Fundamentals of Nursing Chapter 48: Skin
Integrity and Wound Care exam questions
and answers
1. The nurse is working on a medical-
surgical unit that has been participating in a
research project associated with pressure
ulcers. The nurse recognizes that the risk
factors that predispose a patient to pressure
ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.
ANS: B
Patients who are confused or disoriented or
who have changing levels of consciousness are
unable to protect themselves. The patient may
,feel the pressure but may not understand what
to do to relieve the discomfort or to
communicate that he or she is feeling
discomfort. Impaired sensory perception,
impaired mobility, shear, friction, and moisture
are other predisposing factors. Shortness of
breath, muscular pain, and a diet low in calories
and fat are not included among the
predisposing factors.
2. The nurse is caring for a patient who was
involved in an automobile accident 2 weeks
ago. The patient sustained a head injury and
is unconscious. The nurse is able to identify
that the major element involved in the
development of a decubitus ulcer is
a. Pressure.
b. Resistance.
,c. Stress.
d. Weight.
ANS: A
Pressure is the main element that causes
pressure ulcers. Three pressure-related factors
contribute to pressure ulcer development:
pressure intensity, pressure duration, and
tissue tolerance. When the intensity of the
pressure exerted on the capillary exceeds 12 to
32 mm Hg, this occludes the vessel, causing
ischemic injury to the tissues it normally feeds.
High pressure over a short time and low
pressure over a long time cause skin
breakdown. Resistance (the ability to remain
unaltered by the damaging effect of something),
stress (worry or anxiety), and weight
(individuals of all sizes, shapes, and ages
, acquire skin breakdown) are not major causes
of pressure ulcers.
3. Which nursing observation would indicate
that the patient was at risk for pressure
ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the
right shin.
d. The patient's capillary refill is less than 2
seconds.
ANS: B
The presence and duration of moisture on the
skin increase the risk of ulcer formation by
making it susceptible to injury. Moisture can
originate from wound drainage, excessive
perspiration, and fecal or urinary incontinence.
Integrity and Wound Care exam questions
and answers
1. The nurse is working on a medical-
surgical unit that has been participating in a
research project associated with pressure
ulcers. The nurse recognizes that the risk
factors that predispose a patient to pressure
ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.
ANS: B
Patients who are confused or disoriented or
who have changing levels of consciousness are
unable to protect themselves. The patient may
,feel the pressure but may not understand what
to do to relieve the discomfort or to
communicate that he or she is feeling
discomfort. Impaired sensory perception,
impaired mobility, shear, friction, and moisture
are other predisposing factors. Shortness of
breath, muscular pain, and a diet low in calories
and fat are not included among the
predisposing factors.
2. The nurse is caring for a patient who was
involved in an automobile accident 2 weeks
ago. The patient sustained a head injury and
is unconscious. The nurse is able to identify
that the major element involved in the
development of a decubitus ulcer is
a. Pressure.
b. Resistance.
,c. Stress.
d. Weight.
ANS: A
Pressure is the main element that causes
pressure ulcers. Three pressure-related factors
contribute to pressure ulcer development:
pressure intensity, pressure duration, and
tissue tolerance. When the intensity of the
pressure exerted on the capillary exceeds 12 to
32 mm Hg, this occludes the vessel, causing
ischemic injury to the tissues it normally feeds.
High pressure over a short time and low
pressure over a long time cause skin
breakdown. Resistance (the ability to remain
unaltered by the damaging effect of something),
stress (worry or anxiety), and weight
(individuals of all sizes, shapes, and ages
, acquire skin breakdown) are not major causes
of pressure ulcers.
3. Which nursing observation would indicate
that the patient was at risk for pressure
ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the
right shin.
d. The patient's capillary refill is less than 2
seconds.
ANS: B
The presence and duration of moisture on the
skin increase the risk of ulcer formation by
making it susceptible to injury. Moisture can
originate from wound drainage, excessive
perspiration, and fecal or urinary incontinence.
