Exam 35: Skin Integrity-Wound Healing

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client

What is the primary difference between acute and chronic wounds? Chronic wounds:

For the client with a stage IV pressure ulcer,what would an applicable patient goal/outcome be?

Which actions would the nurse take when emptying the patient's closed-wound drainage system? Select all that apply.

Which of the following are examples of nonselective mechanical debridement methods? Select all that apply.

When applying heat or cold therapy to a wound,what should the nurse do?

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance.He also has a draining wound.Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?

The patient experiences extensive third-degree burns.What type of healing does the nurse expect? Healing by:

The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity?

What is the primary goal that the nurse should establish for a patient with an open wound?

The patient with a colostomy has been incorrectly applying his ostomy appliance.The continuous contact with liquid stool has caused a skin wound around the ostomy.The nurse assesses bleeding and purulent drainage that has extended into the dermis.How will the nurse classify and document this contaminated wound?

Why is the information obtained from a swab culture of a wound limited?

Your patient has multiple open wounds that require treatment.When performing dressing changes,you should:

A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis.When documenting the depth of the wound,how would the nurse classify it?

The nurse learns in report that the assigned patient has a stage III pressure ulcer.What type of tissue does the nurse expect to find in the wound? Select all that apply.

The nurse is caring for a patient with an infected full-thickness wound with moderate drainage and no odor.What type of dressing will be most appropriate for the nurse to apply?

The patient has shiny ulcerations on a red base over the medial calf of the right leg.There is quite a bit of fluid drainage.He takes anticoagulants because of recurrent deep vein thrombosis.He also reports a sedentary lifestyle.How would the nurse classify this chronic wound?

A patient has a contaminated right hip wound that requires dressing changes twice daily.The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed.The nurse recognizes that the surgeon is using which form of wound healing?

An adult patient is fully able to detect and respond to pain and discomfort.He has no incontinence or mobility limitations.He is of normal weight and consumes a nutritious diet.The patient has no problem with rubbing,friction,or shear.What is the Braden score for this patient?

When teaching a patient about the healing process of an open wound after surgery,which of the following points would the nurse make?