Fundamental Nursing Skills and Concept 10th Edition Timby
Fundamental Nursing Skills and Concept 10th Edition Timby
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Chapter 28- Wound Care
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
| 1. | A 7-year-old child is brought to a health care facility following a fall from a swing. The nurse notes that surface layers of the skin have been scraped away due to the fall. How should the nurse document this wound? | |
| A) | Incision | |
| B) | Laceration | |
| C) | Abrasion | |
| D) | Puncture | |
| Ans: | C | |
| Feedback: | ||
| The nurse should document this wound as an abrasion. An abrasion is an open wound in which the surface layers of the skin are scraped off. An incision can be described as a clean separation of skin and tissue with smooth, even edges. A laceration is described as a separation of skin and tissue in which the edges are torn and irregular. A puncture is an opening in the skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object. | ||
| 2. | A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse most accurately describe the client’s wound? | |
| A) | A clean separation of skin and tissue with smooth, even edges. | |
| B) | A shallow crater in which skin or mucous membrane is missing. | |
| C) | A wound in which the surface layers of the skin are scraped away. | |
| D) | A separation of skin and tissue in which the edges are torn and irregular. | |
| Ans: | A | |
| Feedback: | ||
| The nurse can describe a wound caused by a sharp knife as an incision wound with clean separation of skin and tissue with smooth, even edges. Ulceration is a shallow crater in which skin or mucous membrane is missing. An abrasion is a wound in which the surface layers of the skin have been scraped away. A laceration is the separation of skin and tissue in which the edges are torn and irregular. | ||
| 3. | A nurse is caring for a client with a puncture wound that is currently in the proliferation phase of the wound repair process. Which of the following statements describes this phase of the wound repair process? | |
| A) | Physiologic defense immediately after tissue injury | |
| B) | Period during which new cells fill and seal a wound | |
| C) | Process by which damaged cells recover and reestablish normal function | |
| D) | Period during which the wound undergoes change and maturation | |
| Ans: | B | |
| Feedback: | ||
| The proliferation phase is the period during which new cells fill and seal a wound. This phase occurs from 2 days to 3 weeks after the inflammatory phase. The inflammatory phase is the physiologic defense immediately after tissue injury. Resolution is the process by which damaged cells recover and reestablish their normal function. Remodeling follows the proliferation phase and is the period during which the wound undergoes change and maturation. | ||
| 4. | A nurse notes that a client who is being treated for a puncture wound at a health care facility is in the second stage of the inflammatory phase. The nurse should know that which of the following functions is a part of the second stage of inflammation? | |
| A) | Blood vessels constrict to control blood loss. | |
| B) | The body produces white blood cells. | |
| C) | Blood vessels dilate to deliver platelets. | |
| D) | Damaged cells become permeable. | |
| Ans: | B | |
| Feedback: | ||
| The nurse should understand that during the second stage of the inflammatory phase, the body keeps producing more white blood cells. A second wave of defense follows the local changes when leukocytes and macrophages (types of white blood cells) migrate to the site of injury, and the body produces more and more white blood cells to take their place. During the first stage, local changes occur. Immediately following an injury, blood vessels constrict to control blood loss and confine the damage. Shortly thereafter, the blood vessels dilate to deliver platelets that form a loose clot. The membranes of the damaged cells become more permeable, causing the release of plasma and chemical substances that transmit a sensation of discomfort. | ||
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