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NUR2356 Multidimensional Care 1 Final
Exam with Answers
What is primary intention wound healing? - Wound edges are well-approximated. Place in order the wound healing process. - Hemostasis - > Inflammation - > Proliferate - > Maturation T/F: Serous-sanguinous drainage is blood mixed with pus. - False. What is sometimes common to see in evisceration? - Fistulas, total separation of the wound, caused by IAP (increased abdominal pressure) What is a partial-thickness wound with loss of epidermis and some dermis? - Stage 2 What is a full-thickness wound with loss of skin and visible subcutaneous tissue? - Stage 3 What is a full-thickness wound with loss of the skin and visible bone and undermining? - Stage 4 What is a wound that has more than 75% of the wound bed covered? - Unstageable
The Braden Scale includes sensory, moisture, activity, and _________________? - Mobility, nutrition, and friction/shear What are some interventions to reduce the risk for skin injury? - Elevate the bed no greater than 30-degrees; offload and reposition; control and inspect skin daily; encourage intake of protein, calories, minerals, and fluids. T/F: The wound assessment should include location, size, color, wound base, drainage, edges, and peri-wound skin. - True. What is an ABI (ankle-brachial index) test? - Determines the atrial flow, determines inadequate blood flow, determines delayed healing. T/F: Hand washing is the best way to prevent infection. - True. How much PSI is needed for proper wound irrigation? - 35 - 70 PSI What is an example of a laceration? - Skin tear What is an example of a portal of entry? - Blood T/F: Virulence is the power of the pathogen to cause disease. - True. T/F: Standard precaution should be used for all the patients. -
Tonometry T/F: Vasoconstriction can cause increased perfusion. - False. T/F: A patient who is 25-years-old needs an MRI. The nurse know it's important to ask about any tattoos. - False. T/F: A patient with kyphosis doesn't have any high-risk. - False. What should the nurse do when assisting with movement or mobility? - Face the movement. What causes shearing and friction injuries? - Opposite pulling of the skin. T/F: Traction should include skin and hygiene assessment. - True. The nurse should suspect ACS (acute compartment syndrome) when the patient complains of _______________. - Rapid, discoloration, pain worse than that of the fracture, weak pulse, and tightness. What fracture is complete with injury to the skin? - Open. T/F: The nurse can control bleeding form a fracture by applying pressure below the site.
T/F: A patient with musculoskeletal inflammation should avoid stretching activities. - False. T/F: The nurse should include in the education, ways to prevent falls. Some activities include removal or rugs and clutter. - True. T/F: Medication such as Ibuprofen can be used for arthritis. - True. The nurse is performing a general survey. What is a component to observe related to musculoskeletal? - Posture and abnormalities. As a nurse, you know that during aging a normal musculoskeletal change would be ____________. - Kyphotic posture T/F: Not bending forward at the waist or neck is a good way to have posture. - True. T/F: Using high-heels helps with posture. - False. Crepitus in osteoarthritis is due to ___________. - Loss of bone particles T/F: The abduction pillow is used to prevent internal rotation after hip surgery. - True.
T/F: Patient with lupus ha a high risk for kidney failure. - True. Calcinosis, Raynaud's, esophygeal dysmotility, sclerodacyly and telangiectasia is known as _________________. - CREST syndrome - a widespread connective tissue disease characterized by changes is the skin, blood vessels, skeletal muscles, and internal organs.
