1. What are the two types of skin loss caused by external factors mentioned in
the provided question?
Skin Tears and Abrasions
MARSI and Ulcers
Pressure Injuries and Skin Tears
Skin Tears and MARSI
2. In a clinical scenario, if a patient develops a wound due to sheer strain, what
specific intervention should be prioritized to prevent further tissue damage?
Using a compression bandage on the wound
Applying topical antibiotics to the wound
Relieving pressure on the affected area
Increasing the patient's fluid intake
3. In a clinical setting, if a patient is experiencing delayed wound healing, what
strategy involving oxygen delivery could be implemented to improve tissue
viability?
Implement intermittent oxygen delivery to restore blood flow.
Increase the patient's fluid intake without oxygen therapy.
Use continuous oxygen delivery without considering blood flow.
Apply topical antibiotics without changing oxygen delivery methods.
,4. Describe why a constant low pressure surface is suitable for a patient with a
stage 3 pressure injury.
A constant low pressure surface is only effective for stage 1 pressure
injuries.
A constant low pressure surface helps to redistribute pressure and
reduce the risk of further tissue damage.
A constant low pressure surface is designed to keep the patient warm.
A constant low pressure surface increases blood flow to the injury
site.
5. Describe the role of epithelial migration in the partial thickness wound
healing process.
Epithelial migration occurs only in full thickness wounds.
Epithelial migration is crucial for covering the wound and restoring
the skin barrier.
Epithelial migration is not involved in wound healing.
Epithelial migration helps in the formation of scar tissue.
6. Which type of injury would be most appropriate to utilize a low air-loss (LAL)
bed in a patient with a low Braden mobility and moisture subscale score?
IAD (incontinence associated dermatitis).
Stage 4 heel injury.
Stage 2 occiput injury.
Stage 3 sacral pressure injury.
,7. Why is a bariatric surface with low shear cover considered the best option for
a paraplegic patient with a deep tissue pressure injury?
It is designed specifically for patients with superficial wounds.
It is the most cost-effective option available.
It provides optimal pressure relief and minimizes shear forces on the
skin.
It is the only option that can be used for all patients.
8. Which patient is likely at risk for developing a pressure injury?
patient with unrelieved pressure who has a hip fx
left-handed pt with a broken left wrist
paralyzed patient who is being turned and repositioned every 2 hours
patient with hx of sports-related injuries and concussions
9. Describe the significance of transepidermal water loss (TEWL) in maintaining
skin health.
TEWL is a measure of skin elasticity and firmness.
TEWL is important because it indicates the skin's barrier function;
increased TEWL suggests compromised skin integrity.
TEWL is beneficial as it helps in nutrient absorption through the skin.
TEWL is irrelevant to skin health as it only measures hydration levels.
10. Describe how sheer strain affects the skin and underlying tissues compared
to other types of pressure injuries.
Sheer strain leads to superficial skin loss, while other injuries cause
compression.
, Sheer strain has no significant impact on blood vessels compared to
other types of injuries.
Sheer strain causes damage primarily through distortion of blood
vessels in SQ tissue, unlike other pressure injuries that may involve
skin loss or edema.
Sheer strain only affects the epidermal layer, while other injuries
affect deeper layers.
11. What is the definition of a fissure in dermatology?
A fissure is a type of skin rash.
A fissure is a benign tumor of the skin.
A fissure is an infection of the skin.
A fissure is a linear crack or break in the skin.
12. Dr. Martinez prescribes an emollient for a client with a diagnosis of atopic
dermatitis with complaints of pruritus. The client asks why the emollient
should be applied immediately after a bath or shower. How should the nurse
respond?
L. "This prevents evaporation of water from the hydrated
epidermis."
T. "This minimizes cracking of the dermis"
B. "This prevents inflammation of the skin"
A. "This makes the skin feel soft."
13. What is the primary purpose of collecting data on facility-acquired pressure
injuries (PIs)?
Minimizing staff workload