Wound Healing and Care, Exams of Nursing

Download Wound Healing and Care and more Exams Nursing in PDF only on Docsity! Wound Care WCC Practice Exam And Answers. The skin is comprised of two layers, the epidermis and the dermis. Each layer consists of numerous cells. Which cells would you find in the dermis? - \Macrophage, Fibroblast, Mast Cells The dermis is made up of proteins, i.e. collagen and elastin. These two proteins are responsible for: - \Giving skin tensile strength and providing the skin with elastic recoil Red blood cells also known as erythrocytes are the most abundant cells in the blood. They account for 40-45% of the blood. The % of blood made up of RBC's is measured by a lab known as - \Hematocrit Stem cells produce a protein that makes red blood cells look red and gives them the ability to transport oxygen. What is this protein called? - \Hemoglobin WBC produce protein that makes RBC look red and gives them the ability to transport oxygen. What is this protein called? - \Neutrophil Assessment and documentation of a skin lesion should include location, sensation, duration, morphology, and configuration. What is configuration? - \shape or outline Dermatomal corresponding to nerve root distribution is - \zosteriform To assess pain with non-verbal cognitively impaired patients or non-English speaking patients, it is recommended to use - \Wong Baker Faces Pain rating scale Pain quantification would include: - \intensity, location, quality, onset, duration, aggravating, alleviating factors T/F- Staging is used for Pressure Ulcers ONLY - \True T/F- Wound assessments should be documented every four weeks at a minimum - \False---Should be documented weekly! T/F- A stage III pressure ulcer is partial thickness skin loss involving the epidermis, dermis or both. - \False T/F-Painful blood filled blister located on the heel would be considered unstageable. - \False---Suspected deep tissue injury T/F- As we age, the basement membrane between the dermis and epidermis flattens out. - \True Circular, free fluid filled, greater than 1 cm - \Bulla Superficial, solid, less than 1 cm, color varies. - \Papule Circular, free fluid filled, up to 1 cm - \Vesicle Linear erosion; destruction of skin by mechanical means - \Excoriation Loss of epidermis; caused by exposure to body fluids - \Denuded Smaller red macules located adjacent to the body of main lesions - \Satellite lesions Change in color of skin, circular flat discoloration, less than 1 cm - \Macule Firm, edematous plaque, infiltration of dermis, may last few hours - \Wheal Bottom of foot. - \Plantar Inner aspect of ankle - \medial Outer apect of ankle - \Lateral Tunneling and undermining is caused by - \pseudomonas There is no one specific lab test that indicates the dx of osteomyelitis; however, 3 labs done together with positive results could be indicative of osteomyelitis. What 3 labs? - \CBC, WBC, Pre Albumin If giving pain medication parenterally, the clinician should wait ______, when given orally, the clinician should wait _____. - \15-30 min, 1 hour Presence of replicating microorganisms which do not cause injury to the host is - \colonization Signs and symptoms of a wound infection would include - \induration, erythema, pain If epiboly occurs a wound margins wound healing will - \stop What would be a COMPLETE wound order? - \Location, frequency, barrier, primary, secondary, cleansing solution, secure with, duration The dressings that provide an environment for autolytic debridement are - \alginates, hydrocolloids and transparent dressings. T/F--All chronic wounds are infected. - \False T/F--When a pressure ulcer has high levels of exudate, consider it infected. - \False The best method to determine whether a wound is infected is to perform a - \tissue culture T/F--Dressing changes 4 times a day will assist with pain reduction and prevent infection. - \False T/F--Safe irrigation pressures are 3-25 psi - \False The recommended treatment for systemic wound infection is the application of ______ or _____ along with______ - \topical antiseptic or antibiotics; systemic antibiotics Hydrocolloid dressings are ____ and provide ____ - \occlusive; autolytic debridement The Joint Commission recommends a nutritional assessment be completed within ______ of admission. - \24 hours People with _____ have difficulty swallowing and may experience pain while swallowing. - \Dysphagia Albumin measures ______ - \visceral protein stores Half life for Albumin is - \18-21 days At risk level for Albumin is - \<3.5 gm/dl Pre-albumin is a more sensitive measure of visceral protein stores, providing a more current picture of protein status. What is the half life and at-risk level for Pre-albumin? - \1-2 days, <16 mg/dl Transferrin is another laboratory test that measures visceral protein stores, this test however is not recommended in patients who have____ - \iron deficiency Hemoglobin, used to monitor for anemia, is a protein that carries oxygen in the blood, and is contained in red blood cells. Normal values in a male would be___ - \14-18 gm/dl Fat soluble vitamins are not excreted by the body, and remain in the liver and fat tissue until they are used. Deficiencies are rare. What are the fat soluble vitamins? - \A, D, E, K Vitamin A effects healing and is needed for promoting deposition of - \collagen C vitamins effect healing and are needed for promoting deposition of _____ and ____ function. - \collagen; fibroblast Water soluble vitamins are derived from water components of food, carried in the blood stream, not stored in the body and excreted in the urine. What are the water soluble vitamins? - \B, C ____vitamins are necessary for the production of energy from glucose, amino acids and fat, and are required for cross linking of collagen fibers in tissue rebuilding. - \B Patients with pernicious anemia are given what vitamin and how? - \B12 injection The primary goal for wound healing nutritionally is to provide adequate - \calories and protein Heavily draining wound. Use__ - \alginate dressing Dry stable intact eschar on heel. Use__ - \dry dressing Partial thickness friction wound on shoulder. Use__ - \transparent film Radiation burn. Use__ - \Hydrogel Contraindicated or use with silver products. - \Enzymatic ointment Partial thickness pressure ulcer in sacral area of incontinent patient. Use___ - \Hydrocolloid Fragile wound bed. Use___ - \Contact layer Dressing that keeps the bed the warmest. - \Foam dressing For pseudomonas infection use___ - \Acetic acid What is the risk assessment tool used for? - \Predicting pressure ulcer development and determining risk level Tools used to assess for pressure ulcer risk. - \Norton, Braden, Norton Plus What tool is used to determine pressure ulcer healing? - \friction Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle are not exposed is what stage? - \Stage III Serum filled blister on heel is what stage? - \Stage II Coccyx, with 90% yellow firmly adherent slough and bone in the wound bed. - \Stage IV Pressure area to sacrum that is 100% covered with black eschar is what stage? - \Unstageable R trochanter that is red, non-blanchable, boggy and the skin is still intact. - \Stage 1 Full thickness wound that occurs in wrinkle or furrow skin. Both epidermis and dermis are pulled apart as if an incision has been made, exposing tissue below. What category skin tear? - \Category 1A Occurs when a patient develops a tissue reaction in a previously irradiated filed following the administration of a chemotherapeutic agent. - \Radiation recall Incision closed by primary intention, the incision is usually covered with a sterile dressing for how long? - \24-48 hours Pyoderma Gangrenosum is a rare inflammatory disease of unknown etiology with painful skin ulcers. Clinically their appearance is - \irregular, jagged, raised wound edges that are violet or bluish in color. Sickle cell ulcerations are chronic usually appearing on the leg, and recurrence rates are high. A laboratory test used for Diagnosing Sickle cell ulcerations is - \Hemoglobin electrophoresis A fistula is an abnormal passage between two or more structures or spaces. Contributing factors to fistula formation are - \Inflammatory bowel disease, cancer, diverticulitis, sepsis, malnutrition Fistulas drain bile, stool, or urine. This can pose a problem for the peri fistula area. What could you use that would protect the peri fistula area? - \pouches, skin barriers, petroleum/ zinc based ointments. If intrinsic means "located within", what does extrinisic mean? - \external A palliative care patient suddenly developed a dark pear shaped ulcer on the sacrum with irregular borders that progressed rapidly in size. This suggest the pt has: - \A Kennedy Terminal Ulcer Upon assessment of a wound it observed to have a nodular cauliflower shaped tissue in the wound bed with heavy seropurulent exudate accompanied by a pungent odor. This suggest: - \fungating wound A patient presents with multiple painful necrotic lesions located on her legs and torso. Labs results elevated serum calcium, phosphate, BUN and creatinine. This suggest: - \Calciphylaxis An indication for HBO (hyperbaric oxygen therapy) is - \gas gangrene What important information should the wound care team forward to discharge planner upon a pts discharge? - \Wound treatment and Emergency contact phone number. One time only "snap shot" of the number of cases at a given time is - \prevalence Pt admitted to ER c/o abdominal pain. Upon exam the lower right quad of the Abd appears red, swollen, and hot to touch. The skin becomes blue gray, fluid filled blisters. This is symptoms of - \necrotizing fasciitis Odor in wounds is caused by - \anaerobic bacteria, necrotic tissue, saturated dressing A pt dx with colon cancer develops candida rash under her breast. The most appropriate tx is - \Miconazole Due to increased epidermal-to -dermal cohesion, deficient stratum corneum and impaired thermoregulation neonates are at high risk for - \epidermal stripping A 2 year old child has a stage II pressure ulcer on his elbow. Use what treatment? - \Apply liquid barrier film to peri-wound and apply transparent dressing.