introduction to nursing (SHERPATH) WEEK 7 & 8
Questions With Complete Solutions
Which nutrients would need to be increased in the diet of a
patient with full-thickness burns?
Zinc
- Zinc is essential for healing the skin that is burned.
Copper
- Copper is needed for healing of the skin.
Protein
- Fibroblasts need protein to make collagen.
Vitamin A
- Vitamin A would be needed for healing of the burn.
Vitamin C
- Vitamin C would be needed for collagen formation.
Which classification would the nurse use for staging a pressure
injury that has a full-thickness wound and extends into the
subcutaneous tissue, but not into the fascia, muscle, or bone?
Stage 3
- Stage 3 pressure injuries are characterized by full-thickness
wounds that extend into the subcutaneous tissue, but not into the
fascia, muscle, or bone.
,Which phase of wound healing is characterized by a patient who
reports that the bumpy and granular injured site "bleeds easily"?
Proliferative
- The proliferative phase is the phase of healing and repair in
which new tissue bleeds easily and has a granular and bumpy
texture.
Which type of opening occurs in a patient who has an
enterocutaneous fistula?
Between the skin and the intestine
- An opening between the skin and the intestines is described as
enterocutaneous. "Entero" means intestines, and "cutaneous"
means skin.
Which complication would the nurse identify for the health care
provider in a patient whose surgical incision "popped" open and
is draining fluid?
Dehiscence
- Dehiscence is a partial or complete separation of tissue layers
and includes a "popping" sound with an increase in drainage.
This accurately describes the scenario.
Which processes occur in the proliferative phase of wound
healing?
Stimulation of angiogenesis
- Stimulation of angiogenesis occurs in the proliferative phase to
provide the new tissue with oxygen and nutrients.
Creation of granulation tissue
,- Creation of granulation tissue occurs in the proliferative phase
to fill in the wound with new cells.
Which patient situation is a medical emergency?
Shock
- A patient experiencing shock is a medical emergency because
it indicates the patient is hemorrhaging internally or externally.
Match the type of wound to its typical colors.
Purple or maroon
- Suspected deep-tissue injury
White, brown, or black
- Full-thickness burn
Beefy red and bumpy
- Wound in proliferative phase
Red and purulent
- Infected wound
Which interpretation would the nurse make about a wound that
is colonized?
Contains microorganisms on the surface of the wound only
- A colonized wound contains one or more microorganisms on
the surface of the wound, with no clinical signs of a wound
infection.
Which factor that affects skin integrity is depicted in this
image?
, Prolonged pressure
Prolonged pressure can damage bony prominences and pressure
areas on the body, which are depicted in this image.
Which classic signs would the nurse observe in a wound that is
in the inflammatory phase of healing?
Swelling
- Swelling would occur in the inflammatory phase.
Erythema
- Erythema is a classic sign that occurs in the inflammatory
phase of wound healing.
Which pressure injury stage is depicted in the image?
2
The nurse would classify this as a stage 2 pressure injury. It is a
partial-thickness wound involving the epidermis and dermis.
Which factors can directly cause the fibroblasts and collagen to
be altered or ineffective in the proliferative phase of wound
healing?
Prolonged decrease of oxygen perfusion to skin
- A prolonged decrease of oxygen perfusion to the skin reduces
the production of cells that produce collagen (fibroblasts) and
decreases collagen formation.
Lack of protein
- A lack of protein would directly affect collagen because
protein is needed for fibroblasts to make collagen.
Questions With Complete Solutions
Which nutrients would need to be increased in the diet of a
patient with full-thickness burns?
Zinc
- Zinc is essential for healing the skin that is burned.
Copper
- Copper is needed for healing of the skin.
Protein
- Fibroblasts need protein to make collagen.
Vitamin A
- Vitamin A would be needed for healing of the burn.
Vitamin C
- Vitamin C would be needed for collagen formation.
Which classification would the nurse use for staging a pressure
injury that has a full-thickness wound and extends into the
subcutaneous tissue, but not into the fascia, muscle, or bone?
Stage 3
- Stage 3 pressure injuries are characterized by full-thickness
wounds that extend into the subcutaneous tissue, but not into the
fascia, muscle, or bone.
,Which phase of wound healing is characterized by a patient who
reports that the bumpy and granular injured site "bleeds easily"?
Proliferative
- The proliferative phase is the phase of healing and repair in
which new tissue bleeds easily and has a granular and bumpy
texture.
Which type of opening occurs in a patient who has an
enterocutaneous fistula?
Between the skin and the intestine
- An opening between the skin and the intestines is described as
enterocutaneous. "Entero" means intestines, and "cutaneous"
means skin.
Which complication would the nurse identify for the health care
provider in a patient whose surgical incision "popped" open and
is draining fluid?
Dehiscence
- Dehiscence is a partial or complete separation of tissue layers
and includes a "popping" sound with an increase in drainage.
This accurately describes the scenario.
Which processes occur in the proliferative phase of wound
healing?
Stimulation of angiogenesis
- Stimulation of angiogenesis occurs in the proliferative phase to
provide the new tissue with oxygen and nutrients.
Creation of granulation tissue
,- Creation of granulation tissue occurs in the proliferative phase
to fill in the wound with new cells.
Which patient situation is a medical emergency?
Shock
- A patient experiencing shock is a medical emergency because
it indicates the patient is hemorrhaging internally or externally.
Match the type of wound to its typical colors.
Purple or maroon
- Suspected deep-tissue injury
White, brown, or black
- Full-thickness burn
Beefy red and bumpy
- Wound in proliferative phase
Red and purulent
- Infected wound
Which interpretation would the nurse make about a wound that
is colonized?
Contains microorganisms on the surface of the wound only
- A colonized wound contains one or more microorganisms on
the surface of the wound, with no clinical signs of a wound
infection.
Which factor that affects skin integrity is depicted in this
image?
, Prolonged pressure
Prolonged pressure can damage bony prominences and pressure
areas on the body, which are depicted in this image.
Which classic signs would the nurse observe in a wound that is
in the inflammatory phase of healing?
Swelling
- Swelling would occur in the inflammatory phase.
Erythema
- Erythema is a classic sign that occurs in the inflammatory
phase of wound healing.
Which pressure injury stage is depicted in the image?
2
The nurse would classify this as a stage 2 pressure injury. It is a
partial-thickness wound involving the epidermis and dermis.
Which factors can directly cause the fibroblasts and collagen to
be altered or ineffective in the proliferative phase of wound
healing?
Prolonged decrease of oxygen perfusion to skin
- A prolonged decrease of oxygen perfusion to the skin reduces
the production of cells that produce collagen (fibroblasts) and
decreases collagen formation.
Lack of protein
- A lack of protein would directly affect collagen because
protein is needed for fibroblasts to make collagen.
