Wound Assessment

Match the following types of wounds.

• self-inflicted from excessive scratching

• Abscess

• skin torn open with jagged edges

• Contusion

• superficial scrape

• Excoriation

• closed wound caused by blunt trauma

• Abrasion

• localized collection of pus by bacteria

• Laceration

The nurse is educating a client on how to decrease the risk of poor skin integrity. What statement by the client indicates further teaching is required?

• Maceration happens when you keep the wound dry from moisture.

• I need to inspect my feet due to my diminished sensation.

• If my albumin level is below 3.5 that increases my risk.

• I need to increase my mobility to ensure I do not lie in the same position for a long period of time.

Reorder the following pressure ulcer stages

• Intact skin with nonblanchable redness

• Full thickness tissue loss involving subcutaneous tissue

• Partial thickness tissue loss involving dermis

• Full thickness tissue loss with necrosis or damage to muscle or bone

Bobby has four wounds. The first wound has a leathery necrotic tissue over it called ​ (a)   . Bobby coughed and now has an ​ ​ (b)   complication on his abdominal wound with his intestines exposed. When the nurse was taking out Bobby's staples the incision had ​ (c)   at the bottom of the wound. This required the nurse to ​ (d)   and apply steri strips. Bobby's last wound is a pressure ulcer on his bottom but cannot be staged because of the yellow ​ (e)   present.

• Eschar
• Evisceration
• Dehiscence
• stop
• slough
• keep going
• Fistula
• Infection

The nurse is measuring a client's wound. The nurse finds an area with the cotton swab applicator that is deeper than the wound bed on the left side. What term would the nurse use to describe this finding?

• Undermining

• Tunneling

• Hyper-granulation

• Necrosis

In an emergency situation, the nurse understands the correct order when addressing a wound is:

• Culture Wound (if applicable)

• Apply appropriate dressing

• Stabilize the client (ABCs)

• Assess wound

• Cleanse the Wound