Theory Exam 2 (Skin Integrity and wound care) Exam
Practice Questions and Answers (100% Pass)
dehiscence - ✔️✔️separation of the layers of a surgical wound; may be partial, superficial, or a
complete disruption of the surgical wound
erythema - ✔️✔️redness of the skin
evisceration - ✔️✔️protrusion of viscera through an incision
exudate - ✔️✔️fluid that accumulates in a wound; may contain serum, cellular debris, bacteria,
and white blood cells
eschar - ✔️✔️thick, leathery scab or dry crust that is necrotic and must be removed for
adequate healing to occur
debridement - ✔️✔️cleaning away devitalized tissue and foreign matter from a wound
fistula - ✔️✔️an abnormal passage from an internal organ to the skin or from one internal
organ to another
hematoma - ✔️✔️localized mass of usually clotted blood
ischemia - ✔️✔️deficiency of blood in a particular area
maceration - ✔️✔️softening through liquid; overhydration
Pressure drainage - ✔️✔️death of cells and tissue
Skin (essential for maintaining life) - ✔️✔️What is the largest organ in the body?
Skin, subcutaneous layer, and appendages of the skin - ✔️✔️What is the integumentary made
up of?
epidermis & dermis - ✔️✔️What are the 2 layers of the skin?
·protection-barrier
temperature regulation- compensates for both heat and cold
psychosocial- external appearance
sensation- touch, pain, pressure, temperature
vitamin D production-activated by ultraviolet rays from the sun
immunologic-triggered when the skin is broken
absorption- medications
elimination-sweat (water, electrolytes, and nitrogenous wastes) - ✔️✔️What are the functions
of the skin?
Fragile, high risk for injury and infection. - ✔️✔️Developmental considerations affecting skin
integrity:
Infants
Becomes increasingly resistant to injury and infection. Develop immunology -
✔️✔️Developmental considerations affecting skin integrity:
•Subcutaneous and dermal tissues become thin.
•Skin is dryer and itching may occur - ✔️✔️Older Adult:
Activity of the sebaceous and sweat glands decreases.
Prolonged healing time - ✔️✔️Older Adult:
Cell renewal is decreased.
This causes?
lose elasticity. - ✔️✔️Older Adult:
Collagen fiber is less organized, so it causes skin to?
Age
lifestyle variables
changes in health state
illness
Diagnostic measures
therapeutic measures - ✔️✔️Factors that place a person at risk for skin alteration
Skin loses elasticity and becomes prone to breakdown - ✔️✔️Dehydration and malnutrition: If
fluid, protein and vitamin C is deficient...
Then what occurs?
injury - ✔️✔️Reduced sensation (paralysis, nerve damage):If patient has an inability to sense
temperature extremes, pressure, and friction...
•Then what is he/she at an increased risk for?
It will become compromised and breakdown. Placing the patient at increased risk for injury. -
✔️✔️The nurse correctly identifies if this patient does not receive adequate nutrition what will
most likely happen to the integumentary system?
older adults - ✔️✔️Who is at high risk for pressure ulcers?
high protein diets - ✔️✔️What type of diet promotes healing?
Diabetic Ulcer (chronic condition) - ✔️✔️•Cuts and sores that do not heal.
•Lesions on the lower extremities that ulcerate and become necrotic.
•Recurrent bacterial and fungal infections.
-They have comprised skin integrity due to instability with blood glucose levels- vascular
problems increases delayed healing - ✔️✔️What compromises individuals with diabetes?
Hyperglycemia because it causes more damage; it slows and delays wound healing - ✔️✔️Is a
patient more opt to get a foot ulcer when they are hyper or hypoglycemia?
skin breakdown - ✔️✔️Patients on bed rest have increased risk for ___________
irritant - ✔️✔️Casts are an ______ to the skin
Wound - ✔️✔️· A break or disruption in the normal integrity of the skin and tissues
- Mechanical forces: surgical incisions
- Physical injury: burns - ✔️✔️What may a wound result from?
Intentional wounds - ✔️✔️the result of a planned invasive therapy or treatment.
Purposefully created for therapeutic purposes,
Edges are clean and bleeding is controlled,
Wound made under (normally) sterile conditions with sterile supplies.
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