Exam (elaborations)
NUR 2206 ( LATEST 2024 / 2025 ) MIDTERM | WITH 100% VERIFIED ANSWERS
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NUR 2206 ( LATEST 2024 / 2025 ) MIDTERM | WITH 100% VERIFIED ANSWERS
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NUR 2206 Midterm1. intentional wound
Answer
planned incision
2. unintentional wound
Answer
fall and scrape knee, etc
3. open wound
Answer
skin surface is broken
4. closed wound
Answer
skin surface intact
5. acute wound
Answer
heals quickly, edges approximated, low risk of infection
6. chronic wound
Answer
do not heal as expected, remain in inflammatory phase
--> could be due to arterial or venous inssufficiency
7. phases of wound healing
Answer
1. hemostasis
2. inflammatory phase
,3. proliferation phase
4. materation phase
8. inflammatory phase
Answer
4-6 days; phagocytosis and WBC, generalized body re- sponse to hemostasis, growth factor
released
-acute inflammation (pain, heat, redness, swelling)
9. proliferation phase
Answer
lasts several weeks;
granulation tissue develops to fill in wounds; fibroblastic, regenerative, connective tissue
-new blood cell formation
-oxygen and nutrients needed to heal
10. maturation phase
Answer
begins ~ day 21;
can last months of years; *collagen* remodeled; blood vessels compressed
-scar
11. types of wound healing
Answer
primary, secondary, tertiary intention
12. primary intention
Answer
wound edges well approximated
13. secondary intention
Answer
wound edge not well approximated; heals by granulation tissue formation
,14. tertiary intention
Answer
delayed primary intention
15. desiccation
Answer
drying up of wound; cells die and rust over wound site
16. maceration
Answer
overhydration of cells due to moisture somewhere on skin;
--> leads to softening and breakdown of skin
17. dehiscence
Answer
partial or total separation of wound layers due to excessive stress on wounds that are not healed;
sutures holding wound together pop
--> pts. with a lot of fat, diabetic, or elderly
--> cannot be closed the same way due to bacteria
18. evisceration
Answer
complete separation of wound with protrusion of viscera through incision (intestines/organs
coming out that happens 2-7 days after surgery)
19. fistula
Answer
abnormal passage from internal organ to outside the body or from one internal organ to another
--> skin doesnt heal well or suture slips
--> caused by abscess
, 20. granulation tissue
Answer
During a dressing change, inspection of the wound reveals what appears to be reddish-pink
tissue in the wound. The nurse interprets this as most likely indicating
21. area of maceration
Answer
A patient has a wound caused by exposure to moisture. This wound is considered to be
22. friction
Answer
damaging superficial blood vessels when 2 surfaces rub together (el- bows when patients try to
lift themselves in bed)
23. ischemia
Answer
paleness in area where pressure was applied; deficiency of blood in a particular area
24. reactive hyperemia
Answer
blanchable reddening of the skin when pressure is re- moved
25. stage 1 pressure ulcer
Answer
area of intact skin with nonblanchable redness of localized area usually over bony prominence;
may be painful, firm/soft, warm/cool
26. stage 2 pressure ulcer
Answer
skin loss involving epidermis/dermis (partial-thick- ness), may present as blister;
shallow, open ulcer
27. stage 3 pressure ulcer
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