NUR 2206 Exam 10
- Diaphoresis
Answer excessive sweating
- 6 types of wound
Answer Intentional, unintentional, open, closed, acute, chronic
- Phases of wound healing
- During the inflammatory phase of wound healing, capillary permeability increases. This
Answer Hemostasis Inflammatory Proliferation Maturation
results in
Answer
- white blood cells arriving at the site of inflammation
- Types of wound healing
- primary intention
Answer primary intention secondary intention tertiary intention
Answer wound edges are well approximated
- edges touch each other
- secondary intention 1 / 3
Answer wound edges are not approximated
- not touching
- from bottom up
Hels by granulation tissue formation
- tertiary intention
Answer delayed primary intention
- A large wound with considerable tissue loss allowed to heal naturally by formation of
granulation tissue would be classified as which of the following categories of wound healing?
Answer secondary intention
- No drainage wound
Answer "wound is dry and intact"
- necrosis
Answer dead tissue prohibits wound healing
- desiccation
Answer drying up (dehydration) of wound
- Maceration
Answer overydration of cells
- Trauma to wound
Answer 2 / 3
delays wound healing
- Which patient is most at risk for impaired wound healing
Answer An 80-year-old male who is malnourished and dehydrated with a low oxygen level
- During a dressing change, inspection of the wound reveals what appears to be reddish-pink
tissue in the wound. The nurse interprets this as most likely indicating
Answer granulation tissue
- A patient who has a large abdominal would suddenly calls out for help because she feels
as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. What should the nurse do FIRST?
Answer Cover the exposed tissue with sterile towels moistened with sterile NSS
- A patient has a wound caused by exposure to moisture. This wound is considered to be
Answer an area of maceration
- External Pressure Occurs over
Answer bony prominence
- what position for tube feeding and what can this cause?
Answer shearing
- Which of the following patients would most likely develop a pressure ulcer from shearing
forces?
Answer A patient sitting in a chair who slides down
- / 3