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Which of the following is a hallmark sign of acute inflammation?
A. Pallor
B. Bruising
C. Edema
D. Cyanosis
Answer: C. Edema
Rationale: Edema (swelling) occurs due to increased capillary permeability allowing fluid to leak into tissues—one of the classic signs of acute inflammation (rubor, calor, tumor, dolor).
Which inflammatory chemical is primarily responsible for vasodilation?
A. Leukotriene
B. Bradykinin
C. Histamine
D. Prostaglandin
Answer: C. Histamine
Rationale: Histamine causes vasodilation and increased vascular permeability during early inflammation.
What is the function of macrophages during wound healing?
A. Produce histamine
B. Synthesize fibrin
C. Phagocytose debris and pathogens
D. Prevent bleeding
Answer: C. Phagocytose debris and pathogens
Rationale: Macrophages arrive after neutrophils and help clean the wound and initiate tissue repair.
Which wound healing process involves edges that are approximated with minimal tissue loss?
A. Primary intention
B. Secondary intention
C. Tertiary intention
D. Granulation healing
Answer: A. Primary intention
Rationale: Primary intention healing occurs when wound edges are clean and closed, like in surgical wounds.
Inflammation differs from infection because:
A. Inflammation always involves pathogens
B. Infection never includes swelling
C. Inflammation is always harmful
D. Inflammation is a protective response and may occur without infection
Answer: D. Inflammation is a protective response and may occur without infection
Rationale: Inflammation is the body's protective mechanism to injury, and it can occur without infection.
A patient presents with pain, redness, heat, and swelling at a wound site. These are signs of:
A. Infection
B. Chronic inflammation
C. Acute inflammation
D. Autoimmune disorder
Answer: C. Acute inflammation
Rationale: These are cardinal signs of acute inflammation, which is the body’s immediate response to injury or infection.
A nurse notes purulent drainage from a wound. What does this indicate?
A. Hemorrhage
B. Clean wound
C. Infection
D. Granulation tissue
Answer: C. Infection
Rationale: Purulent drainage, which is thick and may be yellow, green, or foul-smelling, is typically a sign of infection.
Which of the following is NOT a systemic manifestation of inflammation?
A. Fever
B. Leukocytosis
C. Swelling
D. Fatigue
Answer: C. Swelling
Rationale: Swelling is a local, not systemic, response to inflammation.
Which lab test indicates ongoing inflammation in the body?
A. Hematocrit
B. ESR (erythrocyte sedimentation rate)
C. Glucose
D. Creatinine
Answer: B. ESR (erythrocyte sedimentation rate)
Rationale: ESR increases in response to inflammation, indicating chronic or acute inflammatory processes.
Which wound complication involves the separation of wound edges?
A. Maceration
B. Dehiscence
C. Evisceration
D. Undermining
Answer: B. Dehiscence
Rationale: Dehiscence is the partial or complete separation of wound edges due to failed healing.
What is the predominant white blood cell in acute inflammation?
A. Lymphocytes
B. Monocytes
C. Eosinophils
D. Neutrophils
Answer: D. Neutrophils
Rationale: Neutrophils are the first responders in acute inflammation and are responsible for phagocytosing pathogens.
The maturation phase of wound healing includes:
A. Inflammation
B. Collagen remodeling and scar contraction
C. Clot formation
D. Redness and heat
Answer: B. Collagen remodeling and scar contraction
Rationale: This is the final stage of wound healing, where tissue is strengthened and the scar contracts.
In chronic inflammation, the predominant cells are:
A. Basophils and eosinophils
B. Lymphocytes and macrophages
C. Neutrophils
D. Platelets
Answer: B. Lymphocytes and macrophages
Rationale: Chronic inflammation is marked by the presence of macrophages and lymphocytes rather than neutrophils.
What should the nurse do first if a patient has evisceration of an abdominal wound?
A. Administer antibiotics
B. Push organs back in
C. Cover with a sterile saline-soaked towel
D. Apply pressure dressing
C. Cover with a sterile saline-soaked towel
Rationale: The priority is to prevent organ drying and contamination. The wound should be covered with a moist, sterile dressing and the surgeon notified.
A patient is post-op day 2 and has a temperature of 100.8°F. What is the most appropriate nursing action?
A. Notify the provider immediately
B. Document and continue monitoring
C. Start IV antibiotics
D. Remove surgical dressing
Answer: B. Document and continue monitoring
Rationale: A mild temperature elevation post-op is a normal inflammatory response. Monitor closely unless it worsens.
What triggers the systemic inflammatory response of fever and malaise?
A. Histamine
B. Cytokines
C. Fibrin
D. Erythropoietin
Answer: B. Cytokines
Rationale: Cytokines like interleukins and TNF trigger systemic effects like fever, fatigue, and increased WBCs.
Which nutrient is most important for collagen formation during wound healing?
A. Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin K
Answer: C. Vitamin C
Rationale: Vitamin C is essential for collagen synthesis, a critical component of tissue repair.
The inflammatory response helps in healing by:
A. Blocking circulation
B. Preventing white blood cell migration
C. Isolating and removing pathogens
D. Destroying healthy tissue
Answer: C. Isolating and removing pathogens
Rationale: Inflammation neutralizes threats and sets the stage for tissue healing.
Which is an example of healing by secondary intention?
A. Sutured surgical incision
B. Clean puncture wound
C. Pressure ulcer with tissue loss
D. Superficial abrasion
Answer: C. Pressure ulcer with tissue loss
Rationale: Secondary intention occurs when wounds are left open to heal from the bottom up, such as in ulcers and infected wounds.
A wound assessment reveals a deep ulcer with tissue loss under the skin that extends beyond the wound edges. The nurse can insert a cotton swab under the intact skin around the perimeter. How should this finding be documented?
A. Presence of tunneling
B. Presence of slough
C. Presence of undermining
D. Presence of maceration
Answer: C. Presence of undermining
Rationale: Undermining occurs when the tissue under the wound edges becomes detached from the underlying tissue, creating a "lip" or pocket. A cotton swab that slides under intact skin is a clear indicator. Tunneling refers to a narrow passage from the wound bed outward, slough is yellow/white necrotic tissue, and maceration is skin softening from excess moisture.
A nurse is caring for a patient with localized cellulitis. Which manifestation indicates the inflammation is becoming systemic?
A. Redness and warmth
B. Swelling
C. Fever and tachycardia
D. Pain at site
Answer: C. Fever and tachycardia
Rationale: Fever, increased pulse, and other systemic signs indicate the inflammation has spread beyond the local area.
Which patient is at greatest risk for delayed wound healing?
A. 25-year-old athlete
B. 30-year-old with iron-deficiency anemia
C. 40-year-old on high-protein diet
D. 50-year-old with no comorbidities
Answer: B. 30-year-old with iron-deficiency anemia
Rationale: Anemia reduces oxygen delivery to tissues, impairing healing.
Which of the following factors would most impair wound healing?
A. High protein diet
B. Diabetes mellitus
C. Adequate hydration
D. Zinc supplementation
Answer: B. Diabetes mellitus
Rationale: Diabetes impairs circulation, phagocytosis, and collagen synthesis, all of which delay healing.
Which action prevents maceration during wound healing?
A. Keeping dressing dry
B. Using hydrogen peroxide
C. Keeping the wound exposed
D. Debriding the wound aggressively
Answer: A. Keeping dressing dry
Rationale: Maceration (softening and breakdown) of skin can be prevented by keeping surrounding tissue dry and changing dressings as needed.
A nurse is caring for a surgical patient whose wound is healing by primary intention. The wound is in the granulation phase. Which characteristic should the nurse expect to observe?
A. Formation of a dry, black eschar
B. Pink, vascular tissue with budding capillaries
C. Absence of exudate and fully approximated edges
D. Thick scar tissue with no visible redness
Answer: B. Pink, vascular tissue with budding capillaries
Rationale: The granulation phase (5 days to 3 weeks post-injury) is marked by the presence of fibroblasts, new capillary buds, and a pink vascular surface. This tissue is fragile and at risk for injury. Eschar is associated with necrosis, not granulation. Fully approximated edges are part of the initial phase, and thick scar tissue forms in the maturation phase.