-1 Question 2 Type: MCMA The nurse would assess that granulation tissue is developing in a wound when noting which characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Beefy red color 2. Blue-gray tinge to the wound bed 3. Small, round nodules in the wound bed 4. Pearly-appearing wound margins 5. Moist tissue Correct Answer: 1,3,5 Rationale 1: Granulation tissue appears beefy red. Rationale 2: Granulation tissue should not have a blue-gray tinge. Rationale 3: Granulation tissue, so named for its characteristic tiny, round, granule-like nodules, is a highly vascular connective tissue that contains newly formed capillaries, proliferating fibroblasts, and residual inflammatory cells. Rationale 4: Pearl-like wound margins indicate that epithelialization is occurring. Rationale 5: Granulation tissue is moist. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 60-1