Review Practice Exercise 2

Skin integrity and wound healing > Fundamentals

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Practice Exercise 2

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Total Questions : 5

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Question 1:

Proper technique for performing a wound culture includes which of the following?

A. Cleansing the wound prior to obtaining the specimen B. Swabbing for the specimen in the area with the largest collection of drainage C. Removing crusts or scabs with sterile forceps and then culturing the site beneath D. Waiting 8 hours following a dose of antibiotic to obtain the specimen

Answer and Explanation

Choice A:

Cleansing the wound prior to obtaining the specimen: The wound should always be cleansed with normal saline before collecting a culture to remove surface contaminants such as dead tissue or drainage. This ensures that the specimen reflects the true infecting organism rather than superficial bacteria.

Choice B:

Swabbing for the specimen in the area with the largest collection of drainage: Swabbing drainage or pus leads to contamination from surface bacteria. The specimen should be taken from clean granulation tissue in the wound base after cleansing, not from exudate.

Choice C:

Removing crusts or scabs with sterile forceps and then culturing the site beneath: Crusts or scabs should only be removed if clinically indicated for wound care-not routinely for culture collection. The appropriate technique is to cleanse first, then rotate a sterile swab over a clean wound surface.

Choice D:

Waiting 8 hours following a dose of antibiotic to obtain the specimen: Culture collection should be performed before starting antibiotics, not several hours after. Waiting may reduce bacterial growth and yield inaccurate results.

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Question 2:

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is

A. Risk for Impaired Skin Integrity. B. Impaired Skin Integrity. C. Impaired Tissue Integrity. D. Risk for Infection.

Answer and Explanation

Choice A:

Risk for Impaired Skin Integrity: This diagnosis is used when the skin is still intact but there are factors that may lead to breakdown (e.g., immobility, incontinence, malnutrition). Since excoriation is already present, the risk has become an actual problem.

Choice B:

Impaired Skin Integrity is the appropriate nursing diagnosis because excoriation means the epidermis has been damaged. This label applies when there is a disruption of the skin surface due to mechanical, chemical, or allergic causes.

Choice C:

Impaired Tissue Integrity: This diagnosis is appropriate when damage extends into deeper tissues such as muscles, tendons, or bones. Excoriation from scratching affects only superficial skin layers (epidermis/dermis), not deeper tissues.

Choice D:

Risk for Infection: While infection is a related risk in excoriated skin, the primary problem is already impaired skin integrity. “Risk for Infection” may be a secondary diagnosis but not the most accurate primary one.

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Question 3:

A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, “I am so ugly now.” Based on this statement, what nursing diagnosis would be most appropriate?

A. Pain B. Impaired Skin Integrity C. Disturbed Body Image D. Disturbed Thought Processes

Answer and Explanation

Choice A:

Pain: Pain is a physical experience and would be the correct diagnosis if the patient’s primary complaint was physical discomfort. The patient’s statement expresses self-image distress, not pain.

Choice B:

Impaired Skin Integrity: This could be a valid nursing diagnosis for the actual tissue injury (incision/wound across nose and cheek), but the patient’s verbalization (“I am so ugly now”) reflects psychosocial distress about appearance, so the priority diagnosis addressing her expressed concern is disturbed body image.

Choice C:

Disturbed Body Image: The adolescent’s statement reflects negative perceptions and emotional distress about appearance following facial injury and surgery. Disturbed body image captures feelings of altered self-concept and is the most appropriate nursing diagnosis to guide psychosocial interventions (support, therapeutic communication, referral).

Choice D:

Disturbed Thought Processes: This diagnosis would be used for cognitive alterations (confusion, delusions, impaired judgment) - not appropriate here; the teen is cognitively coherent and expressing a normal emotional response to a change in appearance.

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Question 4:

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:

A. A sign of infection B. Eschar C. Exudate D. Granulation tissue

Answer and Explanation

Choice A:

A sign of infection: Infection often presents with purulent drainage, increased pain, spreading erythema, warmth, and sometimes malodor or systemic signs. Reddish-pink, bumpy, moist tissue is not infection per se.

Choice B:

Eschar: Eschar is necrotic, dry, leathery, and dark (black or brown), not reddish-pink.

Choice C:

Exudate: Exudate refers to fluid (serous, sanguineous, purulent) draining from a wound, not tissue appearance.

Choice D:

Granulation tissue: Healthy granulation tissue appears reddish-pink, moist, and granular and indicates new capillary growth and connective tissue formation during the proliferative phase of healing.

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Question 5:

The nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply

A. The patient takes time to think about her responses to questions. B. The patient’s age of 86 years. C. Patient reports inability to control urine. D. A scheduled hip arthroplasty E. Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61.1 mg/dL). F. Patient reports increased pain in right hip when repositioning in bed or chair.

Answer and Explanation

Choice A:

The patient takes time to think about her responses to questions: Mild cognitive slowing is common in older adults and does not directly increase the risk for pressure ulcer formation unless accompanied by confusion or immobility. This finding alone is not a significant risk factor.

Choice B:

The patient’s age of 86 years: Advanced age is a major risk factor because the skin becomes thinner, less elastic, and has reduced blood flow and subcutaneous fat, making it more susceptible to pressure injury.

Choice C:

Patient reports inability to control urine: Urinary incontinence contributes to moisture-associated skin breakdown, creating an environment that weakens the skin’s protective barrier and promotes bacterial growth.

Choice D:

A scheduled hip arthroplasty: Hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility

Choice E:

Lab findings include BUN 12 and creatinine 0.9: These are normal renal values, indicating adequate hydration and kidney function. They do not increase risk for pressure ulcer development.

Choice F:

Patient reports increased pain in right hip when repositioning in bed or chair. Pain that limits mobility contributes significantly to pressure ulcer risk. If the patient avoids turning or shifting due to pain, pressure on certain areas becomes prolonged, leading to ischemia and tissue breakdown.

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Practice Exercise 2

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