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Fundamentals of Nursing, 9th Ed., Taylor, Lynn, Bartlett

Unit VI: Promoting Healthy Physiologic Responses

Skin Anatomy

Epidermis

Which of the following is considered to be the outside layer of the skin?

Keratinocytes

Which of the following are the barrier cells that protect the body from environmental damage?

Melanocytes

Which of the following is found at the bottom of the epidermis and gives skin its color?

Dendritic Cells

Which of the following are antigen-presenting immune cells located in the epidermis?

Merkel Cells

Which of the following cells are involved in the body's sensation to touch and determination of shapes and textures of objects?

Dermis

Which of the following is considered to be the middle layer of the skin?

Sweat Glands

Which of the following secrete water and help the body decrease temperature during stress, exercise, or fever?

Hair Follicles

Which of the following are rooted in the dermis but extend all the way up to the epidermis?

Sebaceous Glands

Which of the following glands secrete a waxy and oily substance onto the hair and skin?

Hypodermis

Which of the following is composed of connective tissue that attaches the skin to the skeleton?

Characteristics

Pressure Ulcers

Types

Stage 1 - Non-Blanchable Redness

What best describes a stage 1 pressure ulcer?

Stage 2 - Partial Thickness

What best describes a stage 2 pressure ulcer?

Stage 3 - Full Thickness Skin Loss

What best describes a stage 3 pressure ulcer?

Stage 4 - Full Thickness Tissue Loss

What best describes a stage 4 pressure ulcer?

Unstageable

What best describes a pressure ulcer that has dead tissue obscuring it like a scab?

Possible Deep Tissue Injury

What should you be concerned about when finding a pressure ulcer that looks like a deep bruise?

Considerations

Skin Color Alterations

Regarding pressure ulcers, what clinical finding cannot be relied upon necessarily in assessing severity?

Remove Necrotic Tissue Before Staging

What is an important diagnostic consideration regarding pressure ulcers?

Types of Wound Healing

Types of Wounds

Acute

Which of the following is most likely a classification associated with the different types of wound healing?

Chronic

Healing Process

Primary Intention

Which of the following represents a type of wound that is characterized in the wound healing process?

Approximated Edges

Which of the following is most likely a characteristic of primary intention wounds?

Secondary Intention

Edges Not Approximated

Which of the following is most likely a characteristic of secondary intention wounds?

Tertiary Intention

Which of the following most likely characterizes a wound left open due to infection or necrosis and surgically closed at a later date?

Delayed Closure due to Infection and Necrosis

Which of the following is most likely a characteristic of tertiary intention wounds?

Postoperative Care

Head to Toe Assessment

Which of the following is most likely the first priority when a patient returns from surgery?

Complications

Hemorrhage

Which of the following postoperative complications is important to be aware of and often presents with hypotension and tachypnea?

Clotting

Which of the following is most likely a postoperative complication to be aware of?

Pain

Which of the following complications is most likely to occur after surgery?

Dehiscence or Evisceration

Which of the following postoperative complications are characterized by wound separation or organ prolapse through sutures?

Respiratory Complications

Paralytic Ileus

Infection

Wound Drainage Types and Devices

Drainage Types

Serous

Which of the following types of wound drainage is a watery substance that appears clear to yellow and is typically seen in the early stages of healing?

Serosanguineous

Which of the following types of wound drainage most likely consists of leukocytes and blood and is a light pink watery fluid?

Sanguineous

Which of the following types of wound drainage is bright red and is associated with active bleeding, poor wound healing, or reinjury?

Purulent

Which of the following types of wound drainage is most likely green, dark yellow, or brown in color and has a foul smell?

Drainage Devices

T-tube

Which of the following is most likely a drainage device associated with wound drainage?

Penrose

Jackson-Pratt (JP)

Hemovac

Record Drainage Amounts

Which of the following is most likely a consideration associated with wound drainage devices?

Check Device Function

Chapter 32: Skin Integrity and Wound Care

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