Skin Integrity Quiz & Flashcards: Chapter 31 Review

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Questions and Answers

What should the nurse assess in a postoperative client who feels like something has just given away?

Dehiscence of the wound

Which client has the highest risk for developing a pressure ulcer?

80-year-old active client

50-year-old client recovering from surgery

65-year-old incontinent client with a hip fracture on bed rest (correct)

30-year-old client with no medical issues

What action should the nurse take to prevent a pressure ulcer in a 78-year-old client on bed rest?

Use pillows to maintain a side-lying position as needed.

Which complications of wounds are accurately described? Select all that apply.

Dehiscence Signup and view all the answers

In which situations has the nurse used a dressing properly? Select all that apply.

Place an OpSite over a central venous access device insertion site Signup and view all the answers

What is true about the dermis? Select all that apply.

The major cell produces collagen and elastin Signup and view all the answers

Which dressing will the nurse select to cover the site where blood was drawn?

Gauze Signup and view all the answers

What should the nurse immediately assess for if a postoperative client describes feeling like something just popped?

Dehiscence Signup and view all the answers

What is the best practice regarding wound healing when applying a saline-moistened dressing?

Wounds heal better when a moist wound bed is maintained. Signup and view all the answers

What should the nurse do to keep the swab and inside of the culture tube sterile when obtaining a wound culture?

Keep the swab and inside of the culture tube sterile. Signup and view all the answers

Which teaching should the nurse provide to a caregiver about wound healing for an 85-year-old client? Select all that apply.

Consider having a home health aide to decrease the client's stress level. Signup and view all the answers

What requires further nursing teaching regarding Steri-Strips after a Cesarean section?

Steri-Strips will hold my wound together until it heals. Signup and view all the answers

Which client is particularly susceptible to impaired wound healing?

An obese woman with a history of type 1 diabetes Signup and view all the answers

What is the primary goal of debridement in wound care?

To remove dead or infected tissue Signup and view all the answers

What activity should the nurse implement to decrease shearing force on a client with a stage II pressure ulcer?

Support the client from sliding in bed. Signup and view all the answers

How long will the inflammation phase last for a fissure due to chafing?

3 days. Signup and view all the answers

Which implement should a nurse use to measure the depth of a client's tunneled wound accurately?

A sterile, flexible applicator moistened with saline. Signup and view all the answers

What does wound dehiscence indicate?

There is an unintentional separation of the wound. Signup and view all the answers

Which guideline should the nurse follow when cleaning a wound?

Clean the wound from the top to the bottom, and center to outside. Signup and view all the answers

What type of diet should the nurse recommend to promote wound healing?

A diet high in protein, vitamin A, and vitamin C. Signup and view all the answers

What is the appropriate action for the nurse when applying a heating pad for neck pain?

Keep the pad in place for 20 to 30 minutes, assessing it regularly. Signup and view all the answers

Which client is most likely to develop a pressure ulcer from shearing forces?

A client sitting in a chair who slides down. Signup and view all the answers

Which wound would most likely heal by primary intention?

A surgical incision with sutured approximated edges Signup and view all the answers

Which of the following is not considered a skin appendage?

Connective tissue Signup and view all the answers

How should the nurse document well-approximated edges of a wound with no signs of infection?

Incision. Signup and view all the answers

How long should a client refrain from douching before a Pap procedure?

24-48 hours. Signup and view all the answers

What indicates effective nursing teaching regarding the use of an ice pack?

I will put a layer of cloth between my skin and the ice pack. Signup and view all the answers

What type of injury results from falling onto both knees?

Contusion. Signup and view all the answers

What does a Jackson-Pratt drain do?

It provides a way to remove drainage and blood from the surgical wound. Signup and view all the answers

What should the nurse instruct the client with a Cesarean section about caring for her incision?

It is important to keep your sutured incision clean. Signup and view all the answers

Which dressing supply should the nurse gather for expected blood and drainage?

Montgomery straps Signup and view all the answers

To determine a client's risk for pressure ulcer development, what question should the nurse ask?

Do you experience incontinence? Signup and view all the answers

Which skin layer should a student nurse recognize as a source of energy in an undernourished client?

Subcutaneous tissue. Signup and view all the answers

What laboratory finding increases a client's risk for pressure ulcer development?

Albumin 2.8 mg/dL. Signup and view all the answers

What statement describes common skin characteristics in children?

An infant's skin and mucous membranes are easily injured and at risk for infection. Signup and view all the answers

What factor is responsible for the increased risk of developing a decubitus ulcer when clients are pulled up in bed?

Shearing force. Signup and view all the answers

What should the nurse recognize when assessing pale white skin over a client's coccyx?

This is ischemia, followed by reactive hyperemia. Signup and view all the answers

What skin infection is caused by beta-hemolytic streptococci and common in children?

Impetigo. Signup and view all the answers

How will the nurse respond to a client asking why their large surgical wound is still open?

Your wound will heal slowly as granulation tissue forms and fills the wound. Signup and view all the answers

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

False Signup and view all the answers

What is the wound measurement method for determining depth?

Moistening a sterile, flexible applicator with saline and inserting it gently into the wound. Signup and view all the answers

What should be done before removing sutures encrusted with blood?

Moisten sterile gauze with sterile saline to loosen crusts. Signup and view all the answers

What response should the nurse give about the potential for curing psoriasis?

You will likely experience periods of increased skin outbreaks and periods of remissions. Signup and view all the answers

What type of burn is characterized by pink skin with small blisters?

Second degree. Signup and view all the answers

What does dehiscence refer to in wound healing?

Dehiscence is when a wound has partial or total separation of the wound layers. Signup and view all the answers

What skin type characteristic suggests an increased risk for pressure ulcer development?

An albumin level of 2.8 mg/dL. Signup and view all the answers

Which layer of skin serves as a potential energy source in an undernourished client?

Subcutaneous tissue. Signup and view all the answers

What should the nurse document after a dressing change?

Document the color, odor, amount, and type of wound drainage. Signup and view all the answers

What should the nurse assess before beginning negative-pressure wound therapy?

Assess the wound for active bleeding. Signup and view all the answers

Adequate blood flow to the skin requires that local capillary pressure must be ___________ than external pressure.

higher Signup and view all the answers

What should the nurse teach about healing of a minor surgical wound by first intention?

Very little scar tissue will form. Signup and view all the answers

What type of healing occurs when a wound like a surgical incision has clean edges with little tissue loss?

Primary intention. Signup and view all the answers

What factor complicates healing in an obese client with a pressure ulcer?

Adipose tissue is poorly vascularized. Signup and view all the answers

Study Notes

Skin Integrity and Wound Care

Susceptibility to impaired wound healing is heightened in individuals who are obese, especially those with diabetes.
The main goal of debridement is to remove necrotic or infected tissue to enhance the healing process.
To reduce shearing forces on clients with pressure ulcers, support the client to prevent sliding in bed, as shearing causes tissue damage.
The inflammation phase of wound healing typically lasts about 3 days.
For accurate measurement of a tunneled wound, a sterile, flexible applicator moistened with saline is required.
Dehiscence in wounds refers to an unintentional separation of edges, particularly concerning in surgical wounds.
When cleaning a wound, it is recommended to move from top to bottom and center to outside to avoid contaminating the wound.
A diet rich in protein, vitamin A, and vitamin C is crucial for promoting wound healing; fish is an excellent choice for protein.
When using a heating pad, monitor the application for 20 to 30 minutes to avoid skin damage.
Clients who slide down in chairs are more at risk for developing pressure ulcers due to the effects of shearing forces.
Primary intention healing occurs in well-approximated surgical incisions, contrasting with secondary intention, which occurs in larger, complicated wounds.
Connective tissue is not classified as a skin appendage; hair, sebaceous glands, and eccrine sweat glands are.
Wounds with smooth edges and no signs of infection should be documented as incisions, not as avulsions or abrasions.
Clients should avoid douching 24-48 hours prior to a Pap test to preserve diagnostic cells.
An effective ice pack application involves placing a cloth barrier between the skin and ice to prevent frostbite.
Contusions result from injuries to soft tissue, commonly appearing as bruises with swelling.
A Jackson-Pratt drain allows blood and fluid to exit through a bulb-like structure post-surgery.
Proper care of surgical incisions includes maintaining cleanliness to prevent infection.
Montgomery straps are essential for managing drainage in dressing changes alongside gauze.
Assessing a client’s incontinence is critical in determining their risk for pressure ulcers, as moisture vulnerability increases the risk.
Subcutaneous tissue serves as a potential energy source in undernourished individuals, while the epidermis provides protection.
A low albumin level (2.8 mg/dL) indicates nutritional deficiency, increasing the likelihood of pressure ulcer development.
Infants’ skin is highly susceptible to injury due to its delicate nature and can lead to infection.
Shearing forces, caused by friction between layers of tissue, elevate the risk for decubitus ulcers.
Assessing areas that blanch and then become red is indicative of ischemia and reactive hyperemia, not a stage I pressure ulcer.
Impetigo is a common skin infection, particularly among children, caused by beta-hemolytic streptococci.
Wounds healing by secondary intention typically require more time and tissue formation than those healing by primary intention.
A Penrose drain is inserted through a stab wound for effective drainage.
Documenting wound drainage involves noting aspects such as color, odor, amount, and type.
Negative-pressure wound therapy requires assessment for any active bleeding prior to treatment.
Four factors are vital for adequate skin perfusion: capillary pressure, cardiac output, blood volume, and patent vascular systems.
Healing by first intention minimizes scar formation; primary intention wounds generally heal cleanly and quickly.
Obese clients may face challenges in wound healing due to the poor vascularity of adipose tissue.
Signs of wound dehiscence may include a sudden feeling of something giving way, especially post-operation.
Older, incontinent clients with limited mobility, such as those with hip fractures, are at a heightened risk for pressure ulcers.### Pressure Ulcer Prevention
Use pillows to support a side-lying position, helping to change pressure on bony prominences.
Change client’s position at least every 2 hours to prevent pressure ulcers.
Perform incontinent care every 2 hours and as needed to minimize moisture and skin irritation.
A foot board prevents foot drop but does not lower pressure ulcer risk.

Wound Complications

Dehiscence: Partial or total disruption of wound layers.
Evisceration: Viscera protrudes through the incision.
Postoperative fistula: Manifests as drainage from an opening, often due to delayed healing.
Symptoms of wound infection appear within 1-2 weeks after injury or surgery.
Delayed healing in thin clients may stem from malnutrition rather than tissue layer thickness.
Increased serosanguineous fluid between postoperative days 4-5 can indicate impending dehiscence.

Proper Dressing Usage

OpSite is ideal for covering central venous access device sites with minimal drainage.
Aseptic techniques must be employed when changing dressings.
Sof-Wick should be placed around drain insertion sites to absorb drainage and protect the wound.
Do not place transparent dressings over ABD pads; use tape instead to monitor drainage.
Telfa dressings allow drainage to pass through without adhering to the wound.

Dermis Characteristics

Major cells in the dermis produce collagen and elastin and it is the thickest skin layer.
The dermis is located beneath the epidermis, the skin’s outer layer.
Epidermis major cells produce keratin, while basal epidermal cells produce melanin.

Blood Draw Dressing

Use gauze to cover the site after blood is drawn.
Transparent dressings like OpSite are meant for IV sites.
Hydrocolloid dressings maintain moisture in wounds.

Immediate Assessment in Postoperative Client

Assess for dehiscence when a client feels a "pop" during transfer, signaling potential wound disruption.
Infection symptoms include redness, warmth, and swelling.
Evisceration refers to protruding intra-abdominal contents.

Wound Healing Response

A moist wound bed is beneficial for healing, contrary to the myth that wounds heal better when dry.

Wound Culture Process

Maintain sterility of the swab and culture tube when obtaining wound cultures.
Cleanse the wound prior to culture collection.
Ensure the culture swab does not touch surrounding skin.
Use separate swabs for multiple culture sites.

Wound Healing in Older Adults

Healing may take twice as long in older adults compared to younger individuals.
Consider a home health aide to help reduce caregiver stress.
Long-term sun exposure can delay wound healing.
Normal aging changes include decreased appetite, and depression may impact healing but is not a normal response.

Client Education on Cesarean Section Wound Care

Steri-Strips are insufficient for holding a Cesarean section wound; sutures or staples are used initially.
Healthcare providers will remove the staples after a set period.

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Description

This quiz focuses on concepts related to skin integrity and wound care as outlined in Chapter 31. It includes recognition of factors affecting wound healing, such as obesity and diabetes. Test your knowledge and understanding of these critical nursing concepts.

Chapter 31: Skin Integrity and Wound Care