WOUND CARE FINAL EXAM|VERIFIED QUESTIONS AND
ANSWERS|GRADED A+|LATEST 2026/2027
what is force acting tangentially on an area of an object? - ANSWER✔ shear force
skin remains stationary and the tissues below the skin (fat/muscle) are deformed or distorted is an
example of: ____________ - ANSWER✔ shear force
what do shear stresses on a tissue do? - ANSWER✔ decrease the ability to withstand normal loads
-tissue subjected to shear force can suffer ischemia at only HALF the pressure than without shear
the resistance to motion in a parallel direction relative to the common boundary of 2 surfaces is:
___________ - ANSWER✔ friction
what is friction pressure usually associated with? - ANSWER✔ skin/bedding on skin/seating cushion
interfaces
temperatures of ____ cause increased perspiration, increasing the maceration risk of the skin and
increasing the pH - ANSWER✔ 95 deg. F
what is the normal skin pH?
what about urine and feces? - ANSWER✔ 4-6.5
-urine is around 6.8 and feces around 7-7.5 --> tend to be closer to a neutral pH
what are the 3 elements that lead to the development of an actual pressure ulcer? - ANSWER✔ -
intensity of pressure & vascular occlusion
-duration of the pressure AND
-tissue tolerance
,what is normal capillary blood pressure?
what happens if external pressure exceeds capillary blood pressure? - ANSWER✔ 12-32 mmHg
-if external pressure exceeds capillary blood pressure --> blood flow is impeded --> ischemia and
breakdown occur
tissue damage was thought to be caused by compression of capillaries, known as ________ _________
_________ - ANSWER✔ capillary closing pressure
what happens if pressure to the skin is relieved within a few hours? - ANSWER✔ a brief period of
reactive hyperemia occurs (redness) with NO lasting tissue damage
-will have blanching
what happens if pressure to the skin is unrelieved? - ANSWER✔ the endothelial cells lining the
capillaries become disrupted with platelet aggregation --> forming micro-thrombi that BLOCK blood flow
and cause anoxic necrosis of surrounding tissue
what is more sensitive to pressure: muscle or skin? - ANSWER✔ muscle is more sensitive to pressure
what is considered hypoalbuminia and why is this important? - ANSWER✔ <3.4 g/dL --> important
because malnutrition can lead to increased risk at developing a pressure ulcer
what are the common locations of pressure ulcers in supine position? - ANSWER✔ occiput, scapula,
sacrum, heels
what are the common locations of pressure ulcers in sidelying (lateral)? - ANSWER✔ ear, acromion
process, elbow, trochanter, medial and lateral epicondyles and malleoli, heels
what are the common locations of pressure ulcers in prone? - ANSWER✔ elbow, ear, cheek, nose,
breasts/genitals, iliac crest, patella, toes
, what is the scale used to assess who is AT RISK of developing a pressure ulcer?
what is the cut-off?
what is it out of? - ANSWER✔ Branden Scale Score (done by nursing staff)
cut off: 16-18 --> trigger alternative mattresses and nursing interventions
out of 23 (the lower the score the WORSE)
what are the 3 options for scales of who is at RISK for developing a pressure ulcer? - ANSWER✔ -
branden scale score
-norten sclae (oldest)
-gosnell scale
what is a stage 1 pressure ulcer like? - ANSWER✔ non-blanchable
-pt's with darker skin will present with: discoloration of the skin, warmth, edema, induration, or
hardness as indicators
what is a stage 2 pressure ulcer like?
how does it present clinically?
how will it heal? - ANSWER✔ -partial thickness skin loss involving the epidermis and/or dermis
-will heal via re-epithelializaiton
-presents clinically as an abrasion, blister or SHALLOW crater
what is a stage 3 pressure ulcer like?
how does it present clinically? - ANSWER✔ full thickness skin loss, involving damage or necrosis of
the subcuteanous tissue, which may extend down to but NOT THROUGH underlying fascia
-presents clinically as a deep crater with or without undermining of adjacent tissue
-will heal with granulation tissue
ANSWERS|GRADED A+|LATEST 2026/2027
what is force acting tangentially on an area of an object? - ANSWER✔ shear force
skin remains stationary and the tissues below the skin (fat/muscle) are deformed or distorted is an
example of: ____________ - ANSWER✔ shear force
what do shear stresses on a tissue do? - ANSWER✔ decrease the ability to withstand normal loads
-tissue subjected to shear force can suffer ischemia at only HALF the pressure than without shear
the resistance to motion in a parallel direction relative to the common boundary of 2 surfaces is:
___________ - ANSWER✔ friction
what is friction pressure usually associated with? - ANSWER✔ skin/bedding on skin/seating cushion
interfaces
temperatures of ____ cause increased perspiration, increasing the maceration risk of the skin and
increasing the pH - ANSWER✔ 95 deg. F
what is the normal skin pH?
what about urine and feces? - ANSWER✔ 4-6.5
-urine is around 6.8 and feces around 7-7.5 --> tend to be closer to a neutral pH
what are the 3 elements that lead to the development of an actual pressure ulcer? - ANSWER✔ -
intensity of pressure & vascular occlusion
-duration of the pressure AND
-tissue tolerance
,what is normal capillary blood pressure?
what happens if external pressure exceeds capillary blood pressure? - ANSWER✔ 12-32 mmHg
-if external pressure exceeds capillary blood pressure --> blood flow is impeded --> ischemia and
breakdown occur
tissue damage was thought to be caused by compression of capillaries, known as ________ _________
_________ - ANSWER✔ capillary closing pressure
what happens if pressure to the skin is relieved within a few hours? - ANSWER✔ a brief period of
reactive hyperemia occurs (redness) with NO lasting tissue damage
-will have blanching
what happens if pressure to the skin is unrelieved? - ANSWER✔ the endothelial cells lining the
capillaries become disrupted with platelet aggregation --> forming micro-thrombi that BLOCK blood flow
and cause anoxic necrosis of surrounding tissue
what is more sensitive to pressure: muscle or skin? - ANSWER✔ muscle is more sensitive to pressure
what is considered hypoalbuminia and why is this important? - ANSWER✔ <3.4 g/dL --> important
because malnutrition can lead to increased risk at developing a pressure ulcer
what are the common locations of pressure ulcers in supine position? - ANSWER✔ occiput, scapula,
sacrum, heels
what are the common locations of pressure ulcers in sidelying (lateral)? - ANSWER✔ ear, acromion
process, elbow, trochanter, medial and lateral epicondyles and malleoli, heels
what are the common locations of pressure ulcers in prone? - ANSWER✔ elbow, ear, cheek, nose,
breasts/genitals, iliac crest, patella, toes
, what is the scale used to assess who is AT RISK of developing a pressure ulcer?
what is the cut-off?
what is it out of? - ANSWER✔ Branden Scale Score (done by nursing staff)
cut off: 16-18 --> trigger alternative mattresses and nursing interventions
out of 23 (the lower the score the WORSE)
what are the 3 options for scales of who is at RISK for developing a pressure ulcer? - ANSWER✔ -
branden scale score
-norten sclae (oldest)
-gosnell scale
what is a stage 1 pressure ulcer like? - ANSWER✔ non-blanchable
-pt's with darker skin will present with: discoloration of the skin, warmth, edema, induration, or
hardness as indicators
what is a stage 2 pressure ulcer like?
how does it present clinically?
how will it heal? - ANSWER✔ -partial thickness skin loss involving the epidermis and/or dermis
-will heal via re-epithelializaiton
-presents clinically as an abrasion, blister or SHALLOW crater
what is a stage 3 pressure ulcer like?
how does it present clinically? - ANSWER✔ full thickness skin loss, involving damage or necrosis of
the subcuteanous tissue, which may extend down to but NOT THROUGH underlying fascia
-presents clinically as a deep crater with or without undermining of adjacent tissue
-will heal with granulation tissue
