PNR 201 Final Exam Review Questions With Complete
Solutions
Stage 1
an area of intact skin that is reddened, deep pink, or molded that
does not blanch
Stage 2
- partial thickness skin loss involving the dermis and or
epidermis
- the skin appears blistered or abraded or has a shallow crater
- the area surrounding the damaged skin is reddened and
probably will feel hot or warmer than usual
Stage 3
- the skin is ulcerated
- there is a crater like ulcer, and the underlying subcutaneous
tissue is involved in the destructive process
- the ulcer may or may not be infected
- bacterial infection is almost always present at this age,
however, and accounts for continued erosion of the ulcer and the
production of drainage
Stage 4
- there is deep tissue ulceration and necrosis involving deeper
underlying muscle and possibly bone tissue the ulcer can be dry,
black, and covered with a tough accumulation of necrotic tissue,
or it can be made up of wet and oozing dead cells and purulent
, exudates
- depth can be determined
Unstageable
full thickness wound with eschar and or tissue that obscures
depth determination
Signs and Symptoms of Psoriosis
- inflamed lesions on skin with silvery white scales
- usually after URI
Signs and Symptoms of Respiratory Distress w/ Emergency
Phase of Burn
- increased respiratory rate
- use of accessory muscles
- nasal flaring
- retractions
- restlessness
- confusion
- coughing
- coarseness
- rapid shallow respirations
- stridor
- O2 saturation below 95%
How to prevent pressure ulcers
- assess patient skin every 8 - 12 hours
- reposition every 2 hours
- use positioning devices
- float heels
Solutions
Stage 1
an area of intact skin that is reddened, deep pink, or molded that
does not blanch
Stage 2
- partial thickness skin loss involving the dermis and or
epidermis
- the skin appears blistered or abraded or has a shallow crater
- the area surrounding the damaged skin is reddened and
probably will feel hot or warmer than usual
Stage 3
- the skin is ulcerated
- there is a crater like ulcer, and the underlying subcutaneous
tissue is involved in the destructive process
- the ulcer may or may not be infected
- bacterial infection is almost always present at this age,
however, and accounts for continued erosion of the ulcer and the
production of drainage
Stage 4
- there is deep tissue ulceration and necrosis involving deeper
underlying muscle and possibly bone tissue the ulcer can be dry,
black, and covered with a tough accumulation of necrotic tissue,
or it can be made up of wet and oozing dead cells and purulent
, exudates
- depth can be determined
Unstageable
full thickness wound with eschar and or tissue that obscures
depth determination
Signs and Symptoms of Psoriosis
- inflamed lesions on skin with silvery white scales
- usually after URI
Signs and Symptoms of Respiratory Distress w/ Emergency
Phase of Burn
- increased respiratory rate
- use of accessory muscles
- nasal flaring
- retractions
- restlessness
- confusion
- coughing
- coarseness
- rapid shallow respirations
- stridor
- O2 saturation below 95%
How to prevent pressure ulcers
- assess patient skin every 8 - 12 hours
- reposition every 2 hours
- use positioning devices
- float heels
