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The Wound Exam

Cross, Heidi Huddleston; Crestodina, Lea; Smith, June F.; Sorensen, Carolyn A.

Journal of Wound, Ostomy and Continence Nursing: September/October 2011 - Volume 38 - Issue 5 - p 577–580
doi: 10.1097/WON.0b013e31822aefae
GETTING READY FOR CERTIFICATION
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Heidi Huddleston Cross, MSN, RN, FNP-BC, CWOCN, Upstate Medical University Hospital, Syracuse, New York.

Lea Crestodina, ARNP, CDE, CWOCN, Memorial Regional Hospital, Hollywood, Florida.

June F. Smith, RN, BSN, CWOCN, Watauga Medical Center, Boone, North Carolina.

Carolyn A. Sorensen, MSN, CRRN, CWOCN, National Rehabilitation Hospital, Washington, District of Columbia.

Correspondence: Heidi H. Cross, MSN, RN, FNP, Upstate Medical University Hospital, 750 East Adams St, Room 1103, Syracuse, NY 13210 (hcross914@gmail.com).

According to a Chinese proverb, “A journey of a thousand miles begins but with a single step.” As certified wound, ostomy, continence, and foot-care nurses, our journey of a thousand miles begins with the Wound, Ostomy, and Continence Nursing Certification Board (WOCNCB) exams. Taking a national board certification exam can be stressful, and some test takers are wracked with more test anxiety than others. How to best prepare? One great way to reduce test anxiety is to take practice tests in the days leading up to the actual exam. These can familiarize you with the format of the final test and give you practice in answering questions similar to those you will see on the exam. Additionally, they will help highlight weak areas on which you may need to focus.

The WOCNCB offers a variety of resources to help you prepare for the exam, and these can be found on the Web site www.wocncb.org. The most important resource is the Exam Handbook, which can be downloaded or requested from the WOCNCB. Read through it carefully a few times and make sure you understand all the steps involved in registering for and taking the exam.

Study resources listed on the Web site include the Content Outline, suggested review courses, exam-taking tips, a free sample exam, and the Self-Assessment Exams (SAEs). The Content Outline is a necessary starting point and has been discussed extensively in this column. Be sure to have it in hand throughout your studying process. Suggested review courses include those available through the WOCN Global Learning Center, several WOCN Society Regional Affiliates, or through the WOCN Society's Accredited Educational Programs. The exam-taking tips will answer many of your questions about the exam and give you good advice for the exam day. The free sample exam gives you 7 sample questions and immediate answers for a taste of what to expect on the exam.

The SAEs are the best way to prepare you for the actual credentialing exam. There are 4 exams, 1 each for wound, ostomy, continence, and foot care. Each SAE costs $30 and contains 40 questions. The intent of the practice exam is to give you experience with taking an online exam, the format of the questions, and the type of content that you will see. You will have 150 hours within 90 days of purchase to complete each SAE test. You cannot reenter this test once you have submitted it for scoring. Your scored results will include a list of all the questions with correct answers, references, and rationales. Using the SAEs can help you become more confident in your ability to take and pass this important exam.

This article contains sample questions for the wound exam, followed by a section giving correct answers, rationales, and explanations. These questions are specifically from section A, General Principles of Assessment, and from section E, Other Types of Wounds. The Content Outline shows that there are 18 questions on the exam related to General Principles of Assessment (section A) out of a total of 90 questions. Other Types of Wounds (section E) accounts for 8 questions on the exam. Be sure you look closely at all the detailed categories and concepts under each section of the Content Outline and include them in your study plan.

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Practice Questions

  1. Assessment of the periwound skin of a leg ulcer in a patient with rheumatoid arthritis reveals palpable, nonblanchable purpura with petechiae, nodules, and vesicles. The wound is very painful. The wound pathology is most likely related to:
    1. Vasculitis
    2. Infection
    3. Pressure
    4. Calciphylaxis
  2. The gold standard for wound culture is as follows:
    1. Tissue biopsy
    2. Swab culture
    3. Aspiration culture
    4. Gram stain
  3. Which of the following is an appropriate dressing to minimize pain related to fungating tumors?
    1. Sodium-impregnated gauze
    2. Charcoal foam dressing
    3. Nonadherent dressing
    4. Wound drainage pouch
  4. What is the most reliable indicator of the existence of acute pain when performing wound care?
    1. Family's report of patient's pain
    2. Patient's self-report of pain
    3. Observational Pain Intensity Scale
    4. Patient's history of analgesic use
  5. A 54-year-old male patient recently had revascularization surgery of the right lower extremity. He now has an erythematous nodule with swelling on his right inner thigh, chills and fever, subcutaneous crepitus, and exquisite pain at the nodule site. These findings are most consistent with:
    1. Pyoderma gangrenosum
    2. Necrotizing fasciitis
    3. Epidermolysis bullosa
    4. Cellulitis
  6. A patient undergoing radiation therapy for breast cancer is experiencing dry desquamation. An appropriate recommendation for management would be as follows:
    1. Moisturizers such as hydrophilic lotions and creams
    2. Silver-based wound gel with foam dressing
    3. Petrolatum-based products applied twice daily
    4. Alpha-hydroxy acid–based cream applied twice daily
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Answers and Rationale

1. (A). This is an application question, defined as one that tests the ability to comprehend, relate, or apply knowledge to a new or changing situation. These features describe vasculitis, which not only is most often seen in patients with autoimmune disorders but also can be drug-induced. Infection is described as erythema, pain, heat, swelling, and induration. Pressure is described as hyperemia, edema, induration, and discoloration. Calciphylaxis is characterized by dusky, purple, and palpable nodules that progress to necrosis and ulceration, and is often associated with renal disease.

Reference

Nix D. Skin and wound inspection and assessment. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. St Louis, MO: Elsevier Mosby; 2012:117, 421–422.

Content Outline Location: 1A5. General principles of assessment, assess, and interpret wound characteristics.

2. (A). This is a recall question, which tests the ability to recall or recognize specific information, taken straightforward from texts or guidelines. A tissue biopsy is the removal of a piece of tissue with a scalpel or punch biopsy and is considered the gold standard for wound culture. Needle aspiration culture involves insertion of a needle in the tissue adjacent to the wound to aspirate tissue fluid. Swab culture is the most commonly performed technique but can be nonspecific and nonsensitive. The base of the wound is cultured by moving a swab back and forth over the surface of the wound. Gram staining is incorrect because it is not an actual method of culturing.

Reference

Nix D. Wound infection: diagnosis and management. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. St Louis, MO: Elsevier Mosby; 2012:274–275.

Content Outline Location: 1A8. General principles of assessment, describe procedures, and rationale for diagnostic testing.

3. (C) This is a recall question. Minimization of trauma (thereby minimizing pain during dressing changes) by use of nonadherent dressings is a key recommendation for pain management of fungating tumors. Sodium-impregnated gauze as well as charcoal foam dressings assists with odor control. A wound drainage pouch does not assist with pain management, but with exudate control.

Reference

Goldberg M, Bryant R. Managing wounds in palliative care. In: Bryant R, ed. Acute and Chronic Wounds, Current Management Concepts. St Louis, MO: Elsevier Mosby; 2012:509.

Content Outline Location: 1E1d. Recommend topical therapy for neoplastic wounds.

4. (B) This is a recall question. The existence and intensity of pain should be a routine part of wound assessment. The presence of pain is subjective, and self-report is the most reliable indicator. The other choices can be valuable adjuncts in pain assessment, but when possible it is a patient's self-report that should be relied upon.

Reference

Krasner D. Wound pain: impact and assessment. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. St Louis, MO: Elsevier Mosby; 2012:372.

Content Outline Location: 1A4. General principles of assessment: assess for pain.

5. (B). This is an analysis question, defined as one that tests the ability to analyze and synthesize information. This scenario describes necrotizing fasciitis, a serious condition that is characterized by subcutaneous tissue infection that spreads rapidly along the superficial fascial plane. Pyoderma gangrenosum is a chronic neutrophilic inflammatory disease that most often occurs in the presence of autoimmune disease. Epidermolysis bullosa is a group of (primarily) inherited blistering skin conditions that are characterized by various defects in the epidermal basement membrane. Cellulitis involves the subcutaneous tissue and is characterized by pain, warmth, edema, and erythema.

Reference

Bryant R. Intrinsic diseases and uncommon cutaneous wounds. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. St Louis, MO: Elsevier Mosby; 2012: 418.

Content Outline Location: 1E1e. Other types of wounds, atypical wounds.

6. (A). This is an application question. Although there is limited evidence for radiation skin care, there are several literature reviews that reveal similar findings. Heavy metals (such as silver) are contraindicated with radiation therapy, as are petrolatum-based products. Alpha-hydroxy acid–based creams can increase radiation skin reactions.

Reference

Bryant R. Types of skin damage and differential diagnosis. In: Bryant R, Nix D, eds. Acute and Chronic Wounds, Current Management Concepts. St Louis, MO: Elsevier Mosby; 2012:102–105.

Content Outline Location: 1E2c. Other types of wounds, thermal injury (radiation).

For best success on your exam, be sure to use all the resources available to you on the WOCNCB Web site. They are an important first step on your exciting journey of being a certified wound, ostomy, continence, or foot-care nurse!

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Research, Planning, and Execution Are Keys to WOCNCB Exam Success

Each of us can remember taking an educational program knowing that the final test would ultimately determine our success. For many, tests are a source of anxiety, and that anxiety alone can impact your ability to perform at your best. In preparing for any exam, it is important to manage your stress. To do this, you need to recognize those internal and external factors responsible for increasing your stress. For some, life itself becomes a greater source of stress than the exam. Once you recognize your stressors, look for strategies to reduce or even eliminate the stress.

If your anxiety is triggered by the exam, information, preparation, and confidence will help reduce the anxiety. Before becoming eligible for the exam, you will have completed the necessary education. Regardless of the pathway for education, the question that is always at the forefront is “Can you tell us what will be on the exam?” The WOCNCB gives you that information in the form of the Exam Content Outline. This blueprint of exam content identifies not only what areas will be covered, but also how many questions will be asked in each area and how complex the questions will be. A limited number of free sample questions are available online and in the Exam Handbook; these samples illustrate how questions and potential answers are written.

Among your tools for building success are the SAEs that the WOCNCB offers for each of the four specialty areas. These online “practice” tests allow you to experience each test for 30 days or 150 hours. This broad time frame allows candidates a variety of options to match their individual learning styles. For some, this means looking at the questions and possible answers and using the SAE as an open book exam to verify knowledge and prioritize studying. For others, it is more beneficial as a traditional exam. Each SAE offers 40 questions that mirror the real exam in format, content, and complexity. Once the SAE is submitted for scoring, the candidate is able to see each question with the correct answer, rationale, and references. This is an invaluable tool in understanding why an incorrect answer was indeed a wrong answer. Successful completion of the SAE is a wonderful way to increase confidence in your ability to pass the exam.

Almost all educational programs encourage candidates to prepare for the exam with appropriate study, test-taking strategies for success, a careful review of the test blueprint, and use of self-assessment exams. For some programs, the self-assessment exams are not optional. If you are in a program that does not mandate that you take these practice exams, please consider it to be an advantage in optimizing your success. For a very nominal cost of $30 per specialty exam, you can access the SAEs at www.wocncb.org.

Preparing for the WOCNCB certification exam is not unlike the preparation that you do every day as you critically solve problems for patients, physician partners, and facilities. Nurses working in these specialties are driven to succeed and know what it takes to reach their goals. They research what is required to be successful, establish a plan to reach their goal, gather the resources that will be needed, follow that plan—modifying it if needed, and when their plan is realized, they celebrate their success. Education, both didactic and clinical, is a great beginning, but certification is the final step to validate the enhanced knowledge and clinical expertise that has been gained in the journey to becoming a specialist.

The same research, planning, and execution that it takes to reach your goal of becoming a WOCNCB-certified nurse is the same research, planning, and execution that you will bring to your patients and the healthcare partners on a daily basis. Your success with the exams is only the beginning of a lifetime of successful interventions that will improve the lives of patients and families every day.

Diana L. Gallagher, MS, RN, CWOCN, CFCN, CHT, President, WOCNCB

Copyright © 2011 by the Wound, Ostomy and Continence Nurses Society