Chapter 60 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

Chapter 60 Medical Surgical Nursing Preparation For Practice 2nd Edition By Osborn

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

A patient injured in an accident has a large open leg wound that will require hospitalization for several days. The patient states he has just completed a course of steroid therapy. The nurse will include additional monitoring for which condition in the plan of care?

1. Delayed wound healing
2. Increased risk of thromboembolism
3. Increased tendency to bleed excessively
4. Increased pain at the wound site

Correct Answer: 1

Rationale 1: Steroids suppress the inflammatory phase and thus contribute to a delay in wound healing. Chronic use of steroids results in decreased production of histamines, which are needed for the inflammatory response.

Rationale 2: There is no increase in the risk of thromboembolism specifically associated with the use of steroids.

Rationale 3: There is no increase in bleeding specifically associated with the use of steroids.

Rationale 4: Steroid use does not increase pain from wounds.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 60-1

Question 2

Type: MCMA

The nurse would assess that granulation tissue is developing in a wound when noting which characteristics?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Beefy red color
2. Blue-gray tinge to the wound bed
3. Small, round nodules in the wound bed
4. Pearly-appearing wound margins
5. Moist tissue

Correct Answer: 1,3,5

Rationale 1: Granulation tissue appears beefy red.

Rationale 2: Granulation tissue should not have a blue-gray tinge.

Rationale 3: Granulation tissue, so named for its characteristic tiny, round, granule-like nodules, is a highly vascular connective tissue that contains newly formed capillaries, proliferating fibroblasts, and residual inflammatory cells.

Rationale 4: Pearl-like wound margins indicate that epithelialization is occurring.

Rationale 5: Granulation tissue is moist.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-1

Question 3

Type: MCSA

The nurse caring for a patient with an extensive wound would expect angiogenesis to begin during which phase of healing?

1. Remodeling
2. Inflammatory phase
3. Maturation
4. Proliferation

Correct Answer: 4

Rationale 1: Remodeling is the final stage of wound healing and occurs after the phase that includes angiogenesis.

Rationale 2: The purpose of the inflammatory phase is to prepare the wound for the growth of new tissue.

Rationale 3: The maturation phase, also known as the remodeling phase, is the final phase of wound healing.

Rationale 4: During proliferation, growth factors originating from injured vessels stimulate the formation of vascular buds and regrowth of vascular loops. Stimulated endothelial cells multiply and form tubular structures differentiating into arterioles or venules, a process referred to as angiogenesis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 60-1

Question 4

Type: MCSA

A nurse assesses that the periwound area of a patient’s large abdominal wound is macerated. What change in nursing management will be required because of the maceration?

1. Apply a petroleum-based product to the periwound area.
2. Keep the moist dressing off the periwound area.
3. No new measures are necessary, as this is a normal finding.
4. Apply a separate moist dressing to the periwound area.

Correct Answer: 2

Rationale 1: It is not necessary to introduce another product into the care of this wound.

Rationale 2: Maceration occurs when excessive moisture destroys the skin’s integrity. Periwound skin becomes macerated when the wet dressing from the wound extends to the skin around the wound. The most appropriate nursing measure is to keep the skin around the wound dry.

Rationale 3: Maceration is not a normal finding and requires nursing intervention.

Rationale 4: Applying moist dressings to the periwound area would worsen the maceration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 60-5