NSG 300 Exam 2 with precise !| !| !| !| !| !|
detailed answers !|
what places patients at risk for pressure ulcers/impaired skin
!| !| !| !| !| !| !| !| !|
integrity - Correct answer ✔pressure intensity, pressure
!| !| !| !| !| !| !|
duration, tissue tolerance, impaired sensory perception,
!| !| !| !| !| !|
impaired mobility, alteration in LOC, shear, friction, moisture
!| !| !| !| !| !| !|
layers of the skin - Correct answer ✔epidermis, dermis (collagen)
!| !| !| !| !| !| !| !| !|
body's defenses against infection - Correct answer ✔normal
!| !| !| !| !| !| !| !|
flora, inflammatory response, immune response
!| !| !| !|
comprehensive wound assessment - Correct answer ✔-ongoing !| !| !| !| !| !| !|
assessment from time of injury, wound care, any condition
!| !| !| !| !| !| !| !| !|
changes, and on scheduled basis !| !| !| !|
-Important to include cause of injury, history of wound,
!| !| !| !| !| !| !| !| !|
treatment, description, response to therapy !| !| !| !|
-Braden scale: assesses risk for pressure/skin injury every shift
!| !| !| !| !| !| !| !|
Braden Scale - Correct answer ✔assesses risk for developing
!| !| !| !| !| !| !| !| !|
pressure ulcers; includes patient's sensory perception, moisture,
!| !| !| !| !| !| !|
activity, mobility, nutrition, friction and shear; the lower the
!| !| !| !| !| !| !| !| !|
number the higher the risk !| !| !| !|
>9= very high risk
!| !| !|
,10-12= high risk !| !|
13-14= moderate risk !| !|
15-18= mild risk !| !|
19-23= generally not at risk
!| !| !| !|
type 1 ulcers - Correct answer ✔skin is intact but may be red or
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
pink and warm to the touch; no blanching
!| !| !| !| !| !| !|
-for POC, there may be no noticeable blanching but skin color
!| !| !| !| !| !| !| !| !| !| !|
may vary !|
type 2 ulcers - Correct answer ✔partial-thickness loss of dermis;
!| !| !| !| !| !| !| !| !| !|
shallow broken skin; red-pink wound bed
!| !| !| !| !|
type 3 ulcers - Correct answer ✔full-thickness tissue loss with
!| !| !| !| !| !| !| !| !| !|
visible fat (subcutaneous layer); pale-yellow color; may include
!| !| !| !| !| !| !| !|
slough but does not obstruct view of depth of injury
!| !| !| !| !| !| !| !| !|
type 4 ulcers - Correct answer ✔full-thickness tissue loss with
!| !| !| !| !| !| !| !| !| !|
exposed bone, muscle, or tendon. possible tunneling and
!| !| !| !| !| !| !| !|
undermining
unstageable pressure ulcer - Correct answer ✔base of ulcer
!| !| !| !| !| !| !| !| !|
covered by slough and/or eschar in the wound bed so the depth
!| !| !| !| !| !| !| !| !| !| !| !|
is unknown; exudate;
!| !|
,deep tissue injury - Correct 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.
!| !| !| !| !| !| !| !|
how should you clean a wound - Correct answer ✔from least to
!| !| !| !| !| !| !| !| !| !| !| !|
most contaminated !|
eschar - Correct answer ✔black, brown or necrotic tissue in
!| !| !| !| !| !| !| !| !| !|
wound bed; needs to be removed before healing
!| !| !| !| !| !| !|
slough - Correct answer ✔stringy pale-yellowish tissue that lays
!| !| !| !| !| !| !| !| !|
in the wound bed; needs to be removed before healing
!| !| !| !| !| !| !| !| !|
if a patient has slough, eschar, and infectious exudate which one
!| !| !| !| !| !| !| !| !| !|
would you be most concerned about - Correct answer
!| !| !| !| !| !| !| !| !| !|
✔infectious exudate !|
factors influencing heat and cold tolerance - Correct answer
!| !| !| !| !| !| !| !| !|
✔Exposure time !|
Exposed skin !|
Temperature
Age
Perception of sensory stimuli !| !| !|
assessment for pressure ulcers includes - Correct answer !| !| !| !| !| !| !| !|
✔location, staging (depth), type and % of tissue in wound bed,
!| !| !| !| !| !| !| !| !| !| !|
, wound dimensions (including tunneling), exudate description (if
!| !| !| !| !| !| !|
odor is present), and condition of surrounding skin
!| !| !| !| !| !| !|
why is depth of an ulcer important - Correct answer ✔because
!| !| !| !| !| !| !| !| !| !| !|
the wound heals inside-out
!| !| !|
granulation tissue - Correct answer ✔good, fresh tissue that
!| !| !| !| !| !| !| !| !|
forms during the healing of a wound (wound bed will be red,
!| !| !| !| !| !| !| !| !| !| !| !|
moist, and shiny) !| !|
How does a partial thickness wound heal? - Correct answer ✔by
!| !| !| !| !| !| !| !| !| !| !|
regeneration (scratch or abrasion) !| !| !|
-inflammatory response: redness/swelling to area with moderate !| !| !| !| !| !| !|
serous exudate. 1st 24hrs after wounding.
!| !| !| !| !|
-epithelial proliferation (reproduction): starts at wound edges and
!| !| !| !| !| !| !|
epidermal cells lining appendages (quick resurfacing)
!| !| !| !| !| !|
-epithelial migration: epithelial cells only migrate in a moist
!| !| !| !| !| !| !| !| !|
environment. in dry wound, the cells move down into a moist !| !| !| !| !| !| !| !| !| !| !|
level before resurfacing can happen
!| !| !| !|
-reestablishment of epidermal layers: cells slowly establish !| !| !| !| !| !| !|
normal thickness and appear as dry, pink tissue
!| !| !| !| !| !| !|
How does a full thickness wound heal? - Correct answer ✔by
!| !| !| !| !| !| !| !| !| !| !|
forming new tissue/scar formation, which takes longer (pressure
!| !| !| !| !| !| !| !|
ulcers)
-hemostasis: injured vessels constrict and platelets gather to!| !| !| !| !| !| !| !|
stop bleeding
!|
detailed answers !|
what places patients at risk for pressure ulcers/impaired skin
!| !| !| !| !| !| !| !| !|
integrity - Correct answer ✔pressure intensity, pressure
!| !| !| !| !| !| !|
duration, tissue tolerance, impaired sensory perception,
!| !| !| !| !| !|
impaired mobility, alteration in LOC, shear, friction, moisture
!| !| !| !| !| !| !|
layers of the skin - Correct answer ✔epidermis, dermis (collagen)
!| !| !| !| !| !| !| !| !|
body's defenses against infection - Correct answer ✔normal
!| !| !| !| !| !| !| !|
flora, inflammatory response, immune response
!| !| !| !|
comprehensive wound assessment - Correct answer ✔-ongoing !| !| !| !| !| !| !|
assessment from time of injury, wound care, any condition
!| !| !| !| !| !| !| !| !|
changes, and on scheduled basis !| !| !| !|
-Important to include cause of injury, history of wound,
!| !| !| !| !| !| !| !| !|
treatment, description, response to therapy !| !| !| !|
-Braden scale: assesses risk for pressure/skin injury every shift
!| !| !| !| !| !| !| !|
Braden Scale - Correct answer ✔assesses risk for developing
!| !| !| !| !| !| !| !| !|
pressure ulcers; includes patient's sensory perception, moisture,
!| !| !| !| !| !| !|
activity, mobility, nutrition, friction and shear; the lower the
!| !| !| !| !| !| !| !| !|
number the higher the risk !| !| !| !|
>9= very high risk
!| !| !|
,10-12= high risk !| !|
13-14= moderate risk !| !|
15-18= mild risk !| !|
19-23= generally not at risk
!| !| !| !|
type 1 ulcers - Correct answer ✔skin is intact but may be red or
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
pink and warm to the touch; no blanching
!| !| !| !| !| !| !|
-for POC, there may be no noticeable blanching but skin color
!| !| !| !| !| !| !| !| !| !| !|
may vary !|
type 2 ulcers - Correct answer ✔partial-thickness loss of dermis;
!| !| !| !| !| !| !| !| !| !|
shallow broken skin; red-pink wound bed
!| !| !| !| !|
type 3 ulcers - Correct answer ✔full-thickness tissue loss with
!| !| !| !| !| !| !| !| !| !|
visible fat (subcutaneous layer); pale-yellow color; may include
!| !| !| !| !| !| !| !|
slough but does not obstruct view of depth of injury
!| !| !| !| !| !| !| !| !|
type 4 ulcers - Correct answer ✔full-thickness tissue loss with
!| !| !| !| !| !| !| !| !| !|
exposed bone, muscle, or tendon. possible tunneling and
!| !| !| !| !| !| !| !|
undermining
unstageable pressure ulcer - Correct answer ✔base of ulcer
!| !| !| !| !| !| !| !| !|
covered by slough and/or eschar in the wound bed so the depth
!| !| !| !| !| !| !| !| !| !| !| !|
is unknown; exudate;
!| !|
,deep tissue injury - Correct 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.
!| !| !| !| !| !| !| !|
how should you clean a wound - Correct answer ✔from least to
!| !| !| !| !| !| !| !| !| !| !| !|
most contaminated !|
eschar - Correct answer ✔black, brown or necrotic tissue in
!| !| !| !| !| !| !| !| !| !|
wound bed; needs to be removed before healing
!| !| !| !| !| !| !|
slough - Correct answer ✔stringy pale-yellowish tissue that lays
!| !| !| !| !| !| !| !| !|
in the wound bed; needs to be removed before healing
!| !| !| !| !| !| !| !| !|
if a patient has slough, eschar, and infectious exudate which one
!| !| !| !| !| !| !| !| !| !|
would you be most concerned about - Correct answer
!| !| !| !| !| !| !| !| !| !|
✔infectious exudate !|
factors influencing heat and cold tolerance - Correct answer
!| !| !| !| !| !| !| !| !|
✔Exposure time !|
Exposed skin !|
Temperature
Age
Perception of sensory stimuli !| !| !|
assessment for pressure ulcers includes - Correct answer !| !| !| !| !| !| !| !|
✔location, staging (depth), type and % of tissue in wound bed,
!| !| !| !| !| !| !| !| !| !| !|
, wound dimensions (including tunneling), exudate description (if
!| !| !| !| !| !| !|
odor is present), and condition of surrounding skin
!| !| !| !| !| !| !|
why is depth of an ulcer important - Correct answer ✔because
!| !| !| !| !| !| !| !| !| !| !|
the wound heals inside-out
!| !| !|
granulation tissue - Correct answer ✔good, fresh tissue that
!| !| !| !| !| !| !| !| !|
forms during the healing of a wound (wound bed will be red,
!| !| !| !| !| !| !| !| !| !| !| !|
moist, and shiny) !| !|
How does a partial thickness wound heal? - Correct answer ✔by
!| !| !| !| !| !| !| !| !| !| !|
regeneration (scratch or abrasion) !| !| !|
-inflammatory response: redness/swelling to area with moderate !| !| !| !| !| !| !|
serous exudate. 1st 24hrs after wounding.
!| !| !| !| !|
-epithelial proliferation (reproduction): starts at wound edges and
!| !| !| !| !| !| !|
epidermal cells lining appendages (quick resurfacing)
!| !| !| !| !| !|
-epithelial migration: epithelial cells only migrate in a moist
!| !| !| !| !| !| !| !| !|
environment. in dry wound, the cells move down into a moist !| !| !| !| !| !| !| !| !| !| !|
level before resurfacing can happen
!| !| !| !|
-reestablishment of epidermal layers: cells slowly establish !| !| !| !| !| !| !|
normal thickness and appear as dry, pink tissue
!| !| !| !| !| !| !|
How does a full thickness wound heal? - Correct answer ✔by
!| !| !| !| !| !| !| !| !| !| !|
forming new tissue/scar formation, which takes longer (pressure
!| !| !| !| !| !| !| !|
ulcers)
-hemostasis: injured vessels constrict and platelets gather to!| !| !| !| !| !| !| !|
stop bleeding
!|
