Week 2: Wound Assessment Flashcards

(195 cards)

1
Q

Definition

Fluid that is red and contains blood. It indicates active bleeding or recent trauma to the wound.

A

Define

Sanguineous Exudate

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2
Q

Define

Collagen

A

A protein that provides structural support to tissues and is a key component of the extracellular matrix in wound healing.

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3
Q

Definition

The density and health of blood vessels in the wound area, which impacts the delivery of oxygen and nutrients essential for healing.

A

Define

Vascularity

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4
Q

Define

Hypoxia

A

A condition where there is a deficiency of oxygen in the tissues, which can impede wound healing.

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5
Q

Define

Cavity

A

A space within the wound bed that may need to be filled for proper healing.

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6
Q

Definition

A passage that extends under the skin from the wound surface to deeper tissues.

A

Tunnelling

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7
Q

Definition

A type of chronic wound that occurs in people with diabetes, often due to nerve damage and poor circulation.

A

Define

Diabetic Foot Ulcer

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8
Q

Definition

New tissue that forms over a wound during the healing process, characterized by a reddish, bumpy appearance and a rich supply of blood vessels.

A

Define

Granulation Tissue

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9
Q

Define

Pressure Ulcer

A

A wound caused by prolonged pressure on the skin, often found in areas over bony prominences. Also known as a bedsore or decubitus ulcer.

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10
Q

Define

Arterial Ulcer

A

A wound that results from poor blood flow in the arteries, often located on the feet or lower legs.

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11
Q

Definition

The area of tissue within the wound where healing occurs, including granulation tissue and any remaining necrotic tissue.

A

Define

Wound Bed

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12
Q

Definition

A protein that provides structural support to tissues and is a key component of the extracellular matrix in wound healing.

A

Define

Collagen

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13
Q

Definition

Dead tissue that is often dark, dry, and leathery. It can be black or brown and impedes the healing process by preventing new tissue from forming.

A

Define

Necrotic Tissue

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14
Q

Definition

The perimeter of the wound. Assessing the edges helps determine if the wound is healing correctly and if new tissue is forming.

A

Define

Wound Edges

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15
Q

Definition

The process where new epithelial cells grow over the wound bed, covering the wound with new skin.

A

Define

Epithelialization

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16
Q

Define

Purulent Exudate

A

Thick, yellow, green, or brown fluid containing pus, indicating infection or inflammation.

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17
Q

Define

Tunnelling

A

A passage that extends under the skin from the wound surface to deeper tissues.

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18
Q

Definition

A structured approach to wound assessment that stands for Tissue, Inflammation/Infection, Moisture, Edges, and Surrounding Skin.

A

Define

T.I.M.E.S. Framework

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19
Q

Define

Wound Culture

A

A test used to identify microorganisms present in a wound to determine the appropriate antibiotic treatment.

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20
Q

Define

Slough

A

A layer of dead tissue that may be yellow, gray, or brown and is loosely attached to the wound bed. It often needs to be removed for proper healing.

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21
Q

Define

Venous Ulcer

A

A type of chronic wound that occurs due to poor blood flow in the veins, typically found on the lower legs and ankles.

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22
Q

Definition

Fluid that leaks out of blood vessels into the surrounding tissues during the inflammatory phase of wound healing. It can be clear, bloody, or pus-like.

A

Define

Exudate

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23
Q

Definition

A space within the wound bed that may need to be filled for proper healing.

A

Define

Cavity

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24
Q

Define

Debridement

A

The process of removing dead or infected tissue from a wound to promote healing and prevent infection.

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25
# Define Sanguineous Exudate
Fluid that is red and contains blood. It indicates active bleeding or recent trauma to the wound.
26
# Definition A narrow channel or tract that can extend from the wound to deeper tissues.
# Define Sinus
27
# Definition An imaging technique where a radiopaque dye is injected into a wound to visualize tunnelling, sinuses, or fistulas.
# Define Sinogram
28
# Definition A slimy layer of microorganisms that adheres to the wound surface and can make infection harder to treat.
# Define Biofilm
29
# Define Exudate
Fluid that leaks out of blood vessels into the surrounding tissues during the inflammatory phase of wound healing. It can be clear, bloody, or pus-like.
30
# Define Granulation Tissue
New tissue that forms over a wound during the healing process, characterized by a reddish, bumpy appearance and a rich supply of blood vessels.
31
# Definition A condition where there is a deficiency of oxygen in the tissues, which can impede wound healing.
# Define Hypoxia
32
# Definition A wound that results from poor blood flow in the arteries, often located on the feet or lower legs.
# Define Arterial Ulcer
33
# Define T.I.M.E.S. Framework
A structured approach to wound assessment that stands for Tissue, Inflammation/Infection, Moisture, Edges, and Surrounding Skin.
34
# Define Necrotic Tissue
Dead tissue that is often dark, dry, and leathery. It can be black or brown and impedes the healing process by preventing new tissue from forming.
35
# Define Doppler Device
A tool used to measure blood flow and detect the presence of arterial or venous disease by using sound waves.
36
# Define Wound Bed
The area of tissue within the wound where healing occurs, including granulation tissue and any remaining necrotic tissue.
37
# Define Epithelialization
The process where new epithelial cells grow over the wound bed, covering the wound with new skin.
38
# Define Wound Edges
The perimeter of the wound. Assessing the edges helps determine if the wound is healing correctly and if new tissue is forming.
39
# Definition A tool used to measure blood flow and detect the presence of arterial or venous disease by using sound waves.
# Define Doppler Device
40
# Define Sinus
A narrow channel or tract that can extend from the wound to deeper tissues.
41
# Define Biofilm
A slimy layer of microorganisms that adheres to the wound surface and can make infection harder to treat.
42
# Define Serous Exudate
A type of clear, thin fluid that is typically associated with mild inflammation and helps to keep the wound moist.
43
# Define Wound Margin
The border or boundary of the wound, which includes the edges and surrounding skin.
44
# Define Vascularity
The density and health of blood vessels in the wound area, which impacts the delivery of oxygen and nutrients essential for healing.
45
# Define Diabetic Foot Ulcer
A type of chronic wound that occurs in people with diabetes, often due to nerve damage and poor circulation.
46
# Definition A type of clear, thin fluid that is typically associated with mild inflammation and helps to keep the wound moist.
# Define Serous Exudate
47
# Define Sinogram
An imaging technique where a radiopaque dye is injected into a wound to visualize tunnelling, sinuses, or fistulas.
48
# Definition The process of removing dead or infected tissue from a wound to promote healing and prevent infection.
# Define Debridement
49
# Definition The border or boundary of the wound, which includes the edges and surrounding skin.
# Define Wound Margin
50
# Definition A test used to identify microorganisms present in a wound to determine the appropriate antibiotic treatment.
# Define Wound Culture
51
# Definition Thick, yellow, green, or brown fluid containing pus, indicating infection or inflammation.
# Define Purulent Exudate
52
# Definition A wound caused by prolonged pressure on the skin, often found in areas over bony prominences. Also known as a bedsore or decubitus ulcer.
# Define Pressure Ulcer
53
# Definition A layer of dead tissue that may be yellow, gray, or brown and is loosely attached to the wound bed. It often needs to be removed for proper healing.
# Define Slough
54
# Definition A type of chronic wound that occurs due to poor blood flow in the veins, typically found on the lower legs and ankles.
# Define Venous Ulcer
55
What is the key characteristic of an acute wound?
Healing occurs in a timely and organized manner with clean, intact edges and typically heals without complications.
56
What is a chronic wound?
A wound where healing is delayed (more than 6 weeks) and does not follow a timely, orderly process.
57
Name a physical factor that affects wound healing.
Nutritional status Oxygenation Infection Control Wound Environment
58
Why is oxygenation important for wound healing?
Proper blood flow and oxygen delivery are crucial for healing.
59
What psychosocial factor can impact wound healing?
Emotional state social support
60
How can cognitive function affect wound healing?
Understanding and adherence to wound care instructions are important.
61
What should be documented during a wound assessment?
Wound size, depth, edges, and exudate.
62
Why is establishing a baseline evaluation important?
To track healing progress over time.
63
What does ongoing assessment involve?
Regular evaluations to monitor changes and adapt management plans.
64
What impact can chronic diseases have on wound healing?
They can impair wound healing due to poor circulation, altered immune responses, or impaired tissue regeneration.
65
How does aging affect wound healing?
Aging can result in slower healing times and increased risk of complications due to affected skin integrity and repair processes.
66
What issues might obesity cause in wound healing?
Poor circulation and increased risk of infection.
67
How can emaciation impact wound healing?
Insufficient nutritional reserves can affect healing capacity.
68
Why is protein important for wound healing?
Essential for tissue repair and immune function.
69
Which vitamins and minerals are crucial for wound healing?
Vitamins A, C, and zinc.
70
How can immunosuppressive medications affect wound healing?
They can hinder the body's ability to fight infections and repair tissue.
71
How does infection affect wound healing?
Presence of bacteria or other pathogens can delay healing and increase tissue damage.
72
Why is moisture balance important in wound care?
Both excessive moisture and dryness can impair healing.
73
What effect can anticoagulants have on wound healing?
They can affect clotting and increase bleeding risk.
74
How might steroids impact wound healing?
They may reduce inflammation but can also impair wound healing.
75
What negative effects can alcohol abuse have on wound healing?
Impaired immune function and overall health.
76
How does smoking affect wound healing?
It reduces blood flow and oxygen delivery to tissues, slowing healing.
77
What effect can radiation therapy have on wound healing?
It can damage healthy tissues and affect wound repair.
78
How can a lack of social support impact wound healing?
It can affect wound care and healing outcomes.
79
In what way can socioeconomic status influence wound healing?
Limited resources may affect the ability to obtain necessary wound care supplies and treatments.
80
How can psychological stress impact wound healing?
It can impair immune function and exacerbate healing issues.
81
What influence can mental health conditions have on wound healing?
Depression and anxiety can influence self-care practices and overall health.
82
How does psychological stress impact physiological responses related to wound healing?
It can trigger physiological responses that hinder wound healing by affecting hormone levels, immune function, and overall health.
83
What is the purpose of case scenarios and workshops in understanding wound healing factors?
They help illustrate how intrinsic and extrinsic factors affect wound healing and provide practical examples of managing these factors in clinical settings.
84
What is the goal of the Assessment phase in the A-B-C-D-E approach?
To establish a baseline for treatment and identify factors that might impact healing.
85
What does the Wound Assessment involve?
Comprehensive evaluation of the wound's size, depth, edges, and exudate.
86
What is included in the Patient Assessment?
A full review of the patient's medical history, psychosocial factors, and overall health status.
87
What are Evidence-Based Practices used for in the Best Practice phase?
To determine the most effective treatments and interventions for the wound based on current research and guidelines.
88
What should the Treatment Plan in the Best Practice phase include?
Appropriate dressings, debridement methods, and infection control measures.
89
What does the Control Factors phase focus on?
Identifying intrinsic and extrinsic factors that might impede healing and implementing strategies to control or mitigate these factors.
90
Give an example of an intrinsic factor that might be controlled in the Control Factors phase.
Poor nutrition.
91
What is the purpose of Documentation in the A-B-C-D-E approach?
To ensure continuity of care, facilitate communication within the healthcare team, and provide a record for evaluating treatment effectiveness.
92
What should be included in the Documentation phase?
Detailed and accurate records of the wound assessment, treatment plan, and progress.
93
What is the focus of the Evaluation phase?
Ongoing assessment of the wound’s progress and the effectiveness of the treatment plan.
94
How are adjustments made in the Evaluation phase?
Based on the wound’s response to treatment and any changes in the patient’s condition.
95
Why is regular evaluation important in wound management?
To ensure that the treatment plan remains effective and to make necessary adjustments based on the wound’s progress and patient’s condition.
96
Why are investigations important in wound management?
To confirm wound aetiology, identify underlying physical elements, check for poor nutrition, and confirm infection or other issues.
97
What is the purpose of confirming wound aetiology?
To determine the cause of the wound.
98
Why is it necessary to identify underlying physical elements?
To assess conditions that may affect wound healing.
99
What does checking for poor nutrition involve?
Evaluating nutritional status to support healing.
100
Why is confirming infection crucial?
To diagnose infection or other complications that might impede healing.
101
What is the purpose of measuring oxygen saturation?
To assess if the patient is receiving adequate oxygenation for tissue repair.
102
What is the normal range for oxygen saturation?
>95% saturation.
103
Why are random blood sugar readings taken?
To detect impaired glucose metabolism that may affect wound healing.
104
What might elevated glucose levels indicate in wound management?
Poor wound healing and increased infection risk.
105
What is assessed during a peripheral vascular assessment?
Blood flow and circulation in affected limbs.
106
What techniques are used in peripheral vascular assessment?
Inspection, palpation, and auscultation.
107
What is the purpose of the Ankle Brachial Pressure Index (ABPI)?
To measure arterial perfusion in the lower limbs and predict the severity of peripheral arterial disease.
108
What is a limitation of the ABPI?
It does not identify specific blood vessel blockages.
109
What does the Monofilament 10g test assess?
Peripheral neuropathy, especially in diabetic patients.
110
What information does a Full Blood Count/Examination (FBC/E) provide?
Hemoglobin levels and white cell counts to assess oxygen carrying capacity and infection or immunosuppression.
111
What do Random Blood Glucose and HbA1c tests detect?
Undiagnosed diabetes and uncontrolled blood glucose levels.
112
What do C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) measure?
Inflammation and infection markers.
113
What do renal function tests assess?
Kidney function, including levels of urea, creatinine, and electrolytes.
114
Why are liver function tests important in wound assessment?
They assess liver health and protein synthesis capabilities.
115
What do Vitamins/Elements tests measure?
Levels of iron, vitamins B12 and D, zinc, selenium, and folate.
116
What is the purpose of wound swabs?
To identify specific organisms in infected wounds.
117
What do radiological tests like ultrasound and plain X-rays detect?
Collections, cavities, foreign bodies, and osteomyelitis.
118
How does a Duplex Ultrasound of Lower Limbs assist in wound management?
It measures pressure, flow, waveform patterns, volume changes, venous reflux, and calf muscle pump efficiency.
119
What does a Sinogram identify?
Tunnelling, fistulae, or sinuses in wounds.
120
What is the purpose of biopsies in wound management?
To investigate atypical wounds, unusual locations, or non-responsiveness to therapy.
121
What distinguishes an acute wound from a chronic wound?
Acute wounds typically heal within 3-4 weeks, while chronic wounds take more than 6 weeks and may have delayed healing due to ongoing factors.
122
What should be documented when assessing the location of a wound?
The anatomical position and landmarks of the wound.
123
Why is it important to measure a wound?
To document the wound's size, depth, and changes over time.
124
What are the key measurements to document for a wound?
Surface area, length, width, depth, and presence of any cavities, sinuses, or tunnelling.
125
What does the "T" in the T.I.M.E.S. framework stand for?
TISSUE
126
What should you identify when assessing tissue in a wound?
Type of tissue (granulation, necrotic, slough), tissue viability, and its colour and texture.
127
How can you determine if the tissue in the wound bed is viable?
By assessing if the tissue is living or dead based on its appearance and response to treatment.
128
What are the signs of inflammation versus infection in a wound?
Inflammation includes erythema, heat, oedema, and pain; infection signs include increased exudate, pain, odour, and delayed healing.
129
What is biofilm, and why is it significant in wound management?
Biofilm is a slimy layer of microorganisms that complicates healing and resists treatment.
130
What should you assess when evaluating moisture in a wound?
Colour, consistency, odour, and amount of exudate.
131
What does the "E" in the T.I.M.E.S. framework refer to?
EDGES
132
Why is it important to assess the edges of a wound?
To evaluate granulation and epithelialization, which are crucial for wound healing.
133
What should be assessed regarding the surrounding skin of a wound?
The condition of the skin around the wound and any signs of infection or abnormalities.
134
How should pain be assessed in wound management?
By evaluating severity, type, and frequency of pain.
135
What should be included in wound documentation?
Patient assessment, investigations, wound assessment chart, care plan, interventions, and progression.
136
Why is accurate documentation essential in wound management?
To ensure continuity of care, facilitate communication, and track changes and effectiveness of treatments.
137
What are some potential complications that could affect wound healing?
Infection, inadequate nutrition, poor circulation, and biofilm formation.
138
What is the clock face method used for in wound measurement?
It is used to orient the wound for measuring length and width, with specific directions (e.g., heel to toes for foot wounds, head to feet for general wounds).
139
How should you measure the width of a wound?
Measure at right angles to the length, identifying the widest part of the wound.
140
What is the definition of wound depth?
The distance from the visible surface of the wound to the deepest point.
141
Which tool is commonly used to measure the depth of a wound?
A cotton tip applicator.
142
What should you do to ensure accurate depth measurements?
Take several measurements in different areas of the wound.
143
How should cavities or sinus tracts within a wound be measured?
Use a cotton tip applicator to probe gently and record the direction and depth.
144
What is wound tracing, and why is it used?
Wound tracing is creating a visual representation of the wound to track changes in size and shape over time.
145
How can you create a visual representation of a wound for tracing?
Use templates, or place a clear cover or cling film over the wound, then trace the outline onto the film or dressing pack.
146
What are some additional tips for accurate wound measurement?
Measure dimensions consistently at each dressing change, use sterile tools, and ensure the wound area is clean.
147
Why is it important to document wound measurements accurately?
Accurate documentation helps in tracking healing progress, assessing treatment effectiveness, and making necessary adjustments to the care plan.
148
Pink, red, yellow and black tissues is called what, respectively?
Pink - epithleial Red - granulation Yellow - slough Black - necrotic
149
Symptoms of inflammation include:
Erythema Heat Oedema Pain
150
Symptoms of infection include:
Delayed healing Malodour Development of biofilm Increased exudate
151
What are some ways we describe the surrounding skin?
Intact Erythema Macerated Oedematous Dermititis
152
What are some types of wound edges?
Level Raised Undermined Tunnelled Rolled
153
Identify the tissue type
Epithelial
154
Is this tissue viable or non-viable?
Viable
155
Identify the tissue type
Granulation
156
Viable or non-viable?
Viable
157
Identify the tissue type
Slough
158
Viable or non-viable
non-viable
159
Identify the tissue type
Necrotic
160
Viable or non-viable?
Non-viable
161
What are the 5 stages of biofilm development?
1. Attachment 2. Cell-to-cell adhesion 3. Proliferation 4. Maturation 5. Dispersion
162
Describe the attachment stage of biofilm development
Planktonic (free-floating) bacteria adhere to the biomaterial surface
163
Describe the cell-to-cell adhesion stage of biofilm development
Cells aggregate, form micro colonies and excrete extracellular polymeric substances
164
Describe the proliferation stage of biofilm development
A biofilm is formed and matures, and the cells form multilayered clusters. Further maturation of the biofilm provides protection against host defence mechanisms and antibiotics
165
Describe the maturation stage of biofilm development
The biofilm reaches a critical mass
166
Describe the Dispersion stage of biofilm development
Dispersal of planktonic bacteria, ready to colonise other surfaces
167
Which of the following best describes an acute wound? A. Heals within a predictable time frame and is typically caused by a specific event B. Persists beyond the expected healing time and may be due to underlying conditions C. Always involves chronic inflammation D. Is only associated with surgical procedures
A. Heals within a predictable time frame and is typically caused by a specific event
168
Chronic wounds are characterized by: A. Rapid healing and minimal complications B. Healing that exceeds the normal time frame, often with ongoing inflammation C. Immediate closure with minimal intervention D. Complete absence of microbial contamination
B. Healing that exceeds the normal time frame, often with ongoing inflammation
169
Which of the following is a common feature of chronic wounds? A. Complete resolution within a few days B. Presence of granulation tissue and re-epithelialization C. Prolonged inflammation and delayed healing D. Immediate pain relief and resolution
C. Prolonged inflammation and delayed healing
170
The primary goal of wound assessment is to: A. Determine the patient's insurance coverage B. Identify the specific cause of the wound C. Evaluate the wound's characteristics and plan appropriate care D. Predict the exact time frame for healing
C. Evaluate the wound's characteristics and plan appropriate care
171
Which of the following is NOT a key principle of wound management? A. Keeping the wound dry at all times B. Assessing the wound regularly for changes C. Selecting appropriate dressings based on wound characteristics D. Ensuring patient comfort and pain control
A. Keeping the wound dry at all times
172
What should be considered when developing a wound management plan? A. The patient's lifestyle and comorbid conditions B. The availability of the latest technology only C. Patient's ability to afford the most expensive treatments D. The number of wounds present
A. The patient's lifestyle and comorbid conditions
173
The 'T' in T.I.M.E.S stands for: A. Tissue type B. Temperature of the wound C. Time of the wound D. Treatment frequency
A. Tissue type
174
Which element of T.I.M.E.S refers to the management of excessive moisture and exudate? A. Tissue type B. Infection C. Moisture balance D. Edge of the wound
C. Moisture balance
175
The 'S' in T.I.M.E.S relates to: A. Size of the wound B. Surrounding skin condition C. Surgical history D. Sensitivity to dressings
B. Surrounding skin condition
176
Which tissue type is characterized by a shiny, red appearance and indicates healthy granulation tissue? A. Necrotic tissue B. Slough C. Eschar D. Granulation tissue
D. Granulation tissue
177
What type of tissue is commonly yellow, moist, and often found in chronic wounds? A. Granulation tissue B. Slough C. Necrotic tissue D. Eschar
B. Slough
178
Eschar is typically described as: A. Soft, moist tissue that is easily removed B. Hard, dry, and black tissue C. Red, beefy tissue indicating new growth D. Yellowish tissue with a slimy texture
B. Hard, dry, and black tissue
179
Which type of tissue indicates a lack of blood supply and is often associated with the need for debridement? A. Granulation tissue B. Slough C. Necrotic tissue D. Healthy epithelial tissue
C. Necrotic tissue
180
The peri-wound skin is important to assess because: A. It determines the size of the wound B. It helps in identifying infection and maceration C. It is not related to wound healing D. It indicates the type of dressing required
B. It helps in identifying infection and maceration
181
Which condition of the peri-wound skin suggests excessive moisture exposure? A. Dry, flaky skin B. Redness and swelling C. Hardened, calloused areas D. Normal skin tone and texture
B. Redness and swelling
182
Healthy peri-wound skin should appear: A. Dry and cracked B. Red and inflamed C. Smooth and intact D. Yellow and moist
C. Smooth and intact
183
Maceration of the peri-wound skin can lead to: A. Improved healing B. Increased risk of infection C. Decreased wound size D. Enhanced tissue regeneration
B. Increased risk of infection
184
Which type of exudate is thin, clear, and typically seen in early stages of healing? A. Serous B. Sanguineous C. Serosanguineous D. Purulent
A. Serous
185
A purulent exudate is characterized by: A. Clear and thin fluid B. Red, bloody fluid C. Thick, yellow or green fluid D. Pink, watery fluid
C. Thick, yellow or green fluid
186
Which type of exudate is often associated with infection and has a foul odor? A. Serous B. Sanguineous C. Serosanguineous D. Purulent
D. Purulent
187
Management of serous exudate typically involves: A. Using highly absorbent dressings B. Applying antimicrobial agents C. Monitoring for infection signs D. Regularly changing dressings to prevent maceration
D. Regularly changing dressings to prevent maceration
188
Acute wound infection is typically characterized by: A. Persistent redness and swelling B. Sudden onset with signs of redness, warmth, and purulent drainage C. Long-term presence of biofilm D. Minimal pain and discomfort
B. Sudden onset with signs of redness, warmth, and purulent drainage
189
Chronic wound infection may be indicated by: A. Rapid resolution of symptoms B. Persistent inflammation and non-healing despite treatment C. Immediate improvement after antibiotic therapy D. Complete absence of any signs of infection
B. Persistent inflammation and non-healing despite treatment
190
Biofilm in a wound is characterized by: A. A single layer of bacteria with no protective barriers B. A complex community of bacteria embedded in a protective matrix C. Complete absence of microbial organisms D. Rapid clearance of bacteria by the immune system
B. A complex community of bacteria embedded in a protective matrix
191
A key difference between acute and chronic infections is: A. Acute infections show no response to antibiotics B. Chronic infections have a longer duration with ongoing symptoms C. Acute infections are less severe than chronic infections D. Chronic infections resolve within a few days
B. Chronic infections have a longer duration with ongoing symptoms
192
Biofilm formation can: A. Enhance the wound healing process B. Protect bacteria from the immune system and antibiotics C. Facilitate rapid wound closure D. Prevent chronic inflammation
B. Protect bacteria from the immune system and antibiotics
193
The presence of biofilm in a wound typically requires: A. Standard wound cleaning with saline B. Use of specific antibiotics and wound debridement strategies C. Immediate surgical intervention D. No treatment as biofilm is harmless
B. Use of specific antibiotics and wound debridement strategies
194
Which of the following is NOT a standard element of wound measurement? A. Length and width B. Depth C. Color of the wound bed D. Volume of exudate
D. Volume of exudate
195
The depth of a wound is measured to: A. Determine the need for pain management B. Assess the extent of tissue damage and guide treatment C. Evaluate the amount of exudate D. Monitor the rate of healing
B. Assess the extent of tissue damage and guide treatment