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Quiz von Amanda Burton, aktualisiert more than 1 year ago
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Erstellt von Amanda Burton
vor etwa 7 Jahre
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Your patient has had abdominal surgery for a ruptured appendix and requires postoperative care and dressing changes. The wound has been left open, and irrigation's are ordered. When irrigating a wound, it is most important to:
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irrigate slowly to prevent discomfort
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ensure the solution reaches the depths of the wound
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prevent wetting of the bed and covers
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use vigorous irrigation flow from the syringe
Frage 2
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If a wound appears infected, you should:
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cleanse it with an antiseptic solution
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obtain an order for culture to be performed
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apply an antibiotic ointment
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change the dressing every 2 hours
Frage 3
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The assessment of the wound indicates healing is occurring when:
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the center tissue is white
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bleeding has stopped
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there is no further drainage from the wound
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pink granulation tissue is visible
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When assessing for wound infection, you know that signs of wound infection may be:
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a rise in temperature
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increasingly rapid respirations
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a WBC above 10,000/dl
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restlessness and discomfort
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purulent drainage
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tenderness around the wound
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When caring for a pressure ulcer, you know that:
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eschar must usually be removed before the wound will heal
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pink granulation tissue should be cleansed with antiseptic solution
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keeping the wound dry and covered will aid healing
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heat treatments hurt new tissue and slow healing
Frage 6
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Hydrocolloid dressing are useful for open wound dressings because they:
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keep the wound moist while blocking entry of microorganisms
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debride the wound and soften eschar
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supply bacteriostatic action to clean the wound
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contain an antiseptic, allow moisture to evaporate, and protect the wound.
Frage 7
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If you are assisting a surgical patient to the bathroom and he suddenly says, "It feels like something has given way," you would suspect that [blank_start]dehisence[blank_end] has occurred.
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dehisence
Frage 8
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Proper technique for removal of sutures is to:
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clip the suture below the knot
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assure the patient that suture removal does not hurt
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refrain from pulling an exposed suture through the wound
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apply a Steri-strip before removing the suture
Frage 9
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Heat is helpful in healing a wound because it:
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causes constriction of blood vessels and reduces edema
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soothes nerve endings, lessening pain
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causes vasodilation, bringing oxygen and nutrients to the injury
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causes vasodilation, which moves blood out of the area
Frage 10
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The ulcer appears as a defined area of persistent redness in lightly pigment skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
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Stage 1
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Stage 2
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Stage 3
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Stage 4
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Eschar
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Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
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Stage 1
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Stage 2
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Stage 3
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Stage 4
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Eschar
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Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
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Stage 1
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Stage 2
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Stage 3
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Stage 4
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Eschar
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Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be present.
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Stage 1
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Stage 2
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Stage 3
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Stage 4
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Eschar
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An unstageable wound, that is thick dry black necrotic tissue.
Image:
Eschar (binary/octet-stream)
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Stage 1
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Stage 2
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Stage 3
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Stage 4
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Eschar
Frage 15
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These wounds heal more quickly, as new skin cells are produced by the epithelial cells remaining in the dermal layer of the skin. Ex: 1st or 2nd degree burns
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Partial-thickness
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Full-thickness
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Contusion
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Hematoma
Frage 16
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These wounds occur when the dermal layer is no longer present except at the wound margins all the way to tendons or bones.
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Partial-thickness
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Full-thickness
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Contusion
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Hematoma
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A closed wound that tissue injury without breaking of skin.
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Contusion (bruise)
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Hematoma
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Sprain
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Incision
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A closed wound that tissue injury that damages a blood vessel; pooling of blood under the unbroken skin.
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Contusion (bruise)
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Hematoma
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Sprain
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Incision
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A closed wound that wrenching or twisting of a joint with partial rupture of its ligaments; causes swelling
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Contusion (bruises)
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Hematoma
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Sprain
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Incision
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An open wound that is a surgically made separation of tissues with clean, smooth edges.
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Incision
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Laceration
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Puncture
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Abrasion
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an open wound that is from traumatic separation of tissues with irregular, torn edges.
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Incision
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Laceration
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Abrasion
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Puncture
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An open wound that is from a traumatic scraping away of surface layers of skin.
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Incision
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Laceration
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Abrasion
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Puncture
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Penetrating
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An open wound that is a variable size through the skin and underlying tissues made by a bullet or metal or wood fragment; may extend deeply into the body.
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Incision
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Laceration
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Abrasion
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Puncture
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Penetrating
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An open wound made by a sharp, pointed object through the skin or mucous membranes and underlying tissue.
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Incision
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Laceration
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Abrasion
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Puncture
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Penetrating
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An open wound that is tearing away of a structure or a part, such as a fingertip, accidentally or surgically.
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Puncture
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Penetrating
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Avulsion
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Ulceration
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Perforation
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An open wound that is an excavation of skin and underlying tissue injury or necrosis.
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Penetrating
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Avulsion
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Ulceration
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Perforation
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Crush
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An open wound is an internal organ or body cavity tissue opened, usually because of infection or a penetrating wound.
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Penetrating
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Avulsion
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Ulceration
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Perforation
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Crush
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An open wound that is a tissue significantly disrupted or compressed because of high level of force being applied.
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Avulsion
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Ulceration
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Perforation
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Crush
Frage 29
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This occurs in the form of fibrous connective tissue that does not have the same functional characteristics as the tissue lost when the wound occurred.
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Replacement
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Regeneration
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Inflammation
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Necrosis
Frage 30
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If the blood supply has been disrupted to the new wound bed and necrosis has occurred, the affected tissue must heal by [blank_start]regeneration[blank_end].
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regeneration
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replacement
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inflammation
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debridement
Frage 31
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Which of these affected tissues will regenerate if lost.
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Skin
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Heart muscle
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nerve cells
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mucous membranes
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bone marrow
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bone
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liver
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kidney
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lung tissue
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ear drum
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No matter what cause of the wound, healing occurs in [blank_start]3[blank_end] distinct phases.
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3
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2
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4
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5
Frage 33
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A phase of the wound healing process begins immediately after injury and lasts about 3 or 4 days. It includes constriction of blood vessels, platelet aggregation, and the formation of fibrin.
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Inflammatory phase
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Proliferation or reconstruction phase
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Maturation or remodeling phase
Frage 34
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The inflammatory phase is the process of
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hemostasis
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homeostasis
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hemorrhage
Frage 35
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Full thickness wounds heal how
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from bottom-up
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from top to bottom
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over 24 hours
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by drying out the bed
Frage 36
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The collection of plasma and electrolytes leaking into the interstitial spaces causes [blank_start]edema[blank_end].
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edema
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collagen
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necrosis
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inflammation
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The phagocytic cells remove debris and protect against bacterial invasion by engulfing of microorganisms or foreign particles called [blank_start]phagocytosis[blank_end].
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phagocytosis
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The clinical signs of inflammatory process are as follows:
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Swelling or edema
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Erythema
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Cyanosis
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increased temperature
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pain steming from pressure
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numbness
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loss of function
Frage 39
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This phase of wound healing begins on the third or fourth day after injury and lasts 2 to 3 weeks while macrophages continue to clear the wound of debris, stimulating fibroblasts, which synthesize collagen.
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Inflammatory phase
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Proliferation or reconstruction phase
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Maturation or remodeling phase
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This phase of wound healing begins about 3 weeks after injury, scar formation, is the process of collagen lysis and collagen synthesis by the macrophages to produce the strongest scar tissue possible.
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Inflammatory phase
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Proliferation or reconstruction phase
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Maturation or remodeling phase
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If collagen overgrowth occurs, which is frequent in dark-pigmented skin, a permanent raised, enlarged scar called this occurs
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Keloids
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Adhesions
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First intention
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Second intention
Frage 42
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The interior of the body, has fibrous bands that hold together tissues that are normally separated and may grow and interfere with function of the internal organs. What are these fibrous bands called
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adhesions
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lesions
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abrasions
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keloids
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A wound with little tissue loss, such as a surgical incision and the edges of the wound approximate and there is only a slight chance of infection, heals by
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First intention
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Second intention
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Third intention
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A wound with tissue loss, such as a decubitus ulcer or severe laceration typically heals by
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First intention
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Second intention
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Third intention
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This type of healing is known as delayed or secondary closure, occurs when there is delayed suturing of a wound. Such wounds are sutured after granulation tissue has began to form.
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first intention
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second intention
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third intention
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If internal hemorrhage is extensive, hypovolemic shock occurs resulting in:
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decreased blood pressure
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increased blood pressure
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increased respiration's
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rapid thready pulse
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bradycardia
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restlessness
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diaphoresis
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cold clammy skin
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elevated temperature
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A localized infection called an [blank_start]abscess[blank_end] is an accumulation of pus made up of debris from phagocytosis when microorganisms have been present.
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abscess
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hematoma
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cellulitis
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fistula
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This is an inflammation of the tissue surrounding the initial wound, with redness and induration.
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Cellulitis
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Fistula
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Exudate
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Abscess
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This is a abnormal passage or communication usually formed between two internal organs or leading from an internal organ to the surface of the body.
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Cellulitis
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Fistula
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Exudate
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Abscess
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The best way to prevent wound infection is to maintain strict asepsis when performing wound care.
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- True
- False
Frage 51
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[blank_start]Dehiscense[blank_end] is the spontaneous opening of an incision, an abdominal wound often involves separation of the layers beneath the skin as well.
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Dehiscense
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Evisceration
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Sinus
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Laceration
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This is the protrusion of an internal organ through the incision.
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Dehiscense
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Evisceration
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Fistula
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Laceration
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The greatest risk for wound dehiscence is on how many postoperative days, before extensive collagen build up.
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4-5
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2-3
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5-6
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10-15
Frage 54
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If dehiscence occurs which steps should be taken
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lay the patient in supine
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lay the patient in semi-fowlers
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place a large sterile dressing
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push the contents back in
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towels soaked in normal saline
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make patients NPO immediately
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There are three basic wound types: red, yellow and black. the type of wound indicates the type of dressing needed.
This wound is clean and ready to heal.
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Red wound
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Yellow wound
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Black wound
Frage 56
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There are three basic wound types: red, yellow and black. the type of wound indicates the type of dressing needed.
This wound has a layer of fibrous debris or exudate. Sloughing may cause drainage and needs to be frequently cleansed and should have a dressing that will absorb the drainage and debride the surface mechanically. These wounds often become infected.
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Red wounds
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Yellow wounds
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Black wounds
Frage 57
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There are three basic wound types: red, yellow and black. the type of wound indicates the type of dressing needed.
These wounds need debridement of the eschar to heal.
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Red wounds
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Yellow wounds
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Black wounds
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This type of drain is a flat rubber tube, often a safety pin is placed external end of the drain to prevent it from slipping into the wound.
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Penrose
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Hemovac
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Jackson Pratt or Jp
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A plastic drainage tubes can be connected to a drainage system that is compressed and closed to create suction, this device contains springs and can hold up to 500 mL of drainage.
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Penrose
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Hemovac
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Jackson Pratt or JP
Frage 60
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A plastic drainage tube can be connected to a drainage system that is compressed and closed, applying slight suction to the drainage tube to help evacuate wound fluids. You must compress the bulb of this device and it holds about 100 mL of drainage.
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Penrose
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Hemovac
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Jackson Pratt or JP
Frage 61
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A transparent film dressing, such as [blank_start]Opsite[blank_end], allows you assess the wound without removing the dressing, these are often used to cover intravenous catheter sites.
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Opsite
Frage 62
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When taping a dressing to your patient you should tape the dressing [blank_start]across the joint or crease[blank_end] to get correct a adhesion.
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across the joint or crease
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up and down along the edges of bandage
Frage 63
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Wound cleansing should be performed by [blank_start]warm[blank_end] isotonic saline.
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warm
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cool
Frage 64
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Surgical wounds and open wounds dressing require [blank_start]sterile[blank_end] technique.
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sterile
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nonsterile
Frage 65
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If the wound is infected, the dressing may be changed how often?
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12-24 hours
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8-12 hours
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48-72 hours
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3 times a week
Frage 66
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Sometimes a wet to dry dressing may also be applied to help he sloughing of necrotic tissue by what
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Mechanical debridement
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Chemical debridement
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Sharp debridement
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Autolytic debridement
Frage 67
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You do not have to have a physicians order to remove sutures or staples.
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- True
- False
Frage 68
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Some therapeutic effect of heat application could be
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Vasodilation
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Vasoconstriction
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Reduced blood viscosity
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Reduced muscle tension
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Increased blood viscosity
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Increased tissue metabolism
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Increased capillary permeability
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Decreased muscle tension
Frage 69
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Some therapeutic effects of cold application.
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Vasoconstriction
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Vasodilation
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Local anesthesia
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Reduced cellular metabolism
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Increased blood viscosity
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Reduced blood viscosity
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Decreased muscle tension
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Reduced muscle tension
Frage 70
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Cold therapy is applied for a maximum of how long each time
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5 minutes
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10 minutes
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20 minutes
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30 minutes
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