Question 1

The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue.Which term will the nurse use to describe the ulcer in the patient's medical record?

Accepted Answer

The nurse will document the ulcer as unstageable as the depth of the wound cannot be determined.Indurated skin feels hard to the touch but is not necrotic.Macerated skin has broken down due to long exposure to moisture.Fluctuant means to change or vary.

Question 2

A postoperative abdominal surgery patient has been admitted to the surgical floor.The nurse is aware that wound healing is delayed due to complications.Which conditions would prevent normal wound healing at the surgical site?

Accepted Answer

Complications of wound healing include any of the following: hemorrhage,hematoma,infection,dehiscence,and evisceration.Hemostasis is a normal response to healing,not a complication.Debridement is the removal of dead or infected tissue from the wound which will promote healing.

Question 3

On admission a patient is noted to have an alteration in skin integrity on the right heel.The nurse uses the Braden Scale.Which areas will the nurse assess when using this scale?

Accepted Answer

The Braden Scale is a highly reliable scale that uses six subscales to identify patients at greatest risk for pressure injuries: sensory perception,moisture,activity,mobility,nutrition,and friction and shear.Infection is not an area that is assessed on the Braden Scale.

Question 4

Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired skin integrity related to immobility and muscle weakness?

Accepted Answer

Appropriate goals for risk for impaired skin integrity include maintenance of intact skin and patient verbalization of methods to prevent skin breakdown.Daily wound assessment and repositioning are interventions.The presence of wounds makes the risk for impaired skin integrity nursing diagnosis inappropriate as wounds have already developed.

Question 5

The patient just sustained a deep laceration that is bleeding profusely.Which stage of healing describes the current state of the patient's wound?

Accepted Answer

Hemostasis phase controls bleeding.Inflammation phase establishes a clean wound bed and obtain bacterial balance.Proliferative phase produces new tissue,epithelialization,and contraction.Remodeling phase reorganizes the collagen to produce a more elastic,stronger collagen for the scar tissue.

Quiz 38: Skin Integrity and Wound Care

The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue.Which term will the nurse use to describe the ulcer in the patient's medical record?

A postoperative abdominal surgery patient has been admitted to the surgical floor.The nurse is aware that wound healing is delayed due to complications.Which conditions would prevent normal wound healing at the surgical site?

On admission a patient is noted to have an alteration in skin integrity on the right heel.The nurse uses the Braden Scale.Which areas will the nurse assess when using this scale?

Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired skin integrity related to immobility and muscle weakness?

The patient just sustained a deep laceration that is bleeding profusely.Which stage of healing describes the current state of the patient's wound?