Multidimensional Care 1 Final Exam well performed 2024.

What is primary intention wound healing? - answersWound edges are well-approximated. Place in order the wound healing process. - answersHemostasis -> Inflammation -> Proliferate -> Maturation T/F: Serous-sanguinous drainage is blood mixed with pus. - answersFalse. What is sometimes common to see in evisceration? - answersFistulas, total separation of the wound, caused by IAP (increased abdominal pressure) What is a partial-thickness wound with loss of epidermis and some dermis? - answersStage 2 What is a full-thickness wound with loss of skin and visible subcutaneous tissue? - answersStage 3 What is a full-thickness wound with loss of the skin and visible bone and undermining? - answersStage 4 What is a wound that has more than 75% of the wound bed covered? - answersUnstageable The Braden Scale includes sensory, moisture, activity, and _________________? - answersMobility, nutrition, and friction/shear What are some interventions to reduce the risk for skin injury? - answersElevate the bed no greater than 30-degrees; offload and reposition; control and inspect skin daily; encourage intake of protein, calories, minerals, and fluids. T/F: The wound assessment should include location, size, color, wound base, drainage, edges, and peri-wound skin. - answersTrue. What is an ABI (ankle-brachial index) test? - answersDetermines the atrial flow, determines inadequate blood flow, determines delayed healing. T/F: Hand washing is the best way to prevent infection. - answersTrue. How much PSI is needed for proper wound irrigation? - answers35-70 PSI What is an example of a laceration? - answersSkin tear What is an example of a portal of entry? - answersBlood T/F: Virulence is the power of the pathogen to cause disease. - answersTrue. T/F: Standard precaution should be used for all the patients. - answersTrue. Who is at greater risk of become infected? - answersElderly, those taking steroids, HIV patients The five cardinal signs of inflammation: - answersWarmth, erythema (redness), pain, decreased function, edema T/F: Cytokines activate the inflammatory process? - answersTrue. What happens to lymphocyte cells for someone with HIV? - answersCD8+T-cells are normal and CD4+T-cells are low What are things a patient who is immuno-compromised should avoid? - answersFresh flowers or plants; raw meat, fruits, and vegetables; avoid crowds T/F: Patients that are immuno-compromised should restrict from drinking and smoking. - answersTrue. HIV patients are a susceptible host for which opportunist conditions? - answersKaposi sarcoma T/F: Evisceration is the total separation of the wound related to increased abdominal pressure (IAP)? - answersTrue. T/F: Sanguineous drainage is clear and not infected? - answersFalse. What test is used to measure IOP (intra-ocular pressure)? - answersTonometry T/F: Vasoconstriction can cause increased perfusion. - answersFalse. T/F: A patient who is 25-years-old needs an MRI. The nurse know it's important to ask about any tattoos. - answersFalse. T/F: A patient with kyphosis doesn't have any high-risk. - answersFalse. What should the nurse do when assisting with movement or mobility? - answersFace the movement. What causes shearing and friction injuries? - answersOpposite pulling of the skin. T/F: Traction should include skin and hygiene assessment. - answersTrue. The nurse should suspect ACS (acute compartment syndrome) when the patient complains of _______________. - answersRapid, discoloration, pain worse than that of the fracture, weak pulse, and tightness. What fracture is complete with injury to the skin? - answersOpen. T/F: The nurse can control bleeding form a fracture by applying pressure below the site. - answersFalse.