HONDROS NUR 205 EXAM 2 ACTUAL
QUESTIONS WITH VERIFIED SOLUTIONS
◉ Tissue Ischemia.
Answer: Pressure applied over a capillary exceeds the normal
capillary pressure, and the vessel is occluded for a prolonged period
of time.
◉ dermal-epidermal junction.
Answer: separates dermis and epidermis
◉ 3 pressure related factors that contribute to pressure ulcer
development.
Answer: -pressure intensity
-pressure duration
-tissue tolerance
◉ Non-blanchable hyperemia.
Answer: redness that persists after palpation and indicates tissue
damage
◉ Stage 1 Pressure Ulcer.
,Answer: -intact skin with nonblanchable redness
-warm to touch, edema, can be a hardened area
◉ Stage 2 Pressure Ulcer.
Answer: -partial thickness skin loss
-shallow but open
-no slough or drainage
-red/pink wound bed
◉ Stage 3 Pressure ulcer.
Answer: -full thickness tissue loss with visible underlying fat
-NO bone, muscle or tendon is visible
-can have slough
-underminning/tunneling
◉ Stage 4 Pressure ulcer.
Answer: -full thickness tissue loss WITH visible muscle, bone or
tendon
-tunneling/underminning
◉ Unstageable Pressure Ulcer.
, Answer: -Full thickness tissue loss in which the base of the ulcer is
covered by slough (yellow, tan, gray, green or brown) and/or eschar
(tan, brown or black) in the wound bed.
-cannot be measured/depth unknown
◉ Suspected Deep Tissue Injury.
Answer: -Purple or maroon localized area of discolored intact skin
or blood-filled blister due to damage of underlying soft tissue from
pressure and/or shear.
-depth unknown
◉ Primary Wound Healing.
Answer: -wound that is closed
-surgical incision
-wound that is sutured or stapled
-heals quickly with minimal scar formation
◉ Secondary Wound Healing.
Answer: -wound edges not approximated
-pressure ulcers, surgical wounds that have tissue loss or
contamination
-wounds heal by granulation tissue formation
QUESTIONS WITH VERIFIED SOLUTIONS
◉ Tissue Ischemia.
Answer: Pressure applied over a capillary exceeds the normal
capillary pressure, and the vessel is occluded for a prolonged period
of time.
◉ dermal-epidermal junction.
Answer: separates dermis and epidermis
◉ 3 pressure related factors that contribute to pressure ulcer
development.
Answer: -pressure intensity
-pressure duration
-tissue tolerance
◉ Non-blanchable hyperemia.
Answer: redness that persists after palpation and indicates tissue
damage
◉ Stage 1 Pressure Ulcer.
,Answer: -intact skin with nonblanchable redness
-warm to touch, edema, can be a hardened area
◉ Stage 2 Pressure Ulcer.
Answer: -partial thickness skin loss
-shallow but open
-no slough or drainage
-red/pink wound bed
◉ Stage 3 Pressure ulcer.
Answer: -full thickness tissue loss with visible underlying fat
-NO bone, muscle or tendon is visible
-can have slough
-underminning/tunneling
◉ Stage 4 Pressure ulcer.
Answer: -full thickness tissue loss WITH visible muscle, bone or
tendon
-tunneling/underminning
◉ Unstageable Pressure Ulcer.
, Answer: -Full thickness tissue loss in which the base of the ulcer is
covered by slough (yellow, tan, gray, green or brown) and/or eschar
(tan, brown or black) in the wound bed.
-cannot be measured/depth unknown
◉ Suspected Deep Tissue Injury.
Answer: -Purple or maroon localized area of discolored intact skin
or blood-filled blister due to damage of underlying soft tissue from
pressure and/or shear.
-depth unknown
◉ Primary Wound Healing.
Answer: -wound that is closed
-surgical incision
-wound that is sutured or stapled
-heals quickly with minimal scar formation
◉ Secondary Wound Healing.
Answer: -wound edges not approximated
-pressure ulcers, surgical wounds that have tissue loss or
contamination
-wounds heal by granulation tissue formation
