Deck 21: Plastic and Reconstructive Surgery

Question 1

Marissa Walton is a 6-year-old girl with full-thickness burns involving both lower legs,circumferentially,excluding her feet,over less than 2% of her body surface area (BSA)and partial-thickness burns over less than 15% of her BSA,after her clothes caught fire during a camping trip when she stepped into the campfire.Based on the American Burn Association and the "Rule of Nines" classifications,Marissa's burns would be classified as __ with a burn surface area percentage of approximately __.

A) minor;17%
B) moderate;17%
C) minor;9%
D) major;18%

Answer 1

C
The percentage of body surface area (BSA)system of the American Burn Association uses the following burn classification:Minor burns:Full-thickness burns over less than 2% of BSA;partial-thickness burns over less than 15% of BSA.Both of Marissa's lower legs were burned circumferentially,giving her a score of approximately 9% for the sum of both lower legs.Moderate burns:Full-thickness burns over 2% to 10% of BSA;partial-thickness burns over less than 15% to 25% of BSA.Major burns:Full-thickness burns over 10% or more of BSA;partial-thickness burns over 25% or more of BSA,including any burns to face,head,hands,feet,or perineum;inhalation and electrical burns;or burns complicated by trauma or other disease processes.

Question 2

In addition to the individualized nursing diagnoses that apply to surgical patients,the patient scheduled for plastic or reconstructive surgery can typically be expected to have the following nursing diagnosis:

A) Risk for Infection related to operative/invasive plastic/reconstructive procedure.
B) Disturbed Body Image related to congenital or acquired defect or developmental abnormality.
C) Risk for Ineffective Tissue Perfusion related to surgical intervention.
D) All of the nursing diagnoses are relevant to most plastic and reconstructive surgery patients.

Answer 2

D
Nursing diagnoses related to the care of the patient undergoing plastic and reconstructive surgery might include the following:Risk for Infection related to operative/invasive plastic/reconstructive procedure,Disturbed Body Image related to congenital or acquired defect or developmental abnormality,Risk for Ineffective Tissue Perfusion related to surgical intervention,Impaired Comfort related to surgical/invasive procedure,Deficient Knowledge related to perioperative process,and Anxiety related to surgical interventions or outcomes.

Question 3

Replantation is an attempt to reattach a completely amputated digit or other body part.Revascularization is the procedure performed on incomplete amputations,when the part remains attached to the body by skin,artery,vein,or nerve.Good candidates for replantation are those with the following amputations:

A) almost any body part of a child.
B) proximal portion of the hand at palm level.
C) distal to middle foot.
D) distal to middle thigh.

Answer 3

A
Good candidates for replantation are those with the following amputations:(1)thumb(2)multiple digits(3)distal portion of the hand at palm level(4)wrist or forearm(5)elbow and above the elbow,and (6)almost any body part of a child.The success of digital replantation depends primarily on the microsurgical repair of one digital artery and two digital veins.
Replantation of an amputated part is ideally performed within 4 to 6 hours after injury,but success has been reported up to 24 hours after injury if the amputated part has been cooled.

Question 4

Skin grafting provides an effective way to cover a wound if vascularity is adequate,infection is absent,and hemostasis is achieved.Skin from the donor site is detached from its blood supply and placed in the recipient site.The best description of a successful skin graft outcome is:

A) the skin is a good color match.
B) the recipient site develops a new blood supply from the base of the wound.
C) capillary refill returns within 24 hours.
D) a split-thickness graft is able to regenerate in an area of full-thickness loss.

Question 5

The three most common skin cancers are basal cell,squamous cell,and melanoma.
Treated early,skin cancers such as squamous cell and basal cell carcinomas may be cured by simple excision and closure (with pathologic diagnosis to ensure disease-free margins).
Melanoma is treated much more aggressively because of its high mortality.The A-B-C-Ds of the warning signs for skin cancer stand for:

A) acute,borderline,color,dysplastic.
B) asymmetry,blanching,cohesion,depth.
C) aplastic,bilateral,chronic,dysplastic.
D) asymmetry,border,color,diameter.

Question 6

The perioperative nurse should verify with the patient that all of the preoperative prescribed skin preparation regimens ordered by the surgeon have been performed.All body jewelry that pierces the skin should be removed before the skin prep.Select the statement that reflects a true special consideration for skin preparation before facial surgery.

A) Use chlorhexidine gluconate (CHG) around the ears and eyes.
B) Leave the eyebrows and eyelashes intact to preserve facial appearance and expression.
C) Prep the skin graft and donor sites together with the same prep set and drape immediately.
D) Isolate rashes,open sores,cuts,or lesions in the prep site with a sterile,clear adhesive patch.

Question 7

When coverage for a defect cannot be achieved through skin grafting,plastic surgeons rely on other techniques to replace tissue.After mastectomy,reconstruction with a transverse rectus abdominis myocutaneous (TRAM)flap is one of several options for nonsynthetic prosthetic reconstruction.Another descriptive term for the TRAM flap is the:

A) pedicle-based flap.
B) free flap.
C) mastopexy.
D) rotated tunneled flap.

Question 8

Marissa Walton is transferred to the OR from the burn unit for debridement of the partial-thickness burn areas and a dressing change under anesthesia.What important preparation for the procedure will the perioperative nurse perform before Marissa arrives in the OR?

A) Procure the allograft skin from the freezer and begin the thaw process.
B) Procure a basic plastic instrument set plus a knife dermatome and sterile mineral oil.
C) Prewarm the OR to above the ambient high temperature for an adult.
D) Collaborate with the anesthesia provider to determine fluid replacement requirements.

Question 9

A broad range of implant materials are used in plastic and reconstructive surgery.Select the implant that represents a biologic composition of a surgical implant.

A) Autologous human tissue
B) Medical-grade sterile silicone
C) Gold
D) Polypropylene

Question 10

The science of plastic and reconstructive surgery,which means to mold or create form and shape,improves appearance and body image through an understanding of:

A) body geometry.
B) the anatomy and biology of tissue.
C) form and function.
D) body image.

Question 11

Josh Tremain,a 28-year-old firefighter,sustained significant full-thickness burns when he fell through the roof of a burning building while fighting an explosive fire.What surgical treatments may Josh need before he is discharged from the burn center to home?

A) Debridement and monitoring of full-thickness skin regeneration
B) Debridement,allograft placement during initial healing,and later split-thickness (ST) and full-thickness (FT) skin grafting
C) Allograft and xenograft placement as temporary dressings until secondary granulation begins
D) Tangential excision of the burn wound with antibiotic-soaked dressings

Question 12

Facial fractures are classified according to a system developed by Rene Le Fort in the early 1900s.A fracture that starts at the nasal bones,crosses the frontal process of the maxilla and lacrimal bones,and extends through the orbital floor,infraorbital rim,and lateral maxillary sinus wall is known as a:

A) Le Fort I.
B) Le Fort II.
C) Le Fort III.
D) Le Fort IV.

Question 13

Microsurgery,a fundamental tool in reconstructive plastic surgery,allows an almost unlimited choice of reconstructive methods,replacement of lost tissue with similar components,and optimal selection of donor sites with minimal morbidity.Reconstructive microsurgical procedures include replantation of amputated body parts,repair of facial nerves,repair of lacerated nerves and blood vessels,treatment of extensive trauma to extremities and hands,reconstruction following removal of extensive cancers,and female to male transsexual reassignment.Today's surgeons skilled in microsurgery can successfully anastomose the ends of a vessel or nerve measuring less than:

A) 2 mm.
B) 1.5 mm.
C) 1 mm.
D) 0.5 mm.

Question 14

There are approximately 1 million reported cases of skin cancer per year with the majority being the highly curable basal or squamous cell cancers,accounting for more than 50% of all cancers.Not as common is the most serious skin cancer,malignant melanoma,with an estimated 68,720 cases per year.Select the individual who is at the highest risk for skin cancer.

A) An African-American outdoor sportsman and airline pilot
B) A fair-complected surfer and beach lifeguard who wears sunblock-protective clothing
C) A fair-complected person testing positive for exposure to human papillomavirus
D) A dark-complected person testing positive for human immunodeficiency virus

Question 15

Denise Michaelson had a scar revision of her knee performed along with her bilateral mastectomy with saline implants and ear piercing procedures.The knee scar,before revision,was an 8-cm linear,thin scar that extended obliquely across the anterior portion of her knee.The tension of the scar tissue met resistance when she would bend her knee.The surgeon opted to remove the scar with a procedure to break up the linear scar and rearrange the tissue direction to form a natural line.The proper name of this tissue transfer scar revision is the:

A) scar lysis.
B) epidermolysis with remodeling.
C) scarplasty.
D) Z-plasty.

Question 16

During the planning phase of a procedure for liposuction or post-bariatric contouring procedures,the perioperative nurse will assemble and organize supplies and devices because the procedure may require:

A) repositioning one or more times during surgery.
B) meticulous accounting of fluid loss and blood replacement.
C) pressure dressings.
D) patient transfer to an alternating-pressure bed.

Question 17

One of the most popular lasers used in plastic and reconstructive surgery is attracted to the water in the skin cells and ablates the cells at a predetermined depth.Collagen material beneath the skin surface is also heated,resulting in smoother and slightly tighter skin.Several lasers are attracted to areas of darker pigmentation.This treatment has virtually replaced dermabrasion,because of its consistency in terms of depth of penetration and also because this technique is less dependent on user technique or skill.Select the laser modality that would be the best option for ablation or removal of a pigmented red tattoo.

A) CO₂ laser
B) Erbium:YAG laser
C) Nd:YAG laser
D) Excimer laser

Question 18

Dermatomes are used for removing split-thickness skin grafts (STSGs)from donor sites.The perioperative nurse preparing for a procedure where STSGs will be taken to cover several large burn areas will need to have available:

A) sterile petroleum jelly and sterile impregnated gauze sheets.
B) sterile mineral oil,tongue blades,and a mesher dermatome.
C) sterile mineral oil and carriers.
D) a nitrogen tank,sterile gauze fluffs,and antibiotic ointment.

Question 19

Denise Michaelson,a 46-year-old woman with an early-stage second primary cancer in her left breast,has elected to have a bilateral mastectomy with saline implants.She has requested that the surgeon also revise a small unsightly scar on her right knee and pierce her ears.While Denise's breast tumor could be treated with an excisional biopsy,she has decided to have a mastectomy of both breasts,which is considered an appropriate preemptive (preventative)surgery for a woman of her age with two primary cancers of the breast.The saline implant insertion surgery is considered a ___ procedure,the scar revision is considered a ___ procedure,and the ear piercing is considered a ___ procedure.

A) reconstructive;reconstructive;reconstructive
B) reconstructive;cosmetic;reconstructive
C) cosmetic;reconstructive;cosmetic
D) reconstructive,cosmetic and cosmetic

Question 20

Marla,the perioperative nurse circulating for a skin contracture release of the ear on a 5-year-old boy,transfers 0.25% bupivacaine via syringe to the scrub person's sterile back table.The scrub person,Jake,questions why she is not giving him bupivacaine with epinephrine,since there may be bleeding expected at the incision site.Marla's reply to Jake is based on the fact that:

A) epinephrine is contraindicated in areas with limited vascularity,such as the ears.
B) Marla is complying with the surgeon's standardized order on the preference list.
C) epinephrine-induced vasoconstriction may interfere with normal tissue planes.
D) pediatric heart rates are higher than adult heart rates and epinephrine can cause tachycardia.

Question 21

Sherrel Farmer,a 49-year-old post-bariatric surgery patient,is scheduled for a Vaser-Assisted LipoSelection with tumescent infiltration.The tumescent is a solution of lactated Ringer's,lidocaine,and epinephrine.The perioperative nurse is aware that using more than 70 mL/kg of wetting solution for infiltration can lead to fluid overload.Select an appropriate nursing action related to minimizing the risk of tumescent solution overload or disproportion to lipoaspirate.

A) The nurse will monitor the patient for syncope,cough,and bounding pulse.
B) The nurse will warm the tumescent solution and monitor fluid volumes.
C) The nurse will communicate and verify with the surgeon and/or anesthesia provider the total lipoaspirate and volume of wetting solution used.
D) The nurse will titrate the flow rate of the tumescent solution in coordination with aspirate outflow.

Question 22

Margaret Slayton,a 52-year-old woman with a left mastectomy followed by a TRAM flap reconstruction,was beginning to emerge from anesthesia after her procedure.The perioperative nurse gently moved Margaret's arms from the abducted position on the armboards in preparation for her transfer to her postoperative bed and admission to the PACU.What risk reduction maneuver did the nurse employ to Margaret's bed before transferring her?

A) Flattened the bed to a horizontal plane with slight reverse Trendelenburg to prevent headaches and support her airway
B) Raised the head of the bead to low Fowler's flex position to reduce the stretching on the abdominal donor graft wound site
C) Raised the foot of the bed to minimize deep vein thrombosis formation
D) Slid a wedge under the top of the mattress on the left side to prevent dependent edema in the graft site

Question 23

A variety of implantable devices are used in aesthetic and reconstructive plastic surgery procedures.Tracking of these devices is critical to patient safety.Institutions must report any incident of death or serious injury relating to the use of a medical device.What regulatory agency,commission,or act mandates this process when medical devices fail or cause injury?

A) The Joint Commission agency for sentinel events
B) Original Equipment Manufacturer Device Tracking Commission
C) Food and Drug Administration Device Failure and Recall Act
D) Safe Medical Device Act

Question 24

Franklin Hardy,a 46-year-old man with multiple moles and skin lesions,was undergoing skin lesion excision surgery performed using a local anesthetic.After 90 minutes of surgery and multiple field block injections of 1% lidocaine with epinephrine 1:100,000 and 0.5% bupivacaine,Franklin told the perioperative nurse that he felt dizzy with ringing sensations in both ears,a metallic taste in his mouth,and numbness of the tongue and lips.He became confused and restless and showed an increased heart rate and blood pressure.The perioperative nurse recognized his signs and symptoms of _ and began immediate treatment with ___.

A) bupivicaine and lidocaine toxicity;airway support
B) local/subcutaneous infiltration;aspiration of gastric contents
C) lidocaine overdose;lipid emulsion infusion
D) a potential life-threatening complication;anticonvulsants and ACLS

Question 25

Mohs' surgery is a specialized excision used to treat basal and squamous cell skin cancers.Select the statement about Mohs' surgery that best reflects the process,procedure,and outcome goal.

A) Mohs' surgery is diagnostic,an ambulatory procedure,and a definitive treatment.
B) Lesions are mapped,excised,and examined by frozen section until clear margins are found.
C) The procedure can be very time-consuming to accomplish,but typically results in the preservation of the surrounding healthy tissue.
D) The segments are excised and microscopically examined and the defect is closed with a drain.