Chapter 29: Skin Integrity and Wound Care

Chapter 29: Skin Integrity and Wound Care

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse knows the following wound would be classified as a closed wound:

a.	A large bruise on the side of the face
b.	A surgical incision that is sutured closed
c.	A puncture wound that is healing
d.	An abrasion on the leg

 

 

ANS:  A

In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin’s surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

 

DIF:    Applying        REF:   pp. 614-615    OBJ:   29.2               TOP:   Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity     NOT:  Concepts: Tissue Integrity

 

2. The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?

a.	“The wound will be red.”
b.	“The wound will have pus.”
c.	“The wound will be warm.”
d.	“The wound will need to be treated.”

 

 

ANS:  B

An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 10⁵ per gram of tissue sampled when cultured. The wound will need to be treated for the infection.

 

DIF:    Applying        REF:   p. 615            OBJ:   29.2               TOP:   Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity     NOT:  Concepts: Tissue Integrity

 

3. The nurse knows the following types of wounds heal by tertiary intention:

a.	An acute wound in which the patient has sutures placed when it happened
b.	A pressure ulcer that was treated with dressing changes and healed
c.	An acute wound in which surgical glue was used to close the wound
d.	A wound that was left open initially and closed later with sutures

 

 

ANS:  D

When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.

 

DIF:    Applying        REF:   p. 615            OBJ:   29.3               TOP:   Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity     NOT:  Concepts: Tissue Integrity

 

4. The nurse is caring for a patient who is postoperative day one from an abdominal surgery. The patient complains of a “popping sensation” and a wetness in her dressing. The nurse immediately suspects:

a.	a wound infection.
b.	the stitches came loose.
c.	wound dehiscence.
d.	wound crepitus.

 

 

ANS:  C

Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

 

DIF:    Analyzing      REF:   p. 617            OBJ:   29.2               TOP:   Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity     NOT:  Concepts: Tissue Integrity