Chapter 31: Skin Integrity and Wound Care Questions and Correct Answers the Latest Update and Recommended Version
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Course
Skin Integrity and Wound Care
Institution
Skin Integrity And Wound Care
The nurse would recognize which client as being particularly susceptible to impaired wound
healing?
an obese woman with a history of type 1 diabetes
Obese people tend to be more vulnerable to skin irritation and injury. More significant,
however, is the role of diabetes in creating both s...
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Chapter 31: Skin Integrity and Wound
Care Questions and Correct Answers
the Latest Update and Recommended
Version
The nurse would recognize which client as being particularly susceptible to impaired wound
healing?
✓ an obese woman with a history of type 1 diabetes
✓
✓ Obese people tend to be more vulnerable to skin irritation and injury. More significant,
however, is the role of diabetes in creating both susceptibility to skin breakdown and
impairment of the healing process.
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's
coccyx wound. What is the primary goal of this action?
✓ removing dead or infected tissue to promote wound healing
✓
✓ Debridement is the act of removing debris and devitalized tissue in order to promote
healing and reduce the risk of infection.
Which activity should the nurse implement to decrease shearing force on the client with a
stage II pressure ulcer?
✓ Support the client from sliding in bed.
✓
✓ Shearing force occurs when tissue layers move on each other, causing vessels to stretch as
they pass through the subcutaneous tissue.
A client has a fissure on her finger due to chafing. The client asks "How long will it be painful?"
The nurse explains that the inflammation phase will last:
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✓ 3 days.
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement
should the nurse use to measure the depth accurately?
✓ a sterile, flexible applicator moistened with saline
A nurse caring for a client who has a surgical wound following a cesarean section notes
dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?
✓ There is an unintentional separation of the wound.
✓
✓ With dehiscence, there is an unintentional separation of wound edges, especially in a
surgical wound. In approximated wound edges, the edges of a wound are lightly pulled
together. Edema is an accumulation of fluid in the interstitial tissue. Redness or
inflammation of an area as a result of dilation is erythema.
A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this
procedure?
✓ Clean the wound from the top to the bottom, and center to outside.
The nurse is helping a confused client with a large leg wound order dinner. Which is the most
appropriate food for the nurse to select to promote wound healing?
✓ To promote wound healing, the nurse should ensure that the client's diet is high in protein,
vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate
choice to promote wound healing.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is
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