Healing Horizons: Skin Integrity And Wound care Quiz

Reactive hyperemia is not a pressure ulcer. Reactive hyperemia refers to the increased blood flow to an area of tissue following a period of reduced blood flow. It occurs as a normal physiological response to restore oxygen and nutrients to the tissue. On the other hand, a pressure ulcer, also known as a bedsore or pressure sore, is a localized injury to the skin and underlying tissue caused by prolonged pressure on the skin. Therefore, the statement that reactive hyperemia is a pressure ulcer is false.

The explanation for the answer "False" is that while the body does adapt to heat and cold over time, the response does not decrease more slowly for the next 30 minutes. In fact, the body's response to temperature changes tends to decrease rapidly after the initial strong stimulation of the skin receptors. Therefore, it is not necessary to increase temperature or lengthen the time of application to achieve the desired effect.

Edema refers to the accumulation of fluid in the tissues, causing swelling. When edema occurs at a wound site, it can compress blood vessels and impede the flow of blood to the area. This reduced blood supply hinders the delivery of oxygen and nutrients to the tissue, thereby affecting wound healing. Similarly, pressure applied to a wound can also disrupt the blood supply, leading to insufficient oxygen and nutrient availability for tissue repair. Both edema and pressure act as local factors that interfere with the blood supply and impede wound healing.

A T-tube is used for bile drainage. The T-tube is a plastic tube that is inserted into the common bile duct during certain surgical procedures, such as gallbladder removal or liver transplant. It allows bile to flow out of the body and into a drainage bag or container, helping to prevent bile buildup and complications.

A sling is a type of binder or bandage that is used specifically for supporting an arm. It is typically made of a triangular piece of cloth or fabric that is wrapped around the neck and used to hold the arm in a secure and elevated position. This helps to immobilize the arm and reduce movement, providing support and stability during the healing process. Slings are commonly used for arm injuries such as fractures, sprains, or dislocations, and they can help to alleviate pain and promote proper healing.

The correct answer is B and C. Pressure ulcers and bedsores are both common forms of skin and tissue disruption. Pressure ulcers occur due to prolonged pressure on the skin, often in individuals who are immobile or bedridden. Bedsores, also known as decubitus ulcers, develop when pressure restricts blood flow to an area of the body, leading to tissue damage. Both conditions can be painful and require proper medical attention and care to prevent complications.

An appropriate nursing diagnosis for a stage III or IV pressure ulcer is "Impaired tissue integrity." This diagnosis refers to the damage and breakdown of skin and underlying tissues, which is characteristic of stage III and IV pressure ulcers. These stages involve significant tissue damage, with stage III ulcers displaying full-thickness skin loss and stage IV ulcers involving extensive tissue loss and damage to muscle, bone, or supporting structures. The impaired tissue integrity diagnosis reflects the need for nursing interventions aimed at promoting wound healing and preventing further tissue breakdown.

A figure-of-eight turn is often used for joints, such as the knee, elbow, ankle, and wrist. This type of bandaging technique helps provide support and stability to the affected joint, preventing excessive movement and promoting healing. The figure-of-eight turn involves wrapping the bandage in a crisscross pattern, resembling the shape of the number eight, which helps distribute pressure evenly and immobilize the joint effectively. This technique is commonly used in sports injuries or conditions that require joint support and protection.

A pressure ulcer can be classified as either an acute wound or a chronic wound depending on the duration and severity of the condition. Acute pressure ulcers develop quickly and are usually caused by a sudden increase in pressure on the skin. On the other hand, chronic pressure ulcers develop over a longer period of time and are often associated with prolonged pressure on the skin. Therefore, whether a pressure ulcer is acute or chronic depends on the specific circumstances and characteristics of the wound.

When the skin reaches a temperature of 15 degrees Celsius (60 degrees Fahrenheit), the application of cold causes maximum vasoconstriction. Vasoconstriction refers to the narrowing of blood vessels, which reduces blood flow to the area. This response helps to conserve heat and maintain the body's core temperature. However, after reaching this point, further application of cold can lead to vasodilation, which is the widening of blood vessels. This occurs as a protective mechanism to prevent tissue damage from prolonged vasoconstriction. Therefore, the statement is true.

False. Healing cannot occur despite necrotic tissue in the wound. Necrotic tissue refers to dead or dying tissue, which can hinder the healing process. It can delay wound closure, increase the risk of infection, and prevent the formation of healthy granulation tissue. Removing the necrotic tissue through debridement is often necessary for proper wound healing to take place.

Dehiscence refers to the partial or total separation of wound layers due to excessive stress on wounds that have not fully healed. In this condition, the muscle is typically still intact. Evisceration, on the other hand, specifically refers to the protrusion of organs through the wound opening. Fistula is a separate condition involving an abnormal connection between two body parts. Therefore, the correct answer is Dehiscence.

The explanation for the answer being "False" is that when determining tunneling of a pressure ulcer, an applicator is not required to determine the deepest point. The nurse should assess the depth of tunneling by gently inserting a cotton-tipped applicator or a gloved finger into the tunnel until resistance is felt. The nurse should then measure the distance from the insertion point to the deepest point of the tunnel. Additionally, the statement about assessing the depth of tunneling in a clockwise method with the patient's feet representing 12 o'clock is not accurate or supported by evidence.

Elimination refers to the process of excreting waste products from the body. In this context, the function of the skin as elimination is described as the excretion of water, electrolytes, and nitrogenous wastes through sweat. Sweat glands in the skin help in regulating body temperature by producing sweat, which contains these waste products. This process aids in maintaining the balance of electrolytes and removing toxins from the body.

During the inflammatory phase of wound healing, the body's immune response is most notably present. This phase begins immediately after injury and lasts for approximately 3-5 days. It is characterized by the release of chemical mediators, such as histamine and prostaglandins, which cause vasodilation and increased permeability of blood vessels. This allows immune cells, such as neutrophils and macrophages, to migrate to the site of injury and remove any debris or pathogens. The inflammatory phase is crucial for initiating the healing process and preparing the wound for the subsequent phases of healing.

The given options do not accurately describe the condition mentioned in the question. A wound with a localized area of tissue necrosis is typically referred to as an ulcer. Ulcers are characterized by the death of skin or underlying tissues, resulting in an open sore. Therefore, the correct answer is "None of the above" as none of the options provided match the given scenario.

Hemostasis, which involves blood vessel constriction and clotting, is a normal physiological response to injury and does not directly contribute to pressure ulcer development. Pressure ulcers are primarily caused by external pressure that compresses blood vessels, friction and shearing forces that injure blood vessels and skin, and other factors that impair blood flow and tissue oxygenation. Therefore, the correct answer is that hemostasis does not contribute to pressure ulcer development.

A penrose drain is a soft, flexible tube that is used in medical procedures to drain fluids or pus from a wound or abscess. It is commonly used after incision and drainage of an abscess to prevent the buildup of fluid and promote healing. Additionally, it can be used in abdominal surgery to drain any excess fluid or blood that may accumulate in the surgical site. Therefore, the correct answer is "All of the above" as a penrose drain can provide a sinus tract, is used after incision and drainage of an abscess, and is used in abdominal surgery.

The sites mentioned in the answer - trochanter, coccyx, sacrum, and calcaneus (heel) - are all areas of the body that are at high risk and likelihood for external pressure related bedsores. Bedsores, also known as pressure ulcers, are caused by prolonged pressure on the skin and underlying tissues, often due to immobility. These areas mentioned are commonly affected because they are bony prominences that are subjected to pressure when a person remains in one position for a long time. Therefore, these sites are at a higher risk for developing bedsores.

When pressure is relieved from an area with ischemia, the blood flow to that area increases significantly. This increased blood flow is necessary to provide oxygen and nutrients to the cells in the area and remove waste products. This process is known as hyperemia.

A straight binder is used for supporting the chest and abdomen.

This answer is correct because the question describes a type of wound that is the result of planned invasive therapy or treatment, and the wound edges are clean. This indicates that the wound was intentionally created during a medical procedure or treatment. Therefore, the correct answer is intentional or intentional wound.

This statement is not true because if the patient has not been moved or repositioned, it would actually take longer for a pressure ulcer to form. When a patient remains in the same position for an extended period of time, the external pressure is continuously applied to the same area, resulting in occluded blood capillaries and poor circulation. This leads to ulcer formation and necrosis due to insufficient circulation. However, it would not take as little as 5-6 hours for a pressure ulcer to form without movement or repositioning.

The sling turn is not a roller bandage method because it involves using a bandage to support and immobilize an injured arm by creating a loop around the neck and attaching the arm to it. This method is used to provide support and stability to the arm, rather than to apply pressure or compression to a specific area of the body, which is the main purpose of roller bandages.

The type of wound described in the question is an avulsion. Avulsion refers to the tearing or separation of skin or tissue from the body. In this case, the militants are peeling the skin off the captive, which involves forcefully removing layers of skin from the body. This results in a severe and traumatic injury, causing significant damage and pain to the victim.

The question asks for a psychological effect of wounds that is not listed among the options. The options provided include anxiety, fear, pain, and changes in body image. However, all of these options are indeed psychological effects of wounds. Therefore, the correct answer is "None of the above."

The correct answer is "All of the above" because all three statements are true. Fat tissue is more prone to infection, as it provides a favorable environment for bacterial growth. Fat tissue has fewer blood vessels, which means that there is less blood flow to the area, resulting in slower healing. Additionally, fat tissue is more difficult to suture because it is less firm and may not hold sutures as securely as other tissues. Therefore, all of these factors contribute to slowing down healing in individuals with large amounts of subcutaneous and tissue fat.

All of the options mentioned (Gauze, Iodoform gauze, and NuGauze) allow healing from the base of a wound. These materials are commonly used as wound dressings and have properties that promote healing. They help to absorb excess moisture, protect the wound from infection, and provide a barrier against external contaminants. Additionally, they create a moist environment that is conducive to wound healing and allows for the growth of new tissue from the base of the wound. Therefore, all of the options mentioned can aid in the healing process.

An acute wound is the correct answer because it is characterized by wounds that usually heal quickly within days to weeks. The wound edges are well approximated, meaning they are close together, and the risk of infection is lessened. Acute wounds are typically caused by a traumatic event, such as a cut or a surgical incision, and they have a predictable healing process.

p. 1192

The Y in RYB stands for yellow, which may be indicative of exudate or slough and requires wound cleaning. It is often accompanied by purulent drainage.

Growth factors are naturally occurring proteins that are used to promote healing, promote granulation, and promote cell proliferation and cell migration. However, they are not specifically used for patients with acute wounds. They can be used in various types of wounds, including chronic wounds, to enhance the healing process.

During the process of hemostasis, blood vessels initially constrict to reduce blood flow and allow blood clotting to occur. This constriction helps to prevent excessive bleeding. After clot formation, the blood vessels then dilate to increase capillary permeability. This increased permeability allows plasma and blood components to leak out into the injured area, facilitating the healing process by delivering necessary nutrients and immune cells. Therefore, the correct answer is Hemostasis.

In wounds that heal by primary intention, epidermal cells do not seal the wound within 24 to 28 hours. The correct timeline for epidermal cell sealing is within 48 to 72 hours. Additionally, in wounds that heal by primary intention, the granulation tissue is not visible, as this type of healing involves minimal tissue loss and the wound edges are brought together, resulting in minimal scar formation.

A stage IV pressure ulcer is characterized by extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. It may also require skin grafts and sinus tracts may be present. However, it is not marked by the presence of eschar.

A T-binder is used for supporting the rectum and perineum, as well as in the groin area. This type of binder helps provide compression and support to these areas, which can be beneficial for individuals recovering from surgeries or experiencing muscle weakness or injury in these regions. It helps in reducing discomfort, providing stability, and promoting healing in these specific areas.

p. 1205

The statement is false because the application of heat does not necessarily produce maximum vasodilation in 5 to 10 minutes. The time required for maximum vasodilation can vary depending on various factors such as the individual's response to heat, the intensity and duration of heat application, and the specific area of the body being treated. While heat initially causes vasodilation, prolonged exposure can lead to tissue congestion and vasoconstriction. Therefore, the statement that maximum vasodilation occurs in 5 to 10 minutes and beyond that point vasoconstriction occurs is incorrect.

Secondary intention refers to the healing process of a large or open wound, such as a burn or major trauma, that is left alone to heal without surgical closure. In this process, the wound is allowed to heal naturally by granulation tissue formation, contraction, and epithelialization. This differs from primary intention where the wound edges are brought together and closed with sutures, and from delayed primary intention where the wound is initially left open but later closed surgically. Tertiary intention refers to a wound that is initially left open but is later closed surgically after a period of healing by secondary intention.

Wet-to-dry dressings are not needed for a stage II pressure ulcer. Stage II pressure ulcers are characterized by partial-thickness skin loss involving the epidermis and/or dermis. These ulcers present clinically as an abrasion, blister, or shallow crater. The goal of treatment for stage II pressure ulcers is to maintain a moist healing environment, which can be achieved through the use of occlusive dressings that promote natural healing but prevent the formation of a scar. Wet-to-dry dressings are not recommended as they can cause trauma to the wound bed and delay healing.

Cold is not generally applied to surgical wounds because it can constrict blood vessels and impair blood flow to the area, which is crucial for proper healing. Cold therapy is commonly used for acute injuries like direct trauma, dental pain, and muscle spasms to reduce inflammation and provide pain relief. However, for surgical wounds, other methods like keeping the wound clean, using dressings, and promoting proper blood circulation are preferred for optimal healing.

A cold pack is not a form of moist cold. Cold packs typically contain a gel or liquid that can be frozen and then applied to the affected area. They do not require any additional moisture like gauze or a washcloth soaked in water. Therefore, the statement that a cold pack is a form of moist cold is false.

A closed wound is a classification of wounds that occurs when there is no break in the skin. It is caused by a blow, force, or strain from trauma, such as a fall or car accident. In this type of wound, the skin remains intact, but there may be damage to underlying tissues, muscles, or organs. The term "closed" refers to the fact that there is no open wound or visible break in the skin.

During the inflammatory phase of wound healing, leukocytes are the first type of white blood cells to arrive at the site of injury. They play a crucial role in the immune response by ingesting bacteria and cellular debris through a process called phagocytosis. This helps to eliminate pathogens and clean up the damaged tissue, preparing the wound for the next phase of healing. Macrophages, which are a type of leukocyte, also participate in this process. Therefore, the correct answer is leukocytes.

A stage III pressure ulcer is characterized by full-thickness skin loss and damage or necrosis of subcutaneous tissue. The ulcer presents clinically as a deep crater. However, it is not true that a stage III pressure ulcer extends through underlying fascia.

The dermis is the middle layer of the skin, composed mainly of connective tissue that provides strength and flexibility. It contains nerves that transmit sensory information, allowing us to feel touch, pain, and temperature. The dermis also houses hair follicles, which are responsible for hair growth. Additionally, it is rich in blood vessels that supply nutrients and oxygen to the skin. Therefore, all the options mentioned (connective tissue, nerves, hair, and blood vessels) are present in the dermis, making the correct answer "None of the above".

Wet-to-dry dressings do not have a decreased risk of infection. In fact, they can increase the risk of infection because the moist environment created by the wet gauze can promote bacterial growth. Additionally, the process of removing the dressing can cause trauma to the wound and disrupt the healing process, potentially leading to infection.

A Penrose drain is a soft and flexible drain that is used to passively drain fluid from a wound. It does not have a collection device attached to it, and it is secured in place using a large safety pin. However, it is not sutured in place like other types of drains. Instead, it is left loosely in the wound to allow for drainage. Therefore, the statement "Is sutured in place" is not true of a Penrose drain.

The correct answer is "The sealant glues the epidermal surfaces together." This answer is true because fibrin sealants are used to glue or bond the epidermal surfaces together. Fibrin sealants are made from a mixture of bovine (cow) blood proteins and are commonly used in surgical procedures to promote wound healing and prevent bleeding. Dressings may be used in conjunction with fibrin sealants to prevent infection, but this is not specifically mentioned in the question. Therefore, the correct answer is that the sealant glues the epidermal surfaces together.

Repeated trauma to a wound area does not necessarily result in delayed healing or the inability to heal. While it is true that trauma can impede the healing process, it is not always the case. Factors such as the severity of the trauma, the individual's overall health, and proper wound care can also influence the healing process. Therefore, it is incorrect to claim that repeated trauma always affects wound healing as a systemic factor.

Aquathermia pads are a form of dry heat therapy, not moist heat. Moist heat therapies involve the application of water or moist substances to the body, such as soaks, hot compresses, and sitz baths. Aquathermia pads, on the other hand, use a heating element to provide dry heat to the affected area. Therefore, aquathermia pads do not fall under the category of moist heat therapies.

The spiral turn is used for wrists, fingers, and trunk because it provides a secure and even compression to these areas. It helps to immobilize and support the joints, preventing further injury and promoting healing. The spiral turn involves wrapping the bandage or binder in a spiral pattern, which allows for flexibility and movement while still providing stability. This technique is commonly used in sports injuries, sprains, and strains in these areas.

Dental pain is not typically treated using the application of heat. Instead, dental pain is often treated using other methods such as pain medication, dental procedures, or addressing the underlying cause of the pain. Applying heat to dental pain may actually worsen the pain or cause further damage to the affected area. Therefore, heat is not commonly used as a treatment for dental pain.

The first indication that a pressure ulcer may be developing is blanching, which refers to the whitening of the skin when pressure is applied. This occurs due to the restriction of blood flow to the area, also known as ischemia. Both blanching and ischemia are early signs of pressure ulcers and indicate that the skin is not receiving enough oxygen and nutrients. Therefore, the correct answer is A and B.

A hot compress is not a form of dry heat because it involves the use of a moist or wet material, such as a towel or cloth, that is heated and then applied to the body. Dry heat, on the other hand, does not involve the use of moisture or water. Hot water bags, aquathermia pads, chemical heat, and electric heating pads all use dry heat to provide warmth and therapeutic benefits.

The systemic effects of extensive, prolonged heat can lead to hypovolemic shock. Hypovolemic shock occurs when there is a significant decrease in blood volume, leading to inadequate perfusion of organs and tissues. In this case, the heat causes blood vessels to dilate, leading to increased blood flow to a large area of the body. At the same time, blood flow to other parts of the body decreases, resulting in decreased blood volume overall. This can eventually lead to hypovolemic shock.

A Jackson-Pratt drain is used after breast removal or in abdominal surgery because it decreases dead space by collecting drainage. Dead space refers to the empty spaces left behind after surgery where fluid can accumulate, leading to the formation of seromas or hematoma. By collecting drainage through the drain, the dead space is minimized, reducing the risk of complications and promoting proper healing.

The question asks for a form of dry cold application that is not included in the given options. The options include ice bags, cold packs, and a hypothermia blanket. All of these options are forms of dry cold application. Therefore, the correct answer is "None of the above."

An unintentional wound is one that occurs accidentally, such as from a fall or a sharp object. These wounds are not deliberately inflicted. Clean edges refer to wounds that have smooth and well-defined boundaries, indicating a clean cut or tear. Therefore, both the options A and C are characteristics of unintentional wounds. High risk for infection is not specific to unintentional wounds and can apply to any type of wound.

The correct answer is B and C. In this scenario, Mr. Griffin's wound has undergone delayed primary intention and tertiary intention healing. Delayed primary intention occurs when a wound is initially left open to heal through granulation tissue formation, and then later sutured. Tertiary intention, also known as delayed closure, involves leaving a wound open for a significant amount of time to allow for cleaning and healing of the wound bed, and then closing it with sutures. In Mr. Griffin's case, the wound was initially left open to heal on its own (delayed primary intention) and then sutured several days later (tertiary intention).

Leaving wounds open to the air without dressing is a valid approach for certain types of wounds. It's called "open wound management" or "open wound healing." In some cases, allowing wounds to be exposed to air can aid in the healing process, especially for small, superficial wounds. However, it's essential to note that this approach may not be suitable for all wounds, and healthcare professionals typically consider various factors when deciding on wound management strategies. So, none of the statements provided are universally true or false for wounds left open to the air; it depends on the specific wound and its context.

Piloerection refers to the phenomenon of goosebumps or the erection of hair on the skin in response to cold temperatures or fear. This response helps to preserve warmth by trapping a layer of air next to the skin, which acts as insulation. The other options mentioned in the question, such as the regulation of body temperature by the thalamus and the processes of vasodilation and vasoconstriction, are not directly related to the preservation of warmth through piloerection.