Deck 39: Tissue and Wound Healing

Question 1

Which finding would the nurse expect when assessing a full thickness wound?

A) Dermis remains intact.
B) Epidermis remains intact.
C) Epidermis and full thickness of dermis is destroyed.
D) Only epidermis is destroyed.

Answer 1

Epidermis and full thickness of dermis is destroyed.

Question 2

Which instruction should be included in the teaching plan for a patient with a chronic wound?

A) Limit fluids to prevent edema.
B) Limit food intake to reduce obesity.
C) Stop smoking to improve wound healing.
D) Maintain bedrest to avoid wound disruption.

Answer 2

Stop smoking to improve wound healing.

Question 3

When assessing a patient's skin, the nurse needs to keep in mind that:

A) light-skinned people do not have melanocytes.
B) light-skinned and dark-skinned people have the same number of melanocytes.
C) melanocytes in light-skinned people do not produce melanin.
D) dark-skinned people have more melanocytes than light-skinned people.

Answer 3

light-skinned and dark-skinned people have the same number of melanocytes.

Question 4

What type of wound would the nurse expect to find in a patient who has a wound healing by primary intention?

A) A surgical wound with a large amount of exudate
B) A large abraded area that is infected
C) A pressure ulcer with pink granulation tissue in the wound bed
D) A surgical wound that is clean and well-approximated

Question 5

In formulating a plan of care for a patient with colon cancer who will be having a colon resection, which local factor should the nurse recognize as affecting wound healing?

A) Smoking
B) Poor nutrition
C) Advanced age
D) Reduced blood flow and hypoxia

Question 6

The nurse in preadmission testing is taking a health history from a patient who will be having an elective hysterectomy. Which vitamin deficiency should be addressed before surgery to ensure proper blood clotting during surgery?

A) Vitamin A deficiency
B) Vitamin C deficiency
C) Vitamin K deficiency
D) Vitamin E deficiency

Question 7

Which nutritional deficiencies should the plan of care address to improve oxygen delivery and wound healing in the patient with a pressure ulcer?

A) Copper deficiency
B) Iron deficiency
C) Magnesium deficiency
D) Zinc deficiency

Question 8

Which response by a parent of a 24-week-old fetus undergoing intrauterine surgery indicates that the parent understands fetal wound healing?

A) "My baby should have little or no scarring if we do the surgery now."
B) "If we wait for 32 weeks' gestation, my baby will have little or no scarring."
C) "Due to a weak inflammatory response, the wound will not heal as strongly as a wound in an adult."
D) "Fetal wounds heal slower than adult wounds."

Question 9

What characteristics would the nurse expect to assess in a patient with a keloid scar?

A) Scar is within boundaries of original injury.
B) Scar extends beyond border of original injury.
C) Scar develops within 1 month of injury.
D) Scar is pruritic and edematous.

Question 10

The nurse is caring for four patients who have abdominal surgical wounds. Which patient in this surgical nurse's assignment does the nurse assess to be at greatest risk for wound dehiscence?

A) A 68-year-old-man with diabetes on postoperative day 5
B) A 60-year-old man on low-dose corticosteroids prior to surgery on postoperative day 1
C) A 40-year-old woman with no past medical history on postoperative day 5
D) A 40-year-old obese woman on postoperative day 2

Question 11

Which assessment findings would alert the nurse of an impending wound dehiscence on a patient with an abdominal incision on postoperative day 5?

A) Incision edges are well-approximated.
B) Abdominal dressing has purulent drainage.
C) Incision has a healing ridge.
D) Incision is pink with scant serous drainage.

Question 12

When assessing a patient's skin, which of the following characteristics of skin should the nurse keep in mind?

A) The epidermis is highly vascular.
B) Lymphatic vessels drain the epidermis.
C) Blood vessels in the dermis nourish the epidermis.
D) Hair follicles originate in the dermis.

Question 13

When changing the dressing on a wound healing by secondary intention, what finding would the nurse expect to observe?

A) An incision closed by sutures
B) A clean incision
C) Minimal granulation tissue
D) A large amount of exudate

Question 14

The nurse is providing discharge instructions to a patient with multiple lacerations and puncture wounds following a motor vehicle accident. Which statement by the patient indicates an understanding of the instructions?

A) "I should remove any scabs that form."
B) "The scab helps with wound repair."
C) "Scabs interfere with healing."
D) "Scabs prevent the wound edges from coming together."

Question 15

When assessing a surgical wound healing by tertiary intention, the nurse expects granulation tissue to begin to appear during which time period?

A) 1-3 days after surgery
B) 3-5 days after surgery
C) A week after surgery
D) Two weeks after surgery

Question 16

Following change-of-shift report, the nurse on a surgical unit is reviewing the assignment. Which 70-year-old patient does the nurse assess as being at greatest risk for impeded wound healing?

A) A man with diabetes mellitus
B) A woman who quit smoking 10 years ago
C) A man with hyperlipidemia
D) A woman on antihypertensive medication

Question 17

The nurse is reviewing the medication list of a patient with impaired wound healing. Which medication would be of concern to the nurse?

A) NPH insulin
B) Prednisone
C) Cefazolin
D) Vitamin C

Question 18

Which finding would the nurse expect when assessing a patient with a hypertrophic scar following second degree burns?

A) Scarring that grows outside boundaries of original injury
B) Scarring raised above the surface of surrounding skin
C) A scar that develops 2 to 3 months after injury
D) Painless scaring

Question 19

In evaluating the effectiveness of negative pressure wound therapy in patients with high-risk surgical wounds, the nurse should expect:

A) healing by secondary intention.
B) greater risk of wound infection.
C) less wound dehiscence.
D) stronger scar formation.

Question 20

When assessing a wound in the remodeling phase of healing, the nurse would expect to find:

A) scar tissue formation.
B) acute inflammation.
C) a fibrin clot.
D) granulation tissue.