WOUND CERTIFICATION EXAM TEST QUESTIONS AND
ANSWERS
What are 6 risk factor components of Braden Scale for pressure ulcer? -
ANSWER>>sensory perception, moisture, mobility, activity, nutrition, and shear/friction
What is the name of the organization that developed the pressure ulcer staging? -
ANSWER>>NPUAP (national pressure ulcer advisory panel)
pathological effect of excessive pressure on soft tissue can be attributed by 3 factors? what
are they? - ANSWER>>tissue tolerance, duration of pressure, and intensity of pressure
what are the extrinsic factors that impact pressure ulcers? - ANSWER>>increase in
moisture, friction and shearing
how does friction play a role in shearing which eventually leads to pressure ulcer? -
ANSWER>>friction alone causes only superfical abrasion, but with gravity it plays a
synergistic effect leading to shearing. When gravity pushes down on the body and
,resistance (friction) between the patient and surface is exerted, shearing occurs. because
skin does not freely move, primary effect of shearing occurs at the deeper fascial level.
what are the intrisinc factors of pressur ulcers? - ANSWER>>nutritional debilitation,
advanced age, low BP, stress, smoking, elevated body temperature
Aging skin undergoes what elements affecting risk for pressure ulcer? -
ANSWER>>dermoepidermal junction flattens, less nutrient exchange occurs, less
resistance to shearing, changes in sensory perception, loss of dermal thickness, increased
vascular fragility; ability of soft tisuse to distribute mechanical load w/out comprosing
blood flow is impaired
What does nonblanching erythema indicate in the skin r/t PU? - ANSWER>>when pressure
is applied to the erythematic area skin becomes white (blanched), but once relieved,
erythema returns -indicating blood flow; however in nonblanching erythema, skin does not
blanche-indicating impaired blood flow-suggesting tissue destructon
why does sitting in a chair pose more of a risk in skin break down than lying? -
ANSWER>>deep tissue injury or PU is likely to occur sooner sitting down because tissue
offloading over boney prominences is higher
Describe what you will see in deep tissue injury? - ANSWER>>purple or maroon localized
area of discolored intact skin skinor blood filled blister; may be preceded by painful, firm,
mushy, or boggy; skin may be warmer to cooler in adjacent tissue. In dark skin, thin blister
or eschar over a dark wound bed may bee seen
, Describe stage I pressure ulcer? - ANSWER>>Intact skin with nonblanchable redness of
localized area. Will not see blanching in dark skin, but changes in skin tissue consistency
(firm vs boggy when palpated), sensation (pain), and warmer or cooler temperature may
differ from surrounding area
Describe stage II pressure ulcer? - ANSWER>>partial-thickness wound where epidermis
and tip of dermis is lost with red-pink wound bed w/out slough. may also present as intact
or open/ruptured serum -filled blister
Describe stage III pressure ulcer? - ANSWER>>full-thickness wound where both epidermis
and dermis is lost and subcutaneous tissue may be visible, but deeper structures such as
muscle, bone, and tendon are not exposed; slough my be present but it doesn't obscure
depth and tunneling and undermining may be present
Describe stage IV pressure ulcer? - ANSWER>>full-thickness wound with exposed
bone,tendon, and muscle; slough or eschar may be seen in some parts of the wound bed.
you will often see tunneling and undermining. Osteomyelitis may be dxed at this stage,
since bone is palpable
Describe unstageble ulcers? - ANSWER>>full-thickness wound where base of the ulcer is
covered by slough and/or eschar, obscuring depth
ANSWERS
What are 6 risk factor components of Braden Scale for pressure ulcer? -
ANSWER>>sensory perception, moisture, mobility, activity, nutrition, and shear/friction
What is the name of the organization that developed the pressure ulcer staging? -
ANSWER>>NPUAP (national pressure ulcer advisory panel)
pathological effect of excessive pressure on soft tissue can be attributed by 3 factors? what
are they? - ANSWER>>tissue tolerance, duration of pressure, and intensity of pressure
what are the extrinsic factors that impact pressure ulcers? - ANSWER>>increase in
moisture, friction and shearing
how does friction play a role in shearing which eventually leads to pressure ulcer? -
ANSWER>>friction alone causes only superfical abrasion, but with gravity it plays a
synergistic effect leading to shearing. When gravity pushes down on the body and
,resistance (friction) between the patient and surface is exerted, shearing occurs. because
skin does not freely move, primary effect of shearing occurs at the deeper fascial level.
what are the intrisinc factors of pressur ulcers? - ANSWER>>nutritional debilitation,
advanced age, low BP, stress, smoking, elevated body temperature
Aging skin undergoes what elements affecting risk for pressure ulcer? -
ANSWER>>dermoepidermal junction flattens, less nutrient exchange occurs, less
resistance to shearing, changes in sensory perception, loss of dermal thickness, increased
vascular fragility; ability of soft tisuse to distribute mechanical load w/out comprosing
blood flow is impaired
What does nonblanching erythema indicate in the skin r/t PU? - ANSWER>>when pressure
is applied to the erythematic area skin becomes white (blanched), but once relieved,
erythema returns -indicating blood flow; however in nonblanching erythema, skin does not
blanche-indicating impaired blood flow-suggesting tissue destructon
why does sitting in a chair pose more of a risk in skin break down than lying? -
ANSWER>>deep tissue injury or PU is likely to occur sooner sitting down because tissue
offloading over boney prominences is higher
Describe what you will see in deep tissue injury? - ANSWER>>purple or maroon localized
area of discolored intact skin skinor blood filled blister; may be preceded by painful, firm,
mushy, or boggy; skin may be warmer to cooler in adjacent tissue. In dark skin, thin blister
or eschar over a dark wound bed may bee seen
, Describe stage I pressure ulcer? - ANSWER>>Intact skin with nonblanchable redness of
localized area. Will not see blanching in dark skin, but changes in skin tissue consistency
(firm vs boggy when palpated), sensation (pain), and warmer or cooler temperature may
differ from surrounding area
Describe stage II pressure ulcer? - ANSWER>>partial-thickness wound where epidermis
and tip of dermis is lost with red-pink wound bed w/out slough. may also present as intact
or open/ruptured serum -filled blister
Describe stage III pressure ulcer? - ANSWER>>full-thickness wound where both epidermis
and dermis is lost and subcutaneous tissue may be visible, but deeper structures such as
muscle, bone, and tendon are not exposed; slough my be present but it doesn't obscure
depth and tunneling and undermining may be present
Describe stage IV pressure ulcer? - ANSWER>>full-thickness wound with exposed
bone,tendon, and muscle; slough or eschar may be seen in some parts of the wound bed.
you will often see tunneling and undermining. Osteomyelitis may be dxed at this stage,
since bone is palpable
Describe unstageble ulcers? - ANSWER>>full-thickness wound where base of the ulcer is
covered by slough and/or eschar, obscuring depth
