3P EXAM QUESTIONS AND ANSWERS
elderly skin changes - Answers-Higher risk for skin tears and pressure injuries
*Skin tears due to flattening of skin cells
*Skin moisture and friction=loss fo tissue integrity
*If pressure is unrelieved, tissue destruction progresses to full thickness ulcer
Collagen fibers stiffen, elastic fibers degenerate, and the amount of subcutaneous
tissue decreases. These changes, with the added effects of gravity, lead to wrinkling.
The junction between the dermis and epidermis flattens. This causes the two layers to
lose their tight bond. Skin tears and other trauma become common as the epidermis
slides separately from the dermis.
Macule - Answers-flat less than 1 cm in diameter with different color than surrounding
tissue
papule - Answers-small, solid, raised lesion on surface of the skin
plaque - Answers-a solid mass greater than 1 cm in diameter and limited to the surface
of the skin
white/scaly patches- psoriasis
ulcers - Answers-deep erosions of the skin which extend neneath the epidermis, and
into the dermis and sub q
Vesicles - Answers-bullae, second degree burns- vesicles with clear liquid <1 cm
pustule - Answers-elevation of skin containing pus
fissure - Answers-linear crack in skin extending into dermis
scar - Answers-connective tissue that fills a wound area
wheal - Answers-small, round, raised area on the skin that may be accompanied by
itching; usually seen in allergic reactions
Stage I Pressure Injury - Answers-Intact skin with nonblanchable redness of a localized
area usually over a bony prominence. Darkly pigmented skin may not have visible
blanching. Its color may differ from the surrounding area. The area may be painful, firm,
soft, warmer, or cooler as compared to adjacent
Stage II pressure ulcer - Answers-Partial-thickness loss of dermis presenting as a
shallow open ulcer with a red-pink wound bed, without slough. May also present as an
intact or open/ruptured serum-filled or serosanguineous-filled blister. Presents as a
, shiny or dry shallow ulcer without slough or bruising. (Bruising indicates deep tissue
injury.)
Stage III - Answers-Full-thickness tissue loss. Subcutaneous fat may be visible but
bone, tendon, or muscle are not exposed. Slough may be present but does not obscure
depth of tissue loss. May include undermining and tunneling. The depth of a
category/stage III pressure ulcer varies by anatomic location.
Stage IV Ulcer - Answers-Full-thickness tissue loss with exposed bone, tendon, or
muscle. Slough or eschar may be present. Often includes undermining and tunneling.
Depth of pressure ulcer varies by anatomic location. Ulcers can extend into muscle
and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis
or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
unstageable pressure ulcer - Answers-Full-thickness tissue loss in which actual depth of
ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or
eschar (tan, brown, or black) in wound bed. Until enough slough and/or eschar are
removed to expose the base of wound, the true depth cannot be determined; but it will
be either a stage III or stage IV. Stable (dry, adherent, intact without erythema, or
fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and
should not be removed
Skin Cancer Assessment - Answers-Asymmetry, Border irregularity, Color change and
variation, Diameter of 6 mm or more, and Evolving in appearance
melanoma skin cancer - Answers-malingant melanoma and cutaneous T cell lymphoma
superficial (first-degree) burns - Answers-Erythema, blanching on pressure, pain and
mild swelling, no vesicles or blisters (although after 24 hr skin may blister and peel
Superficial epidermal damage with hyperemia. Tactile and pain sensation intact
second degree burn - Answers-Fluid-filled vesicles that are red, shiny, wet (if vesicles
have ruptured). Severe pain caused by nerve injury. Mild to moderate edema
Epidermis and dermis involved to varying depths. Skin elements, from which epithelial
regeneration occurs, remain viable.
third degree burn - Answers-Dry, waxy white, leathery, or hard skin. Visible thrombosed
vessels. Insensitivity to pain because of nerve destruction. Possible involvement of
muscles, tendons, and bones
All skin elements and local nerve endings destroyed. Coagulation necrosis present.
Surgical intervention required for healing
elderly skin changes - Answers-Higher risk for skin tears and pressure injuries
*Skin tears due to flattening of skin cells
*Skin moisture and friction=loss fo tissue integrity
*If pressure is unrelieved, tissue destruction progresses to full thickness ulcer
Collagen fibers stiffen, elastic fibers degenerate, and the amount of subcutaneous
tissue decreases. These changes, with the added effects of gravity, lead to wrinkling.
The junction between the dermis and epidermis flattens. This causes the two layers to
lose their tight bond. Skin tears and other trauma become common as the epidermis
slides separately from the dermis.
Macule - Answers-flat less than 1 cm in diameter with different color than surrounding
tissue
papule - Answers-small, solid, raised lesion on surface of the skin
plaque - Answers-a solid mass greater than 1 cm in diameter and limited to the surface
of the skin
white/scaly patches- psoriasis
ulcers - Answers-deep erosions of the skin which extend neneath the epidermis, and
into the dermis and sub q
Vesicles - Answers-bullae, second degree burns- vesicles with clear liquid <1 cm
pustule - Answers-elevation of skin containing pus
fissure - Answers-linear crack in skin extending into dermis
scar - Answers-connective tissue that fills a wound area
wheal - Answers-small, round, raised area on the skin that may be accompanied by
itching; usually seen in allergic reactions
Stage I Pressure Injury - Answers-Intact skin with nonblanchable redness of a localized
area usually over a bony prominence. Darkly pigmented skin may not have visible
blanching. Its color may differ from the surrounding area. The area may be painful, firm,
soft, warmer, or cooler as compared to adjacent
Stage II pressure ulcer - Answers-Partial-thickness loss of dermis presenting as a
shallow open ulcer with a red-pink wound bed, without slough. May also present as an
intact or open/ruptured serum-filled or serosanguineous-filled blister. Presents as a
, shiny or dry shallow ulcer without slough or bruising. (Bruising indicates deep tissue
injury.)
Stage III - Answers-Full-thickness tissue loss. Subcutaneous fat may be visible but
bone, tendon, or muscle are not exposed. Slough may be present but does not obscure
depth of tissue loss. May include undermining and tunneling. The depth of a
category/stage III pressure ulcer varies by anatomic location.
Stage IV Ulcer - Answers-Full-thickness tissue loss with exposed bone, tendon, or
muscle. Slough or eschar may be present. Often includes undermining and tunneling.
Depth of pressure ulcer varies by anatomic location. Ulcers can extend into muscle
and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis
or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
unstageable pressure ulcer - Answers-Full-thickness tissue loss in which actual depth of
ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or
eschar (tan, brown, or black) in wound bed. Until enough slough and/or eschar are
removed to expose the base of wound, the true depth cannot be determined; but it will
be either a stage III or stage IV. Stable (dry, adherent, intact without erythema, or
fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and
should not be removed
Skin Cancer Assessment - Answers-Asymmetry, Border irregularity, Color change and
variation, Diameter of 6 mm or more, and Evolving in appearance
melanoma skin cancer - Answers-malingant melanoma and cutaneous T cell lymphoma
superficial (first-degree) burns - Answers-Erythema, blanching on pressure, pain and
mild swelling, no vesicles or blisters (although after 24 hr skin may blister and peel
Superficial epidermal damage with hyperemia. Tactile and pain sensation intact
second degree burn - Answers-Fluid-filled vesicles that are red, shiny, wet (if vesicles
have ruptured). Severe pain caused by nerve injury. Mild to moderate edema
Epidermis and dermis involved to varying depths. Skin elements, from which epithelial
regeneration occurs, remain viable.
third degree burn - Answers-Dry, waxy white, leathery, or hard skin. Visible thrombosed
vessels. Insensitivity to pain because of nerve destruction. Possible involvement of
muscles, tendons, and bones
All skin elements and local nerve endings destroyed. Coagulation necrosis present.
Surgical intervention required for healing
