InstructiоnsReаd eаch questiоn cаrefully.Answer each questiоn by bubbling your answer on the Scantron answer sheet.After you have finished answering all questions, select TRUE.Click Finish Attempt at the bottom of the page.On the next page, click Submit All and Finish.If a confirmation message appears, click Submit All and Finish again to complete your submission.Once your assessment has been submitted successfully, notify your proctor that you are finished. Please wait for the proctor's instructions before proceeding to the next step.Chapter 48-49 Key/Version A____ 1. What factor requires priority consideration when establishing nursing care priorities for patients with chronic wounds? a. Immediate control of hemorrhage and prevention of contamination to minimize infection risk and complications c. Patient preferences, daily activity planning, and family caregiver education for discharge and home care management b. Frequent dressing changes and intensive monitoring to detect early signs of deterioration and healing complications d. Rapid wound closure techniques and aggressive debridement to accelerate healing and reduce treatment duration ____ 2. What principle guides the documentation of pressure injury healing progression in the staging system? a. Healing pressure injuries are restaged weekly based on current wound assessment findings and tissue characteristics observed c. Healing pressure injuries are reverse-staged from higher to lower stages as tissue regenerates and wound depth decreases b. Pressure injuries are documented using percentage of healing achieved with complete healing representing 100 percent tissue restoration d. Pressure injuries maintain their original stage designation throughout healing and are documented as healing with original stage ____ 3. What nutritional component is essential for collagen synthesis during wound healing? a. Vitamin A supplementation reducing negative effects of corticosteroids and supporting immune function during healing process c. Zinc and copper trace elements supporting epithelialization processes and collagen fiber linking in wound bed tissue b. Protein and amino acids acquired by fibroblasts to form collagen along with vitamin C necessary for collagen synthesis d. Adequate caloric intake providing energy source needed to support cellular activity and metabolic demands of tissue repair ____ 4. What extrinsic factor most significantly increases skin susceptibility to pressure injury development? a. Advanced age with decreased collagen production leading to diminished structural support and reduced vascular integrity c. Low blood pressure with decreased tissue perfusion causing inadequate oxygen delivery to cells and impaired cellular metabolism b. Presence of shear, friction, and moisture reducing tissue tolerance and ability to withstand externally applied pressure d. Poor nutritional status with inadequate protein intake causing delayed wound healing and reduced tissue repair capacity ____ 5. What determines the selection of appropriate nursing diagnoses for patients experiencing sensory alterations? a. Specific type of sensory deficit identified through physical assessment and screening tool results c. Medical diagnosis and prescribed treatments requiring nursing monitoring and collaborative management b. Way in which sensory alteration affects patient's ability to function in daily activities d. Patient's expressed concerns and family members' observations about behavioral changes ____ 6. What characteristic of wound edges best differentiates primary intention healing from secondary intention healing? a. Wound edges are widely separated with significant tissue loss requiring granulation tissue to fill the defect completely c. Wound edges show signs of inflammation with moderate exudate production and delayed epithelialization over several weeks b. Wound edges demonstrate irregular borders with necrotic tissue present requiring debridement before healing progresses d. Wound edges are closely approximated or closed with minimal tissue loss and low risk of infection development ____ 7. What physiological condition impairs wound healing by reducing oxygen delivery to tissues? a. Advanced age with decreased elasticity and collagen production leading to fragile skin and impaired tissue integrity c. Immunosuppression from medications or disease processes increasing susceptibility to infection and inflammatory complications b. Poor tissue perfusion from diabetes or peripheral vascular disease limiting oxygenated blood flow to wound site d. Malnutrition with inadequate protein intake causing delayed collagen formation and reduced cellular repair capacity ____ 8. What characteristic distinguishes a Stage 3 pressure injury from a Stage 2 pressure injury? a. Partial-thickness skin loss involving epidermis and dermis presenting as shallow open ulcer with red-pink wound bed c. Full-thickness tissue loss with visible subcutaneous fat but bone, tendon, and muscle are not exposed to assessment b. Presence of intact skin with nonblanchable erythema indicating persistent redness and structural damage to underlying capillary bed d. Full-thickness tissue loss with exposed bone, tendon, or muscle and presence of slough or eschar in wound bed ____ 9. What outcome distinguishes the healing timeframe and infection risk between primary and secondary intention wounds? a. Primary intention wounds require extended healing time with moderate scarring while secondary intention wounds heal quickly with minimal scarring c. Primary intention wounds demonstrate delayed healing with high infection risk while secondary intention wounds heal rapidly with low infection risk b. Primary intention wounds heal rapidly with minimal scarring while secondary intention wounds heal slowly with greater infection risk d. Primary intention wounds heal at moderate pace with significant scarring while secondary intention wounds heal quickly with minimal tissue loss ____ 10. What critical thinking element enables nurses to anticipate expected signs and symptoms when assessing patients with sensory alterations? a. Environmental contextual factors guide consideration of internal and external influences on patient assessment findings c. Knowledge of pathophysiology and typical symptoms allows matching of gathered data with expected clinical patterns b. Previous experience caring for patients with sensory deficits helps recognize functional limitations affecting daily activities d. Therapeutic communication principles facilitate establishment of trusting relationships with patients experiencing sensory problems ____ 11. What nursing intervention reduces sensory overload for hospitalized patients requiring frequent monitoring and repeated tests? a. Organizing patient care by combining activities such as dressing changes, bathing, and vital sign measurements in one visit c. Scheduling rest periods through coordination with family, visitors, and health care colleagues to minimize interruptions b. Implementing quiet time protocols including dimming lights, closing shades, and shutting doors throughout the unit d. Encouraging family members to calmly explain location, identity, and time of day without arguing or contradicting patient ____ 12. What timeframe characterizes the proliferative and new tissue formation phase of full-thickness wound healing? a. Begins immediately after injury and continues for 24 to 48 hours with inflammatory mediator release and hemostasis c. Begins several weeks after injury and continues for more than a year with collagen reorganization and scar maturation b. Begins 7 to 10 days after injury and continues for 3 to 4 weeks with complete epithelialization d. Begins 3 to 4 days after injury and can last as long as 2 weeks with granulation tissue formation ____ 13. What critical thinking element guides the nurse's clinical judgment when assessing a morbidly obese patient with limited turning ability and diaphoresis showing Stage 1 sacral pressure injury? a. Past experience with similar patients to anticipate complications and recognize abnormal wound characteristics c. Application of clinical guidelines for pressure injury prevention and evidence-based wound healing interventions b. Knowledge of normal integument physiology and pathogenesis of pressure injuries to identify risk factors d. Analysis of clustered assessment data to identify related factors guiding intervention selection for care plan ____ 14. What body fluid carries the highest risk for causing skin breakdown when patients have prolonged exposure? a. Purulent wound exudate with bacterial contamination causing localized inflammation and moderate risk for surrounding tissue breakdown c. Gastric and pancreatic drainage with digestive enzyme properties that rapidly irritate and break down skin tissue integrity b. Saliva and serosanguineous drainage with low caustic properties presenting minimal risk for tissue damage in most patient populations d. Urine, bile, stool, and ascitic fluid with moderate caustic properties especially in patients with chronic illness or malnutrition ____ 15. What assessment finding requires the nurse to apply clinical judgment and modify the care plan for a patient at risk for impaired skin integrity? a. Patient verbalizes understanding of pressure relief techniques and demonstrates proper positioning during education session c. Patient maintains adequate nutritional intake with balanced diet including sufficient protein and vitamin supplementation b. Patient demonstrates independent mobility with ability to reposition without assistance and maintains adequate hydration status d. Patient exhibits purulent drainage from surgical wound with tenderness around wound area indicating potential infection ____ 16. What effect does sensory alteration have on a patient's quality of life when social interactions become burdensome? a. Patient loses motivation to engage in social situations resulting in deep sense of loneliness c. Patient experiences enhanced coping mechanisms through increased reliance on remaining functional sensory abilities b. Patient maintains self-esteem through focus on intellectual capabilities rather than sensory limitations d. Patient develops improved problem-solving skills by adapting communication strategies to compensate for deficits ____ 17. What social factor influences the degree of sensory alteration experienced by patients in extended-care settings? a. Access to assistive devices and adaptive equipment supporting independence in activities of daily living c. Participation in scheduled group activities and structured recreational programs offered by facility b. Frequency of therapeutic interventions requiring interaction with multiple health care team members d. Availability of meaningful conversation with supportive family members and significant others during hospitalization ____ 18. What clinical judgment process ensures accuracy when formulating nursing diagnoses for patients with sensory alterations? a. Reviewing available data and analyzing cues while looking critically for patterns and trends revealing nursing diagnoses c. Consulting with interdisciplinary team members to determine medical diagnoses requiring collaborative interventions b. Implementing standardized care plans based on identified sensory deficits and monitoring patient outcomes d. Documenting assessment findings and behavioral observations for health care provider diagnostic confirmation ____ 19. What behavioral manifestation distinguishes sensory overload from sensory deprivation in hospitalized patients? a. Disorientation to time and place with confusion about daily routines and difficulty following simple instructions c. Racing thoughts with scattered attention and restlessness accompanied by anxiety and constant fidgeting with tubes b. Apathy toward environment and decreased motivation with loss of interest in previously enjoyable activities d. Withdrawal from social interaction and decreased attention span with reduced ability to concentrate on tasks ____ 20. What factor determines priority nursing diagnoses for patients admitted to acute care settings with sensory alterations? a. Type and extent of sensory alteration affecting patient combined with safety considerations c. Availability of community resources and family support systems for long-term adaptation needs b. Duration of sensory deficit and patient's previous knowledge about self-care management strategies d. Patient's expressed preferences for learning communication methods and participating in favorite hobbies ____ 21. What nursing intervention supports the Healthy People 2030 objective for adults with sensory disabilities? a. Implementing safety measures to prevent injury and maintaining environmental modifications for independent functioning c. Educating family caregivers about proper communication techniques and environmental safety strategies b. Using therapies to reduce loneliness and focusing on ability to interact rather than disability d. Providing assistive devices and adaptive equipment to compensate for specific sensory deficits ____ 22. What health promotion strategy maintains sensory function at the highest level for patients with existing deficits? a. Involving patients and families in interventions maintaining safe, pleasant, and stimulating sensory environment c. Teaching patients and families to use clinical judgment when selecting interventions for safe functioning b. Incorporating routine screening based on age-related guidelines to detect progressive sensory problems early d. Providing education about daily hygiene practices that support optimal eye and ear health ____ 23. What factor requires priority consideration when the nurse establishes care priorities for a patient with existing wound and risk for pressure injury development? a. Patient's daily hygiene preferences and scheduling wound care around mealtimes to promote comfort and cooperation c. Family caregiver's ability to perform dressing changes and availability for discharge education sessions b. Patient's condition stability versus emergent status and whether acute intervention or preventive care takes precedence d. Availability of wound care specialists and dietitians for consultation regarding complex treatment interventions ____ 24. What assessment technique identifies the severity of a patient's hearing impairment during sensory function evaluation? a. Using the Hearing Handicap Inventory for the Elderly–Screening Version to assess social and emotional effects c. Asking family members about recent behavioral changes and the patient's response to verbal communication b. Observing behavioral indicators including inattentiveness, inappropriate anger, and monotonous voice quality during interactions d. Conducting physical examination with tuning fork tests to evaluate air and bone conduction pathways ____ 25. What outcome should the nurse establish when planning care for a patient with impaired skin integrity related to pressure injury risk? a. Patient will participate in physical therapy sessions to improve mobility and reduce prolonged immobility risks c. Patient will demonstrate improved nutritional intake with adequate protein and caloric consumption to support tissue repair b. Patient will verbalize understanding of repositioning techniques and pressure relief strategies before discharge d. Patient will maintain intact skin without development of additional pressure injuries during hospitalization period ____ 26. What intervention maintains safety for patients admitted to acute care settings with traumatic sensory injury? a. Communicating with home care colleagues about existing deficits and interventions that helped patient adapt c. Determining extent of existing sensory impairment before the acute episode to establish baseline function b. Maximizing existing sensory function through therapeutic management until sensory status stabilizes or improves d. Reinforcing existing self-care knowledge and planning additional instruction before and after discharge ____ 27. What process occurs when sound waves stimulate hair cell receptors in the organ of Corti, causing nerve impulses to travel along the eighth cranial nerve? a. Reaction occurs as the person becomes consciously aware of sound and responds to meaningful auditory stimuli c. Reception begins as specialized sensory receptors grouped in the ear respond to auditory stimulus type b. Adaptation prevents sensory bombardment by discarding repetitive auditory stimuli that become background noise d. Perception integrates auditory information in the temporal lobe based on previous experiences with similar sounds ____ 28. What environmental factor places hospitalized patients at risk for sensory deprivation? a. Immobilization by bed rest or chronic disability preventing normal sensations associated with free movement c. Multiple therapeutic interventions requiring frequent patient interaction with various health care team members b. Bright lighting and numerous visual stimuli from medical equipment displays and television screens d. Constant activity in intensive care units with continuous monitoring equipment alarms and frequent staff conversations ____ 29. What action demonstrates diagnostic reasoning when a nurse lacks sufficient data to make a specific nursing diagnosis? a. Implement general nursing interventions addressing common sensory problems while monitoring patient responses c. Validate preliminary findings with family members to ensure accuracy of identified nursing diagnoses b. Document observed behavioral patterns and physical responses for health care provider review and medical diagnosis d. Continue collecting data and critically analyze changing clinical situations until determining patient's unique situation ____ 30. What component of sensory experience involves integration and interpretation of stimuli in the cerebral cortex based on past experiences? a. Reaction develops when the person responds to meaningful stimuli while discarding less significant sensory information c. Reception occurs when specialized receptor cells respond to specific stimulus types and generate nerve impulses b. Perception takes place as the brain interprets quality and nature of sensory stimuli in specialized cortex regions d. Adaptation prevents overwhelming stimulation by reducing response to repetitive stimuli in the nervous system ____ 31. What evaluation approach determines whether nursing interventions relieved problems associated with sensory alterations? a. Collaborating with family members to determine whether patient's ability to function at home improved c. Assessing patient's ability to function normally without injury following implementation of safety interventions b. Observing whether patient makes recommended environmental changes after direct or indirect education d. Asking patient to explain or demonstrate self-care skills to determine adherence to recommended therapies ____ 32. What environmental modification reduces fall risk for patients with reduced peripheral vision living at home? a. Removing all obstacles from halls and heavily traveled areas while securing carpeting on stairs with tacks c. Recommending electronic safety alert devices that contact emergency services when activated by the wearer b. Placing nonessential items in drawers to eliminate clutter and ensuring end tables have stable straight legs d. Installing bright lighting throughout the home and using contrasting colors to mark edges of steps ____ 33. What assessment technique differentiates blanchable erythema from nonblanchable erythema during skin integrity evaluation? a. Measure skin temperature using tactile assessment and compare warmth of affected area to surrounding unaffected tissue c. Observe skin color changes under natural lighting conditions and document variations in pigmentation across body surfaces b. Apply gentle pressure to reddened tissue and determine whether skin becomes pale with pressure application then reddens with relief d. Palpate tissue firmness and assess for induration or edema indicating underlying structural damage to dermal layers ____ 34. What health promotion habit assessment determines whether patients require education about preventing sensory injury? a. Determining use of safety glasses or hearing-protective devices during sports, recreation, or occupational activities c. Evaluating daily routines for eye and ear care practices incorporated into personal hygiene activities b. Assessing adherence to routine health screening including timing of last eye examination or hearing evaluation d. Identifying participation in activities with potential for chemical exposure, loud noise, or physical trauma ____ 35. What outcome focus addresses the priority nursing diagnosis for patients experiencing progressive vision loss in home settings? a. Improving safety in home environment to support continued independent living c. Learning self-care restrictions and proper medication administration techniques following surgical interventions b. Reducing anxiety through frequent reorientation and introduction of pleasant sensory stimuli d. Developing effective communication strategies to maintain social relationships with family members ____ 36. What age-related sensory change increases fall risk in adults over 60 years old? a. Proprioceptive changes affecting balance, spatial orientation, and coordination with decreased protective responses c. Difficulty discriminating high-frequency consonants and delayed reception of speech sounds affecting communication b. Decreased taste bud number and reduced sensory cells in nasal lining affecting gustatory discrimination d. Declining sensitivity to pain, pressure, and temperature secondary to peripheral vascular disease complications ____ 37. What assessment component determines whether a patient with sensory deficit requires occupational therapy consultation? a. Sensory alterations history revealing nature and characteristics of deficit and ethnic background considerations c. Use of assistive devices including frequency of use, maintenance routines, and perceived benefit b. Physical assessment techniques evaluating vision, hearing, olfaction, taste, and tactile discrimination abilities d. Ability to perform self-care including feeding, dressing, grooming, and instrumental activities of daily living ____ 38. What assessment frequency is indicated for high-risk patients in intensive care, oncology, hospice, or orthopedic units? a. Every 2 hours during repositioning to evaluate pressure points and dependent body surfaces for breakdown c. Minimum of once per shift following agency policy guidelines for routine skin assessment and documentation b. Every 4 hours based on agency policy due to increased risk factors and potential for rapid skin deterioration d. Daily comprehensive assessment with focused evaluation of bony prominences and areas under medical devices ____ 39. What nursing priority distinguishes the immediate care of an acute wound from the ongoing management of a chronic wound? a. Assessment of patient preferences and planning wound care around daily activities to support adherence and independence c. Immediate intervention to control bleeding and prevent infection while promoting rapid healing and tissue repair b. Collaboration with wound care specialists and dietitians to develop comprehensive treatment plans for complex healing d. Patient education on wound care techniques and family caregiver training for discharge planning and home management ____ 40. What cellular activity distinguishes partial-thickness wound healing from full-thickness wound healing? a. Epithelial cells regenerate and migrate across wound bed from edges and epidermal appendages for quick resurfacing c. Collagen fibers undergo remodeling and reorganization over several months to gain tensile strength and normal appearance b. Inflammatory cells release mediators causing vasodilation and increased capillary permeability with exudate formation d. Fibroblasts synthesize collagen to form granulation tissue matrix that fills tissue defects with replacement tissue
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