Galen College of Nursing-Louisville NUR 155
NUR 155 Exam 3 (unit 6-7) EXAM Questions and Verified
Answers
,Factors that alter the structure & function of skin
-diseases
-nutrition
-medication use
-external forces ( pressure/shear)
-aging
Braden Scare
predicts pressure sore risk by using categories; sensory perception, moisture, activity,
mobility, nutrition, friction, and shear
Norton Scale
measures pressure ulcers by using categories; physical condition, mental state, activity,
mobility, continence.
,Prioritizing greatest risk
identify age, any infection, medical devices, diabetes?
Stage 1 pressure injury
nonblanchable erythema of intact skin, temp different than surrounding skin
Stage 2 pressure injury
shallow/superficial, partial thickness skin loss, exposed dermis, intact/ruptured blisters
Stage 3 pressure injury
full-thickness skin loss reaching subcutaneous tissue, potential undermining (tissue loss
under intact skin, "lip"), and tunneling
Stage 4 pressure injury
Full-thickness skin and tissue loss, osteomyelitis, exposure to muscle, bone, or
connective tissue
Unstageable pressure injury
full-thickness skin & tissue loss, unable to assess depth until eschar is removed
Deep tissue pressure injury
intact persistent, nonblanchable, deep red, maroon, purple discoloration
Ture or False
as healing takes place, a pressure injury will not be able to return to a normal state prior
to injury
True
, Serous Drainage
contains clear/yellow watery fluid from plasma
NUR 155 Exam 3 (unit 6-7) EXAM Questions and Verified
Answers
,Factors that alter the structure & function of skin
-diseases
-nutrition
-medication use
-external forces ( pressure/shear)
-aging
Braden Scare
predicts pressure sore risk by using categories; sensory perception, moisture, activity,
mobility, nutrition, friction, and shear
Norton Scale
measures pressure ulcers by using categories; physical condition, mental state, activity,
mobility, continence.
,Prioritizing greatest risk
identify age, any infection, medical devices, diabetes?
Stage 1 pressure injury
nonblanchable erythema of intact skin, temp different than surrounding skin
Stage 2 pressure injury
shallow/superficial, partial thickness skin loss, exposed dermis, intact/ruptured blisters
Stage 3 pressure injury
full-thickness skin loss reaching subcutaneous tissue, potential undermining (tissue loss
under intact skin, "lip"), and tunneling
Stage 4 pressure injury
Full-thickness skin and tissue loss, osteomyelitis, exposure to muscle, bone, or
connective tissue
Unstageable pressure injury
full-thickness skin & tissue loss, unable to assess depth until eschar is removed
Deep tissue pressure injury
intact persistent, nonblanchable, deep red, maroon, purple discoloration
Ture or False
as healing takes place, a pressure injury will not be able to return to a normal state prior
to injury
True
, Serous Drainage
contains clear/yellow watery fluid from plasma
