ch67.doc

[Osborn] chapter 67

Learning Outcomes [Number and Title ]Learning Outcome 1 Compare and contrast the clinical manifestations of the three

phases of wound healing.Learning Outcome 2 Describe wound characteristics and nursing documentation that

is required in a periodic wound assessment.Learning Outcome 3 Describe key factors that are relative to the prevention of

pressure ulcers.Learning Outcome 4 Compare and contrast wound classifications and respective

treatments.Learning Outcome 5 Evaluate therapies and their benefits with respect to wound

healing.Learning Outcome 6 Understand the psychosocial and liability factors pertaining to

wound care.Learning Outcome 7 Describe how research in wound care will lead to better

efficiency and outcomes with evidence-based practice.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1

1. The nurse admits a client with a large open leg wound from a motor vehicle crash. While obtaining the history from this client, the nurse inquired about the use of medications. The client stated he had just completed a course of steroid therapy. The nurse knows the steroids will:

1. Delay wound healing.2. Assist in wound healing.3. Cause an increase in the tendency to bleed.4. Cause a decrease in the tendency to bleed.

Correct Answer: Delay wound healing.

Rationale: Steroids suppress the inflammatory phase and thus contribute to a delay in wound healing. Chronic use of steroids specifically results in decreased production of histamines, which are needed for the inflammatory response. Steroids do not assist in wound healing, they delay it. There is no specific impact from steroids on bleeding or clotting.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


2

2. The nurse assessing the wound for the presence of granulation tissue would look for which normal characteristics of granulation tissue?

Select all that apply.

1. Beefy red2. Has nodules3. Moist4. Has blackened tissue5. Dry

Correct Answer: 1. Beefy red2. Has nodules3. Moist

Rationale: Beefy red. Granulation tissue appears beefy red and moist. Has nodules. Due to angiogenesis, granulation tissue develops. Granulation tissue, aptly named for the recognizable tiny, round, granule-like nodules, is a highly vascular connective tissue that contains newly formed capillaries, proliferating fibroblasts, and residual inflammatory cells. Moist. Granulation tissue appears beefy red and moist. Has blackened tissue. Black and/or dry tissue is eschar, which occurs after a burn injury. Dry. Black and/or dry tissue is eschar, which occurs after a burn injury.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


3

3. In which stage of wound healing does angiogenesis occur?

1. Proliferation2. Inflammation3. Remodeling 4. Maturation

Correct Answer: Proliferation

Rationale: During proliferation, growth factors originating from injured vessels stimulate the formation of vascular buds and regrowth of vascular loops. Stimulated endothelial cells multiply and form tubular structures differentiating into arterioles or venules, a process referred to as angiogenesis. When injury to the epidermis, dermis, and subcutaneous tissue occurs, the inflammatory phase of wound healing begins. Within hours after injury, histamines are released from mast cells, causing local vasodilation and increased capillary permeability. This allows leakage of serous fluid into the injured site, which results in erythema, edema, and the production of exudates. The third and final phase of wound healing is maturation or remodeling, which are synonymous terms. This phase begins after the wound is closed. During this phase the scar changes and matures. The bulk decreases and the color changes from pink to pearly white.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological Integrity LO: 1


4

4. The nurse is assessing a periwound area on a client with a large abdominal wound, and the area appears macerated. What change in nursing management is required due to the maceration?

1. Keep the moist dressing off the periwound area.2. No new measures are necessary, as this is a normal finding. 3. Apply a moist dressing to the periwound area.4. Apply a petroleum-based product to the periwound area.

Correct Answer: Keep the moist dressing off the periwound area.

Rationale: Maceration occurs when excessive moisture destroys the skin’s integrity. Periwound skin becomes macerated when the wet dressing from the wound extends to the skin around the wound. The most appropriate nursing measure is to not have any wet dressing touching the skin around the wound. Maceration is not a normal finding and requires nursing intervention. Applying moist dressings to the periwound area would worsen the maceration. Applying a petroleum dressing to the periwound is not necessary. All that is necessary is to keep the area dry and let the skin heal.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Physiological IntegrityLO: 2


5

5. The nurse is caring for a client with a large open wound. While doing the dressing change, the nurse notes purulent drainage. What additional assessments are necessary for this client?


1. White blood count2. Fever3. Wound odor4. Wound bleeding5. Blood urea nitrogen (BUN)

CHART 67–10 Correct Answer:

1. White blood count2. Fever3. Wound odor

Rationale: White blood count. Purulent drainage indicates infection, which requires the nurse to assess for other indicators of infection. Increased white blood count is another positive indicator of infection. Fever. Fever is an indicator of the presence of infection. Wound odor. Some types of organisms have a distinct odor, such as pseudomonas. The wound should be assessed for the presence of odor. Wound bleeding. Bleeding is not an indicator of infection. Blood urea nitrogen (BUN). BUN is an indicator of renal function, not wound infection.



6

6. The nurse is caring for an 84-year-old client who was just admitted from a nursing home with a large sacral ulcer. When assessing the wound, the nurse notes small areas of both black and white tissue in the wound bed. The nurse understands that the best dressing protocol for this wound is:

1. Wet-to-dry with normal saline every 6 hours.2. Petroleum-based antiseptic dressing once per day.3. Dry dressing twice per day. 4. Wet-to-wet with Dankins solution once per day.

Correct Answer: Wet-to-dry with normal saline every 6 hours.

Rationale: The black and white tissue needs to be debrided from the wound area before healing can occur. Wet-to-dry dressing provides a means of debridement. Petroleum-based products will not provide debridement. Dry dressing and wet-to-wet Dankins solution also will not provide the needed debridement.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Physiological Integrity LO: 2


7

7. The nurse understands that certain clients are more susceptible to pressure ulcer development. Which of the following clients would be at an increased risk?


1. Clients who have restricted activity2. Clients with decreased sensation 3. Clients with poor nutrition 4. Clients who are very thin 5. Clients who have urinary or fecal incontinence

Correct Answer:1. Clients who have restricted activity2. Clients with decreased sensation 3. Clients with poor nutrition 4. Clients who are very thin 5. Clients who have urinary or fecal incontinence

Rationale: Clients who have restricted activity. Clients who have restricted activity, as would occur with quadriplegia, strokes, and fractured hips, are at risk for pressure ulcer development. Clients with decreased sensation. Decreased sensation prevents clients from feeling the pain associated with the development of a pressure ulcer, which increases the risk of development and progression. Clients with poor nutrition. Clients with poor nutrition are more susceptible to pressure ulcer development. Clients who are very thin. Clients who are very thin or have decreased protein in the diet have skin that is more likely to ulcerate. Clients who have urinary or fecal incontinence. Clients who have urinary or fecal incontinence or are exposed to other types of moisture such as perspiration, wound drainage, or emesis are more prone to ulcers.



8

8. When assessing a client for the risk of pressure ulcer development, what factors must be a part of the assessment?


1. Sensory perception and activity level2. Moisture3. Mobility4. Nutrition5. Friction and shear

Correct Answer:1. Sensory perception and activity level2. Moisture3. Mobility4. Nutrition5. Friction and shear

Rationale: Sensory perception and activity level. Decreased sensation increases the risk for pressure ulcer development. Decreased activity increases the risk for pressure ulcer development due to prolonged pressure in one area, thereby decreasing the circulation to that area, resulting in decreased oxygen supply. Moisture. Moisture increases skin breakdown, thereby increasing the risk for pressure ulcer development. Mobility. Decreased mobility level increases the risk for pressure ulcer development due to prolonged pressure in one area. Nutrition. Nutrition supplementation is an essential intervention for pressure ulcer development. Protein is the building block for collagen synthesis, interstitial fluid balance, granulation, and epithelialization. Friction and shear. Friction and shear potentially remove layers of tissue, thereby increasing the risk for loss of skin integrity, which can progress to necrosis of the skin with pressure.

Cognitive Level: ApplicationNursing Process: Assessment Client Need: Physiological Integrity LO: 3


9

9. The nurse understands that in order to prevent pressure ulcer development, he must remove pressure from high-risk areas of the body. What nursing interventions are essential to accomplish this goal?


1. Use pillows to offload pressure.2. Turn the client at least every 2 hours.3. Use a shoe or cast to prevent pressure.4. Keep the client on bed rest.5. Pull the client up in bed every 2 hours or less.

Correct Answer:1. Use pillows to offload pressure.2. Turn the client at least every 2 hours.3. Use a shoe or cast to prevent pressure.

Rationale: Use pillows to offload pressure. Pillows provide a cushion for bony prominences, which decreases pressure. Turn the client at least every 2 hours. Turning takes prolonged pressure off a single area. Use a shoe or cast to prevent pressure. Shoes and properly padded casts protect high-risk areas from pressure by providing a barrier and a cushion. Keep the client on bed rest. This would be inappropriate, as activity and mobility prevent prolonged pressure in one area. Pull the client up in bed every 2 hours or less. Pulling clients up in bed increases friction and shear, but does not prevent pressure.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological Integrity LO: 3


10

11. The nurse is caring for a frail elderly client who has a chronic pressure ulcer. The nurse understands that this wound is not healing due to:

Select all that apply.1. An inadequate blood supply in the tissue.2. Repeated prolonged insults to the tissue.3. Disruptive underlying pathologic processes.4. Recent trauma.5. Pneumonia.

Correct Answer:1. An inadequate blood supply in the tissue.2. Repeated prolonged insults to the tissue.3. Disruptive underlying pathologic processes.

Rationale: An inadequate blood supply in the tissue. Chronic wounds generally occur due to inadequate blood supply in the tissue. Repeated prolonged insults to the tissue. Chronic wounds generally occur due to repeated prolonged insults to the tissue. Disruptive underlying pathologic processes. Chronic wounds generally occur due to disruptive underlying pathologic processes. Recent trauma. Recent trauma is associated with acute traumatic wounds. Pneumonia. Pneumonia is not directly related to wound healing.



11

13. Factors that promote development of a wound in a client with a ___________ are neuropathy, macrovascualar and microvascular changes, and a diminished immunity.

1. Diabetic wound2. Pressure ulcer3. Venous stasis ulcer4. Traumatic wound

Correct Answer: Diabetic wound

Rationale: The mitigating factors that promote development of a wound in a client with diabetes are neuropathy, macro- and microvascular changes, and a slow, decreased immune response. Pressure ulcers develop when pressure causes decreased circulation to an area. Venous ulcers are caused by vein harvesting for coronary artery bypass grafting, pregnancy, and occupations necessitating prolonged standing or sitting, which leads to venous congestion and the development of venous ulcers. Traumatic wounds are those caused by fire, guns, knives, vehicular crashes, and so on, and are not related to neuropathy, micro- and macrovascular changes, and diminished immunity.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological Integrity LO: 5


12

14. Follow-up teaching for a client who has just had a squamous cell carcinoma removed from the skin must include:

Select all that apply.1. Inspecting the skin vigilantly on a routine basis.2. Having caregiver inspect the hard-to-visualize areas of the body.3. Reporting any suspicious-looking areas to the primary health care

provider.4. Using sunscreen routinely. 5. Covering areas where the cancer has occurred with clothing or hats.

Correct Answer:1. Inspecting the skin vigilantly on a routine basis.2. Having caregiver inspect the hard-to-visualize areas of the body.3. Reporting any suspicious-looking areas to the primary health care

provider.4. Using sunscreen routinely. 5. Covering areas where the cancer has occurred with clothing or hats.

Rationale: Inspecting the skin vigilantly on a routine basis. It is important to inspect the skin regularly for a recurrence of cancer. Having caregiver inspect the hard-to-visualize areas of the body. It is important to have the health care provider inspect the client’s skin regularly for a recurrence of cancer. Reporting any suspicious-looking areas to the primary health care provider. Reporting of a suspicious lesion is essential so as to not have the cancer spread. Using sunscreen routinely. Using sunscreen will protect the skin from the sun’s harmful ultraviolet rays. Covering areas where the cancer has occurred with clothing or hats. Covering the skin is another way of protecting it from the sun’s harmful ultraviolet rays.

Cognitive Level: EvaluationNursing Process: ImplementationClient Need: Health Promotion and Maintenance LO: 5


13

15. The nurse is caring for a client with a large wound on her right hip. What nursing measure is the most essential for the client?

1. Keep the client from lying on her right side.2. Turn the client from side to side every 2 hours.3. Keep the client on continuous bed rest.4. Keep the client upright in a chair for a minimum of 8 hours per 24-hour

period.

Correct Answer: Keep the client from lying on her right side.

Rationale: Keeping pressure off the right hip is the essential nursing measure because pressure will decrease blood flow to the area. Blood flow is needed to get oxygen and nutrients to the area in order to heal the wound. Turning the client from side to side is inappropriate because she would be lying on her wound, creating pressure that would diminish the blood supply. A right hip wound does not require complete bed rest or prolonged chair sitting.



14

16. The nurse is caring for a client with a deep wound that has tunneling. Following the dressing change, what factors are essential for the nurse to document?

Select all that apply.1. Size and shape of the tunnel2. Direction and number of tunnels3. Type of drainage coming from the wound4. Length of dressing needed to pack wound5. Amount of irrigation poured into the tunnel

Correct Answer:1. Size and shape of the tunnel2. Direction and number of tunnels3. Type of drainage coming from the wound4. Length of dressing needed to pack wound

Rationale: Size and shape of the tunnel. The size and shape of the tunnel must be documented so the next person changing the dressing has that information as a guide. Direction and number of tunnels. The amount of tunnels and their direction must be documented so that the next person changing the dressing has that information as a guide. Type of drainage coming from the wound. It is essential to document the type of drainage in order to evaluate for the presence of infection. Length of dressing needed to pack wound. It is essential to document the length of dressing to provide information about the depth of the tunnel. Amount of irrigation poured into the tunnel. Irrigation is not indicated during the dressing change for tunneled wounds.



15

17. Specialty support surfaces are mattresses or overlays that provide pressure reduction or pressure relief. When making a decision about which mattress/overlay would be appropriate for a client, the nurse must consider which of the following factors?


1. Risk for skin breakdown2. Presence of ulcers or wounds3. Mobility status4. Moisture and continence issues5. Nutrition status

Correct Answer:1. Risk for skin breakdown2. Presence of ulcers or wounds3. Mobility status4. Moisture and continence issues5. Nutrition status

Rationale: Risk for skin breakdown. High-risk clients for pressure ulcers, such as the frail and elderly, should be placed on a special support surface prophylactically. Presence of ulcers or wounds. If a client currently has pressure ulcers he or she should be placed on a special mattress to prevent progression of the current ulcers and formation of new ones. Mobility status. The client’s level of mobility is a factor due to the increased risk of pressure ulcer development in clients who are unable or unwilling to move. Moisture and continence issues. Incontinent clients or clients who perspire excessively are at an increased risk for skin breakdown due to maceration. They need to be placed on a special mattress to prevent further breakdown from pressure. Nutrition status. Inadequate nutrition will increase the risk of skin breakdown. If a client is malnourished, it is an indication that he or she would benefit from a special mattress to help decrease skin breakdown.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Safe, Effective Care Environment. LO: 5


16

18. Tracing graphs of transparent film are used to assess wound healing rates. The advantages of these assessment tools are that they:


1. Enable health care providers to outline the shape of the wound.2. Show progress of the wound surface contracture.3. Offer a psychological boost to clients whose wounds are healing by

millimeters.4. Prevent infection from iatrogenic causes.5. Keep the wound dry.

Correct Answer:1. Enable health care providers to outline the shape of the wound. 2. Show progress of the wound surface contracture.3. Offer a psychological boost to clients whose wounds are healing by

millimeters.

Rationale: Enable health care providers to outline the shape of the wound. Tracing graphs of transparent film, such as E-Z Graph System of wound assessment, enable health care providers to outline the shape of the wound. Show progress of the wound surface contracture. Tracing graphs of transparent film, such as E-Z Graph System of wound assessment, enable health care providers to show progress of the wound surface contracture. Offer a psychological boost to clients whose wounds are healing by millimeters. These tracings offer a great psychological boost to clients whose wounds are healing by millimeters, when they can see progress as compared to original wound size. Prevent infection from iatrogenic causes. Tracings are not used to prevent infection, they are used to assess wound healing. Keep the wound dry. Tracings are not used to keep wounds dry: they are used to assess wound healing.


19. The nurse is employed in a long-term care facility. The nurse understands that the Joint Commission mandates the documentation of:



17

1. Pressure ulcer incidence.2. Measures taken to prevent pressure ulcers.3. Periodic care plan revisions. 4. Staffing ratios.5. Client census.

Correct Answer:1. Pressure ulcer incidence.2. Measures taken to prevent pressure ulcers.3. Periodic care plan revisions.

Rationale: Pressure ulcer incidence. The Joint Commission mandates that hospitals must have quality assurance records regarding pressure ulcer incidence. Measures taken to prevent pressure ulcers. The Joint Commission mandates that hospitals must have quality assurance records regarding pressure ulcer prevention. Periodic care plan revisions. The Joint Commission mandates that hospitals must keep quality assurance records current. Staffing ratios. Staffing ratio regulations are not related to pressure ulcer incidence and prevention. Client census. Client census regulations are not related to pressure ulcer incidence and prevention.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Safe, Effective Care Environment LO: 6


18

20. The nurse is caring for a young client with a large wound on the arm from necrotizing fasciitis. The nurse knows this client has psychologically adjusted to this wound when the client states:

1. “I am able to look at my wound during dressing changes.”2. “I told my family it would heal without a scar.”3. “I will wear long sleeves for the rest of my life.”4. “I told my mother that she should not look at the wound.”

Correct Answer: “I am able to look at my wound during dressing changes.”

Rationale: Looking at the wound during dressing changes is a sign that the client is beginning to accept the fact that the wound is there. Telling the family it will heal without a scar is denial on the part of the client. Full-thickness injures always leave scars. Wearing long sleeves means that the client does not want anyone to see the scar, which is an indication that the client is bothered by the wound. Telling her mother that she should not look at the wound is not an indication that the client has accepted the wound.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Psychosocial Integrity LO: 6


19

21. To best promote wound healing and prevent infection, research supports the use of:

1. Topical silver.2. Topical gold.3. Normal saline.4. Dankins solution.

Correct Answer: Topical silver.

Rationale: Silver is a product that has come into wide use as a local antimicrobial agent, and continues to be a topic of research. Gold is not a wound care product. Normal saline and Dankins solutions are not antimicrobial agents, and therefore are not used for infection prevention.



20

22. Wound breakdown after healing continues to be an issue with burn victims. Research into __________would help diminish this problem.

1. Techniques to increase tensile strength2. Techniques to decrease wound infection3. Methods to increase client compliance4. Methods to increase family participation

Correct Answer: Techniques to increase tensile strength.

Rationale: Wound breakdown is related to the tensile strength of the scar. Techniques to increase tensile strength would decrease wound breakdown. Techniques to decrease wound infection would not increase tensile strength of healed wounds. Client compliance and family participation have no direct effect on wound strength.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological Integrity LO: 7


21

23. In order to have wound healing occur, the client must receive adequate nutrition. Diets must be high in protein and calories with vitamin and nutritional supplements. Evidence supports that what additional requirements are needed for wound closure?


1. Supplemental amino acids 2. Supplemental fat-soluble vitamins 3. Supplemental water-soluble vitamins 4. Supplemental antioxidants 5. Supplemental fluids

Correct Answer:1. Supplemental amino acids 2. Supplemental fat-soluble vitamins 3. Supplemental water-soluble vitamins 4. Supplemental antioxidants 5. Supplemental fluids

Rationale: Supplemental amino acids. Supplemental amino acids include arginine, glutamine, and hydroxy-methyl butyrate (HMB), which promote tissue growth and wound healing. Supplemental fat-soluble vitamins. Fat soluble vitamins such as A, D, E, and K play a role in the wound healing process. Supplemental water-soluble vitamins. Water-soluble vitamins such as C and the B family are needed for wound healing. Supplemental antioxidants. Antioxidants enhance cell membrane stability and promote wound healing. Supplemental fluids. Maintaining adequate hydration assists in healing and decreases the risk of development of additional wounds.



22

ch67.doc

Documents

Transcript of ch67.doc