NUR 101 Final Exam Study Guide
Questions and Answers Graded A+
Factors that affect skin integrity - Correct answer-1. age (turgor, drier, reduced
collagen, more prone to injury)-frail skin
2. Bedrest/immobility-decrease pressure and shear
3. nutrition/hydration (protein, C, zinc, copper)
4. sensation level (diminished)
5. impaired circulation-(impaired arterial circulation causes muscle atrophy and
thin tissue; impaired venous circulation causes buildup of waste in blood, causes
edema, ulceration, skin breakdown)-loose clothing
6. moisture-incontinence, fever cause moisture and skin maceration (fever
increases metabolic rate ans this tissue demand for oxygen)
7. Edema-decreases skin elasticity; compression stockings
8. Glycemic control-diabetes increases infection risk and delayed wound healing
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,9. Drugs-causes itching, rashes, photosensitivity, pigmentation changes;
vasoconstrictors, steroids (inhibit wound healing); anticoagulants can result in
pooling of blood in subcutaneous tissue, can cause hematoma; chemotherapeutic
agents, antibiotics increase sensitivity to sun-sunburn
10. Impaired cognition
11. Infection-can contaminate a wound
12. Lifestyle-tanning, smoking (decreases oxygen supply to tissues, interferes with
Vit c absorption necessary for collagen), body piercings, tattoos-risk for infection
Nursing actions that limit the impact of the factors that alter skin integrity - Correct
answer-1. Anemia (poor 02 supply)-provide diet rich in iron
2. Nutrition deficits-provide supplements for vitamin c, protein, zinc, copper
3. Drugs (steroids, vasoconstrictors)-additional monitoring
4. Smoking-destroys granulation tissue (encourage/educate on cessation)
5. Mechanical friction-careful positioning, lifting equipment
6. Age-thinning of vascular circulation (protect fragile skin)
7. Obesity-Less blood supply in fatty tissue (monitor skin folds)
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,8. Diabetes-decreased oxygen, poor capillary growth, impaired phagocytosis)-
increase glycemic control
Braden Scale - Correct answer-Pressure ulcers
lower the number, higher the risk
4-23
less than 17 = risk for pressure ulcers
List the characteristics used to classify wounds - Correct answer-1. Skin integrity
(open and closed wound)
-closed (bruise or tissue swelling from fracture)
-open (abrasion, laceration, puncture wound, surgical incision, compound fracture)
2. Length of time for healing-acute (healing progresses normally) and chronic
(delayed healing due to infection, trauma, ischemia, edema)-diabetic ulcers,
pressure injury; lingers for months or years
3. Level of contamination (CDC)
-clean -uninfected, no inflammation, closed, no tracts are entered
-clean-contaminated-resp, genital, urinary, alimentary tracts are entered, no evid. of
infection
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, -contaminated-open, fresh accidental wounds
-dirty-infected-
4. Depth of wound-superficial (epidermal-friction, shearing, burning); Partial
thickness (epidermis but not through dermis; full thickness (extend into
subcutaneous)
Wound types - Correct answer-1. intentional-surgical
-incision (sharp instrument)
2. unintentional-cut, trauma, pressure ulcer
-abrasion (scrape of superficial layers)
-abscess-pus due to entry of microbe
-contusion (bruise)
-crushing (compression of tissue-fracture of bone)
-Laceration (tear in skin)
-penetrating (open wound with object lodged in tissue)
-Puncture (open wound caused by sharp obj-prone to infection)
-tunnel (entrance and exit site)
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Questions and Answers Graded A+
Factors that affect skin integrity - Correct answer-1. age (turgor, drier, reduced
collagen, more prone to injury)-frail skin
2. Bedrest/immobility-decrease pressure and shear
3. nutrition/hydration (protein, C, zinc, copper)
4. sensation level (diminished)
5. impaired circulation-(impaired arterial circulation causes muscle atrophy and
thin tissue; impaired venous circulation causes buildup of waste in blood, causes
edema, ulceration, skin breakdown)-loose clothing
6. moisture-incontinence, fever cause moisture and skin maceration (fever
increases metabolic rate ans this tissue demand for oxygen)
7. Edema-decreases skin elasticity; compression stockings
8. Glycemic control-diabetes increases infection risk and delayed wound healing
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,9. Drugs-causes itching, rashes, photosensitivity, pigmentation changes;
vasoconstrictors, steroids (inhibit wound healing); anticoagulants can result in
pooling of blood in subcutaneous tissue, can cause hematoma; chemotherapeutic
agents, antibiotics increase sensitivity to sun-sunburn
10. Impaired cognition
11. Infection-can contaminate a wound
12. Lifestyle-tanning, smoking (decreases oxygen supply to tissues, interferes with
Vit c absorption necessary for collagen), body piercings, tattoos-risk for infection
Nursing actions that limit the impact of the factors that alter skin integrity - Correct
answer-1. Anemia (poor 02 supply)-provide diet rich in iron
2. Nutrition deficits-provide supplements for vitamin c, protein, zinc, copper
3. Drugs (steroids, vasoconstrictors)-additional monitoring
4. Smoking-destroys granulation tissue (encourage/educate on cessation)
5. Mechanical friction-careful positioning, lifting equipment
6. Age-thinning of vascular circulation (protect fragile skin)
7. Obesity-Less blood supply in fatty tissue (monitor skin folds)
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,8. Diabetes-decreased oxygen, poor capillary growth, impaired phagocytosis)-
increase glycemic control
Braden Scale - Correct answer-Pressure ulcers
lower the number, higher the risk
4-23
less than 17 = risk for pressure ulcers
List the characteristics used to classify wounds - Correct answer-1. Skin integrity
(open and closed wound)
-closed (bruise or tissue swelling from fracture)
-open (abrasion, laceration, puncture wound, surgical incision, compound fracture)
2. Length of time for healing-acute (healing progresses normally) and chronic
(delayed healing due to infection, trauma, ischemia, edema)-diabetic ulcers,
pressure injury; lingers for months or years
3. Level of contamination (CDC)
-clean -uninfected, no inflammation, closed, no tracts are entered
-clean-contaminated-resp, genital, urinary, alimentary tracts are entered, no evid. of
infection
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, -contaminated-open, fresh accidental wounds
-dirty-infected-
4. Depth of wound-superficial (epidermal-friction, shearing, burning); Partial
thickness (epidermis but not through dermis; full thickness (extend into
subcutaneous)
Wound types - Correct answer-1. intentional-surgical
-incision (sharp instrument)
2. unintentional-cut, trauma, pressure ulcer
-abrasion (scrape of superficial layers)
-abscess-pus due to entry of microbe
-contusion (bruise)
-crushing (compression of tissue-fracture of bone)
-Laceration (tear in skin)
-penetrating (open wound with object lodged in tissue)
-Puncture (open wound caused by sharp obj-prone to infection)
-tunnel (entrance and exit site)
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