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List 5 causes of wounds - correct answer 1. surgery 2. trauma 3. Unrelieved pressure or friction 4. Decreased blood flow through arteries or veins 5. Nerve damage A skin tear is: - correct answer A break or rip in the outer layer of the skin Circulatory ulcers are caused by: - correct answer decreased blood flow through arteries and veins The heels and inner aspects of the an...

What cells are major players in healing? - correct answer Platelets, neutrophils, macrophages, and fibroblasts What are the 3 phases of healing - correct answer Inflammation, proliferation, and remodeling How long should a wound take for closure of a chronic wound? - correct answer 2 years Can a wound be stuck in the inflammatory phase - correct answer ...

In a shear injury - correct answer underlying muscle and tissue are involved a friction injury - correct answer the epidermis of the skin is affected. Shear injury presents as necrosis - correct answer in the deep tissues with intact skin, friction injury presents as - correct answer denuded epidermis and torn skin Shear force is a - correct answ...

Which of the following describes a hydrocolloid dressing? 1 A seaweed derivative that is highly absorptive 2 Premoistened gauze placed over a granulating wound 3 A debriding enzyme that is used to remove necrotic tissue 4 A dressing that forms a gel that interacts with the wound surface - correct answer 4 A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound heal...

ALERT - correct answer Assess the patient for allergies to products such as latex, isopropyl alcohol, or tape before pressure injury (PI) or wound assessment The nurse is assessing the patient's PI and finds that some subcutaneous fat is showing, but not muscle tissue is exposed. What stage is the PI? A. Stage 3 B. Stage 2 C. Stage 4 D. Stage 1 - correct answer A. Rationale: This is a stage 3 (full-thickness)...

Abrasion - correct answer a patient has an injury on his arm where the skin has been scraped. This injury is a/an ______ granulated tissue - correct answer New tissue that looks red and semi-transparent that grows to fill in a wound is called _________ laceration - correct answer Your sister accidentally cut her finger while slicing tomatoes. This injury is a(n) _____ Dehiscence - co...

wound - correct answer disruption of normal skin structure or function open wound - correct answer greater risk of infection acute wound - correct answer follows normal healing process chronic wound - correct answer heals slowly and repair does not occur factors influencing wound healing - correct answer hemocri...

Question: During which phase of wound healing does contraction occur? -Epithelialization -Inflammation -Proliferation -Remodeling - correct answer Answer: Proliferation Question: Identify the proper sequence of events in the body's defense mechanism - correct answer Answer: 1. Hemostasis 2. Cleaning up the pathogens 3. Wound sealing 4. Regeneration of epidermal covering 5. Repairing deeper tissue damage Qu...

1. The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal? a. Primary intention b. Secondary intention c. Tertiary intention d. Deliberate intention - correct answer ANS: C When wounds are kept open by a drain, they heal by tertiary intention. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 335 OBJ: 4 TOP: Tertiary intention KEY: Nursing Process Step: Implementation 2. What ...

What step is a component of the planning phase for a patient who has impaired skin integrity? - correct answer Involve the patient and family in choosing interventions. In a supine position, which site is not at risk for a pressure ulcer? - correct answer Medial knee The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indica...

The nurse inspects all wound for signs of infection. When might a contaminated or traumatic wound show signs of infection? - correct answer 2-3 days after injury Why does a wound bed need to stay moist? - correct answer to support healing by enabling granulation tissue to grow Identify the functions of dressings. - correct answer maintaining a moist environment, control of bleeding and ...

Abrasion - correct answer Injury caused by rubbing or scrapping the skin Incision - correct answer cut or wound of body tissue caused by sharp object; surgical cut. Laceration - correct answer wound or injury with jagged, irregular edges Punture - correct answer Injury caused by a pointed object such as a needle or nail Avulsion - correct answer ...

abrasion - correct answer A partial-thickness wound caused by the scaping away or rubbing of the skin arterial ulcer - correct answer An open wound on the lower legs or feet caused by poor arterial blood flow chronic wound - correct answer A wound that does not heal easily clean wound - correct answer A wound that is not infected clean-contaminat...

Functions of Skin - correct answer -Provides for identifying characteristics(including heredity, racial, dietary and emotional considerations) Physiologic functions - protects underlying structures (absorbing, cushioning, restricting) - serves as heat-regulating mechanism (thermoregulation) - serves as sense organ - involved in metabolism of salt and water - stores fat - facilitates gas exchange - converts sunlight into Vitamin D - provides h...

What are the 2 types of Wounds? - correct answer Closed and Open Wound Name 3 types of Wound Dressings - correct answer Montgomery Straps Transparent Film Nonadherent dressings Hydrocolloids Foams Exudate absorbers Wounds are classified by contamination. Name the classifications - correct answer 1-Uninfected (minimal inflammation) 2-Clean contaminated wounds (Surgical wounds with ...

What do you need to determine - correct answer 1.) Cause 2.) extent of the wound 3.) Underlying conditions that would delay or complicate wound repair Subjective exam - correct answer 1.) Patients wound symptoms with -activity/rest -dependency -elevation 2.) Pain 3.) Paresthesia Wound inspection - correct answer 1.) Location, size, severity 2.) Dry or drainage-amount, color, odo...

How will superficial wounds appear? - correct answer involve the epidermis only will not bleed abrasion, superficial burn How will partial thickness wounds appear? - correct answer involve the epidermis and part of the dermis but not through the dermis likely to bleed but will not see adipose tissue ex. blister, superficial, and deep partial thickness burns, stage II pressure ulcers How will full thickness wounds ap...

*Wound assessment* - correct answer *provides the baseline for planning & evaluating the wound care plan *Frequency of wound assessment depends on?* - correct answer *patient's overall condition, policy of the health care setting, type of dressings used, and overall patient goals *Wound-assessment tools* - correct answer *Bates-Jensen Wound Assessment Tool (BWAT) and the Pressure Ulc...

This is damaged skin or soft tissue that occurs as a result of trauma, surgical incision, pressure, burns, and causes risk of infection - correct answer wound what type of wound characteristic is it when the skin not intact - correct answer OPEN wound (incision) what type of wound characteristic is it when there is no opening in the skin; ex. bruise - correct answer CLOSED wound (contus...

Purposes of wound assessment - correct answer - examine the severity (stage) of lesions - determine the status of wound healing - establish a baseline for the wound - prepare a plane of care - report observed changes in the wound over time Primary - correct answer wound edges are approximate or closed by sutures Secondary - correct answer wound has a crater and is healing from the b...