Tissue Impariment Practice #2 PDF

**Question 1: Healing by Intention** A patient has a wound that was left open due to infection and is now being surgically closed after granulation tissue has developed. What type of healing is this? A. Primary intention\ B. Secondary intention\ **C. Tertiary intention**\ D. Granulation intention...

**Question 1: Healing by Intention** A patient has a wound that was left open due to infection and is now being surgically closed after granulation tissue has developed. What type of healing is this? A. Primary intention\ B. Secondary intention\ **C. Tertiary intention**\ D. Granulation intention **Correct Answer:** C\ **Rationale:** Tertiary intention healing occurs when a wound is intentionally left open due to infection or contamination and later closed surgically. **Question 2: Wound Healing Principles** Which nursing intervention is most effective in promoting wound healing? A. Applying a dry dressing to keep the wound dry and clean.\ **B. Providing a diet high in protein and calories to support tissue repair.**\ C. Allowing the patient to ambulate only when necessary.\ D. Applying antiseptic solutions daily to all types of wounds. **Correct Answer:** B\ **Rationale:** Adequate protein and calorie intake is essential for tissue repair and wound healing. **Question 3: Nursing Process for Wound Care** What is the nurse\'s priority when caring for a patient with an open wound? **A. Assessing the size, depth, and color of the wound.**\ B. Changing the dressing once a week to avoid disturbing the wound.\ C. Applying an occlusive dressing to all open wounds.\ D. Avoiding the use of sterile techniques unless infection is present. **Correct Answer:** A\ **Rationale:** Assessment is the first step in the nursing process and provides critical information for planning appropriate wound care. **Question 4: Etiology of Pressure Injuries** A nurse is explaining the development of pressure injuries to a student. Which statement by the student shows understanding? A. \"Pressure injuries are caused solely by shearing forces.\"\ **B. \"Prolonged pressure over bony prominences reduces blood flow, leading to tissue necrosis.\"**\ C. \"Moisture from incontinence is unrelated to pressure injury development.\"\ D. \"Pressure injuries occur only in patients with poor nutrition.\" **Correct Answer:** B\ **Rationale:** Prolonged pressure over bony prominences compresses blood vessels, leading to ischemia and tissue death. **Question 5: Braden Scale Assessment** A patient is assessed with a Braden Scale score of 12. What is the priority nursing intervention? A. Continue routine care as this score is within the normal range.\ B. Reassess the patient\'s skin condition in 48 hours.\ **C. Implement a turning schedule every 1 to 2 hours.**\ D. Document the findings and apply a heating pad to improve circulation. **Correct Answer:** C\ **Rationale:** A Braden Scale score of 12 indicates a high risk for pressure injury, necessitating frequent repositioning to prevent skin breakdown. **Question 6: Preventing Pressure Injuries** Which intervention is most effective in preventing pressure injuries in a bedbound patient? A. Massaging over bony prominences to improve circulation.\ B. Applying a foam dressing to areas prone to pressure injuries.\ **C. Repositioning the patient every 2 hours and using support surfaces.**\ D. Using antiseptic sprays on all areas of skin. **Correct Answer:** C\ **Rationale:** Regular repositioning and the use of support surfaces are critical interventions for preventing pressure injuries. **Question 7: Managing Pressure Injuries with Infection** A patient with a Stage 3 pressure injury has signs of infection. What is the nurse\'s priority action? A. Apply a dry gauze dressing to absorb exudate.\ **B. Obtain a wound culture before administering antibiotics.**\ C. Perform surgical debridement immediately.\ D. Clean the wound with hydrogen peroxide. **Correct Answer:** B\ **Rationale:** A wound culture should be obtained before starting antibiotic therapy to ensure appropriate treatment. **Question 8: Factors Delaying Wound Healing** Which factor is most likely to delay wound healing in a patient? A. Adequate protein intake\ **B. Smoking**\ C. Consistent wound care\ D. Normal blood glucose levels **Correct Answer:** B\ **Rationale:** Smoking impairs circulation and reduces oxygen delivery to tissues, delaying wound healing. **Question 9: Clinical Manifestations of Pressure Injuries** A nurse is assessing a patient's sacral area and observes an open ulcer with a red-pink wound bed and no slough. How should this pressure injury be staged? A. Stage 1\ **B. Stage 2**\ C. Stage 3\ D. Stage 4 **Correct Answer:** B\ **Rationale:** A Stage 2 pressure injury involves partial-thickness skin loss with a red or pink wound bed and no slough. **Question 10: Nursing and Collaborative Management of Pressure Injuries** Which collaborative intervention is most appropriate for a patient with a deep Stage 4 pressure injury? A. Applying a hydrocolloid dressing daily.\ **B. Administering prescribed antibiotics and consulting a wound care specialist.**\ C. Massaging the area to promote blood flow.\ D. Leaving the wound open to air. **Correct Answer:** B\ **Rationale:** Antibiotics address infection, and a wound care specialist provides expert recommendations for managing deep pressure injuries.