What is the nurse's primary focus in the management of urticaria? Removal of triggering substance A patient who is receiving drug therapy for urticaria reports an increasing sedative effect. The patient admits to consuming alcohol on a daily basis. Which category of medication could be the reason for this condition? 1 Antihistamines Which factor may cause a systemic altered inflammatory response? Leukemia Which process occurs in the third intention of wound healing? 1 Removal of debris What method does the nurse use to measure the length of a patient's wound? 12 o'clock position to the 6 o'clock position Which condition may worsen itching in patients with pre-existing pruritus? Perspiration Which description is characteristic of a wound that is healing by third intention? It is a potentially infected surgical wound. A potentially infected surgical wound heals by third intention. The wound is debrided and left open for several days until the inflammation subsides. The wound is then surgically closed. A wound that is made aseptically has minimal tissue destruction and begins to heal as soon as the edges are approximated by close sutures or staples; this wound heals by first intention. A chronic wound with tissue damage such as a pressure injury with extensive damage cannot be smoothly approximated. The wound is left open and left to heal from inside out. Scar tissue is extensive and healing is prolonged; this wound heals by second intention. What category of medication may affect the wound contraction of wound healing? Cytotoxic drugs Which process involves the replacement of damaged tissue with scar tissue that aids in wound healing? Granulation Which clinical manifestation is observed during the inflammatory phase of wound healing? 1 Erythema Erythema is a clinical manifestation that occurs during the inflammatory phase of wound healing. It is characterized by redness or swelling of the skin that exists from skin trauma due to an aseptic surgical incision or a pressure injury. Itching is a clinical feature that occurs in pruritus. Injuries on body surfaces such as the sacrum, hips, and ankles are a characteristic feature in pressure injuries. A rash of white edematous papules or plaques occurs in urticaria. Which process promotes the healing of partial-thickness wounds? 1 Re-epithelialization Partial-thickness wounds are more superficial. In a partial-thickness wound, only the epidermis and upper layers of the dermis are damaged. Such wounds heal by re-epithelialization. Granulation is a major process for deep wounds. Maturation is not involved in the healing of partial-thickness wounds. In wound contraction, the size of the wound decreases and the wound finally closes. Which event takes place during the maturation phase of wound healing? Collagen is reorganized to provide greater tensile strength. The nurse is caring for a patient with a loss of tissue integrity. The diagnostic reports reveal damage to the dermis and subcutaneous tissue. What is the name of the process that will replace the damaged tissue? Granulation Loss of tissue integrity that occurs due to damage to the deeper layers of dermis and subcutaneous tissue is a characteristic feature of a deep-partial and full-thickness wound. Granulation replaces damaged tissue with scar tissue and aids in wound healing. Contraction involves the pulling of wound edges inward along the path of least resistance. Resurfacing involves regrowth across the open area. Re-epithelialization involves the production of new skin cells by undamaged epidermal cells in the basal layer of the dermis. What is the duration of the first phase of wound healing? 3 to 5 days Which disease may cause urticaria? Cancer Cancer is one of the causative factors of urticaria. It occurs due to the exposure to allergens, which release histamines into the skin. Vasculitis, lymphedema, and diabetes mellitus cause altered inflammatory responses in wound healing. The nurse is caring for a patient with a surgical incision. Which process of wound healing is affected if there is damage to the hair follicles and sweat glands? Re-epithelialization Which condition is characterized by the presence of a rash of white or red edematous papules? Urticaria What process of wound healing involves the production of keratin? 1 Resurfacing Resurfacing involves regrowth across open surfaces, which is one cell layer thick. As healing continues, the cell layer stratifies and produces keratin. Granulation replaces damaged tissue with scar tissue and aids in wound healing. Contraction involves pulling wound edges inward along the path of least resistance. Re-epithelialization involves the production of new skin cells by undamaged epidermal cells in the basal layer of the dermis. A patient with chronic wounds is worried about treatment costs. What nursing tips for home care may be of help to the patient? Select all that apply. 1 "You can use clean tap water and nonsterile supplies." Which condition will occur from stimulation of the itch-specific nerve fibers? Pruritus What is the best way for the nurse to prevent a patient's stage I pressure injury from advancing to stage II? Promote mobility and/or frequent repositioning. Which condition is associated with pruritus? liver disease
While assessing a patient, the nurse identifies that there is no change in the size of the wound. Which category of medications could be the reason for this condition? Cytotoxic drugs The wound size decreases at a uniform rate of 0.6 to 0.75 mm/day due to the inward pulling of the wound edges by fibroblasts. Cytotoxic drugs impair cellular regulation and collagen synthesis, and thus decrease wound contraction. Antibiotics, antihistamines, and nonsteroidal anti-inflammatory drugs will have no effect on the size of the wound. Arrange the events of the proliferative phase of wound healing in the correct sequence. 1. Fibrin strands form a scaffold or framework. The nurse instructs a patient at high risk for pressure injuries to avoid having any reddened areas massaged. Why does the nurse recommend this? It may damage capillary beds. A patient has pruritus. Which measure is used to reduce skin damage from scratching and prevent secondary infection? Keep the fingernails trimmed short. When educating a patient about pressure injury prevention, what does the nurse suggest? Use barrier ointments to protect intact skin if incontinence is present. What systemic disease causes itching without skin lesions? Liver disease |
Which disorder is a cause of systemic altered inflammatory response in impaired wound healing
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