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Advanced Nursing 2 Overview - 4N0X1 questions with actual answers.
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Advanced Nursing 2 Overview - 4N0X1questions with actual answers.
The Epidermis ANS - Stratum Corneum
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Basale (germinativum)
Stratum Corneum ANS - The thin, outermost layer of the epidermis
Stratum Basale ANS - The bottommost layer of the epidermis
Dermis ANS - Lies below the epidermis and provides tensile strength and protection for the
underlying muscles, bones, and organs
Wound ANS - A disruption of the integrity and function of tissues in the body
Acute ANS - Caused by trauma or a surgical incision; clean and intact
Chronic ANS - Caused by vascular compromise or chronic inflammation; fails to proceed
through an orderly and timely process to produce anatomical and functional integrity
Control Blood Loss
Establish Bacterial Control
Seal the Defect ANS - After an injury occurs, a series of events is initiated to __________
Partial Thickness ANS - Wounds are shallow and has loss of the epidermis and possibly the
dermis layers; very painful and red in appearance; heal by epidermal regeneration
Full Thickness ANS - Wound extends into the dermis and will heal by scar formation due to
deep structural damage; this process takes longer
Four ANS - There are __________ phases involved in the healing process
Hemostasis ANS - Blood vessels constrict and platelets stop the bleeding; fibrin matrix is
formed for cellular repair
Inflammatory Phase ANS - Mast cells secrete histamine initiating vasodilation of
surrounding capillaries and movement of serum and white blood cells to the damaged
tissues
, Ankle or Knee ANS - Attempting to cool the area with an ice pack doesn't have any value
unless the swelling occurs within a closed compartment such as the __________
Proliferative Phase ANS - Begins and lasts from 3 to 24 days; fibroblasts are present and
synthesizes collagen for granulation
Maturation ANS - The collagen scar gains strength; scar tissue usually contains fewer
melanocytes which leads to a lighter color than normal skin
Pressure Ulcers ANS - Patients with decreased mobility, decreased sensory perception, fecal
or urinary incontinence, and/or poor nutrition have an increased risk for development of
__________
Pressure Ulcer Stage 1 ANS - Skin is intact; however, the area is red in appearance and
doesn't blanch with fingertip pressure
Pressure Ulcer Stage 2 ANS - Partial-thickness skin loss involving dermis; area presents with
shallow, open ulcer with a red-pink wound bed
Pressure Ulcer Stage 3 ANS - Full thickness tissue loss that presents as a "deep red crater"
and may extend to the fascia; slough may be present as well as tunneling
Pressure Ulcer Stage 4 ANS - Full thickness tissue loss with extensive tissue necrosis or
damage to tendon, muscle, or bone; the ulcer may appear dry and black with buildup of
tough necrotic tissue or may present wet and oozing
Slough ANS - Yellowish buildup
Eschar ANS - Black in color
Primary Intention ANS - Typically for clean surgical incisions with little tissue loss; wound
edges are approximated (closed); sutures, steri-strips, or Dermabond may be used
Secondary Intention ANS - Wound edges are not approximated so the wound may be left
open until it becomes filled by scar tissue
Tertiary Intention ANS - Closure of wound is delayed until risk of infection is resolved
Clear like plasma ANS - Serous drainage is
Bright red ANS - Sanguineous drainage is
Pink ANS - Serosanguineous drainage is
Thick and yellow, tan, green, or white ANS - Purulent drainage is
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