The key factor in healing an arterial ulcer is: - ANSWER REVASCULARIZATION - If
ischemia is not corrected , wound healing will not occur despite tropical treatment .
Which of the following locations would MOST likely be associated with a neuroischemic
ulcer?
Heel
Lateral aspect of the fifth metatarsophalangeal joint
Medial malleolus
Plantar metatarsal head - ANSWER Lateral aspect of the fifth metatarsophalangeal
joint .
other common locations are the margins of the foot , tips of the toes , and beneath any toe
nails
What is the deepest layer of tissue affected in a Stage 3 pressure injury? -
ANSWER SUBCUTANEOUS TISSUE . A Stage 3 is a full thickness tissue loss involving the
epidermis , dermis and into but not through subcutaneous fat
What is the deepest layer of tissue that can be affected in a Stage 2 pressure injury? -
ANSWER DERMIS . STAGE 2 is a partial thickness tissue loss involving the epidermis ,
dermis or both
Your patient has an unstageable pressure injury to the right ischial tuberosity covered in 50%
slough tissue. Once the slough is removed, what is the LOWEST stage that can be revealed? -
ANSWER STAGE 3 .
Slough will never be present in Stage 1 or Stage 2 so the lowest stage this pressure injury can
once the extent of tissue damage can be confirmed will be a Stage 3 .
1
,Your patient has a deep tissue pressure injury to the right heel. It is now 100% covered by a
thin layer of eschar. How would you stage this pressure injury? -
ANSWER UNSTAGEABLE ,
Intact skin with a localized area (usually over a bony prominence) of non-blanchable
erythema describes a Stage: - ANSWER STAGE 1
You notice an area of intact skin over the left heel of a patient that is purple in color and
non-blanchable. How would you stage this wound? - ANSWER DEEP TISSUE INJURY
What condition is described as having wound edges that curl under? -
ANSWER EPIBOLE - IS A ROLLED / CURLED UNDER EDGES FROM EPITHELIAL
TISSUEMIGRATING DOWN SIDES OF THE WOUND INSTEAD OF ACROSS
A peri-wound skin that is white and wrinkled would be called: - ANSWER MACERATION
Circulation and sweating are the processes the body uses to accomplish what? -
ANSWER THERMOREGULATION
A positive Stemmer's sign indicates which disease process? - ANSWER LYMPHEDEMA
All of the following can cause lymphedema EXCEPT:
Chemotherapy
Developmental abnormality
Radiation therapy
Tumor obstruction - ANSWER CHEMOTHERAPY.
PRIMARY LYMPHEDEMA IS ATTRIBUTED TO DEVELOPMENTAL ABNORMALITY. SECONDARY
LYMPHEDEMA CAN OCCUR FROM SURGERY , RADIATION THERAPY, TUMOR OBSTRUCTION
OR TRAUMA
2
, What is the term for the vertical distance from the visible surface of the skin to the deepest
area in wound bed? - ANSWER DEPTH
For which of the following wounds would biological debridement be contraindicated?
Neuropathic ulcer
Non-healing traumatic wound
Wound with 50% slough tissue
Wound with necrotic bone or tendon - ANSWER WOUND WITH NECROTIC BONE OR
TENDON .
OTHER CONTRAINDICATIONS ARE : WOUNDS WITH EXPOSED VITAL ORGANS OR BLOOD
VESSELS , WOUNDS LIKELY TO COMMUNICATE WITH CNS AND WOUNDS WITH POOR
PERFUSION.
At what point in the wound infection continuum will a host response FIRST occur?
Colonization
Contamination
Local infection
Spreading infection - ANSWER LOCAL INFECTION .
NEITHER COLONIZATION OR CONTAMINATION CASE A HOST RESPONSE OR DELAY WOUND
HEALING .
A darker red appearance to granulation tissue indicates the presence of:
Bacteria
Moisture
Poor blood flow
Pressure - ANSWER PRESSURE .
IF TOO MUCH PRESSURE OR TRAUMA IS APPLIED , GRANULATION TISSUE DARKENS.
3
ischemia is not corrected , wound healing will not occur despite tropical treatment .
Which of the following locations would MOST likely be associated with a neuroischemic
ulcer?
Heel
Lateral aspect of the fifth metatarsophalangeal joint
Medial malleolus
Plantar metatarsal head - ANSWER Lateral aspect of the fifth metatarsophalangeal
joint .
other common locations are the margins of the foot , tips of the toes , and beneath any toe
nails
What is the deepest layer of tissue affected in a Stage 3 pressure injury? -
ANSWER SUBCUTANEOUS TISSUE . A Stage 3 is a full thickness tissue loss involving the
epidermis , dermis and into but not through subcutaneous fat
What is the deepest layer of tissue that can be affected in a Stage 2 pressure injury? -
ANSWER DERMIS . STAGE 2 is a partial thickness tissue loss involving the epidermis ,
dermis or both
Your patient has an unstageable pressure injury to the right ischial tuberosity covered in 50%
slough tissue. Once the slough is removed, what is the LOWEST stage that can be revealed? -
ANSWER STAGE 3 .
Slough will never be present in Stage 1 or Stage 2 so the lowest stage this pressure injury can
once the extent of tissue damage can be confirmed will be a Stage 3 .
1
,Your patient has a deep tissue pressure injury to the right heel. It is now 100% covered by a
thin layer of eschar. How would you stage this pressure injury? -
ANSWER UNSTAGEABLE ,
Intact skin with a localized area (usually over a bony prominence) of non-blanchable
erythema describes a Stage: - ANSWER STAGE 1
You notice an area of intact skin over the left heel of a patient that is purple in color and
non-blanchable. How would you stage this wound? - ANSWER DEEP TISSUE INJURY
What condition is described as having wound edges that curl under? -
ANSWER EPIBOLE - IS A ROLLED / CURLED UNDER EDGES FROM EPITHELIAL
TISSUEMIGRATING DOWN SIDES OF THE WOUND INSTEAD OF ACROSS
A peri-wound skin that is white and wrinkled would be called: - ANSWER MACERATION
Circulation and sweating are the processes the body uses to accomplish what? -
ANSWER THERMOREGULATION
A positive Stemmer's sign indicates which disease process? - ANSWER LYMPHEDEMA
All of the following can cause lymphedema EXCEPT:
Chemotherapy
Developmental abnormality
Radiation therapy
Tumor obstruction - ANSWER CHEMOTHERAPY.
PRIMARY LYMPHEDEMA IS ATTRIBUTED TO DEVELOPMENTAL ABNORMALITY. SECONDARY
LYMPHEDEMA CAN OCCUR FROM SURGERY , RADIATION THERAPY, TUMOR OBSTRUCTION
OR TRAUMA
2
, What is the term for the vertical distance from the visible surface of the skin to the deepest
area in wound bed? - ANSWER DEPTH
For which of the following wounds would biological debridement be contraindicated?
Neuropathic ulcer
Non-healing traumatic wound
Wound with 50% slough tissue
Wound with necrotic bone or tendon - ANSWER WOUND WITH NECROTIC BONE OR
TENDON .
OTHER CONTRAINDICATIONS ARE : WOUNDS WITH EXPOSED VITAL ORGANS OR BLOOD
VESSELS , WOUNDS LIKELY TO COMMUNICATE WITH CNS AND WOUNDS WITH POOR
PERFUSION.
At what point in the wound infection continuum will a host response FIRST occur?
Colonization
Contamination
Local infection
Spreading infection - ANSWER LOCAL INFECTION .
NEITHER COLONIZATION OR CONTAMINATION CASE A HOST RESPONSE OR DELAY WOUND
HEALING .
A darker red appearance to granulation tissue indicates the presence of:
Bacteria
Moisture
Poor blood flow
Pressure - ANSWER PRESSURE .
IF TOO MUCH PRESSURE OR TRAUMA IS APPLIED , GRANULATION TISSUE DARKENS.
3
