NUR 205 EXAM 2 Questions with
Accurate Detailed Answers
Largest Organ of the body - Answer: The Skin
Two layers of the skin - Answer: Epidermis and Dermis
Epidermis - Answer: top layer of skin
Stratum Corneum - Answer: Outermost layer of the epidermis, which consists of flattened,
keratinized cells
Define Pressure Ulcers - Answer: Described as impaired skin integrity related to unrelieved,
prolonged pressure, usually over a boney prominence
Pressure Ulcer Risk Factors - Answer: -decreased mobility
-decreased sensory perception
-fecal or urinary incontinence
-poor nutrition
Individuals at risk for pressure ulcers - Answer: -older adults that have experienced a trauma
-those with spinal cord injuries
-those who have sustained a fractured hip
-those in long-term homes or community care, the acutely ill
-individuals with diabetes
-patients in critical care settings (ICU)
Dermis - Answer: inner layer of skin, provides tensile strength, mechanical support, and protection
for the underlying muscles, bones, and organs
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
Accurate Detailed Answers
Largest Organ of the body - Answer: The Skin
Two layers of the skin - Answer: Epidermis and Dermis
Epidermis - Answer: top layer of skin
Stratum Corneum - Answer: Outermost layer of the epidermis, which consists of flattened,
keratinized cells
Define Pressure Ulcers - Answer: Described as impaired skin integrity related to unrelieved,
prolonged pressure, usually over a boney prominence
Pressure Ulcer Risk Factors - Answer: -decreased mobility
-decreased sensory perception
-fecal or urinary incontinence
-poor nutrition
Individuals at risk for pressure ulcers - Answer: -older adults that have experienced a trauma
-those with spinal cord injuries
-those who have sustained a fractured hip
-those in long-term homes or community care, the acutely ill
-individuals with diabetes
-patients in critical care settings (ICU)
Dermis - Answer: inner layer of skin, provides tensile strength, mechanical support, and protection
for the underlying muscles, bones, and organs
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
