HONDROS NUR 205 EXAM 2 ACTUAL
QUESTIONS WITH VERIFIED SOLUTIONS
◉ Non-blanchable hyperemia.
Answer: redness that persists after palpation and indicates tissue
damage
◉ Stage 1 Pressure Ulcer.
Answer: -intact skin with nonblanchable redness
-warm to touch, edema, can be a hardened area
◉ Stage 2 Pressure Ulcer.
Answer: -partial thickness skin loss
-shallow but open
-no slough or drainage
-red/pink wound bed
◉ Stage 3 Pressure ulcer.
Answer: -full thickness tissue loss with visible underlying fat
-NO bone, muscle or tendon is visible
-can have slough
,-underminning/tunneling
◉ Stage 4 Pressure ulcer.
Answer: -full thickness tissue loss WITH visible muscle, bone or
tendon
-tunneling/underminning
◉ Unstageable Pressure Ulcer.
Answer: -Full thickness tissue loss in which the base of the ulcer is
covered by slough (yellow, tan, gray, green or brown) and/or eschar
(tan, brown or black) in the wound bed.
-cannot be measured/depth unknown
◉ Suspected Deep Tissue Injury.
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.
-depth unknown
◉ Primary Wound Healing.
Answer: -wound that is closed
-surgical incision
-wound that is sutured or stapled
, -heals quickly with minimal scar formation
◉ Secondary Wound Healing.
Answer: -wound edges not approximated
-pressure ulcers, surgical wounds that have tissue loss or
contamination
-wounds heal by granulation tissue formation
◉ Tertiary Wound Healing.
Answer: -wound that is left open to air for several days, then wound
edges are approximated
-wounds that are contaminated and require observation for signs of
infection
-closure of wound is delayed until risk of infection is resolved
◉ Acute Wound.
Answer: -wound that proceeds through an orderly and timely
reparative process
-ex: trauma, surgical incision
-wound edges are clean and intact
◉ Chronic Wound.
QUESTIONS WITH VERIFIED SOLUTIONS
◉ Non-blanchable hyperemia.
Answer: redness that persists after palpation and indicates tissue
damage
◉ Stage 1 Pressure Ulcer.
Answer: -intact skin with nonblanchable redness
-warm to touch, edema, can be a hardened area
◉ Stage 2 Pressure Ulcer.
Answer: -partial thickness skin loss
-shallow but open
-no slough or drainage
-red/pink wound bed
◉ Stage 3 Pressure ulcer.
Answer: -full thickness tissue loss with visible underlying fat
-NO bone, muscle or tendon is visible
-can have slough
,-underminning/tunneling
◉ Stage 4 Pressure ulcer.
Answer: -full thickness tissue loss WITH visible muscle, bone or
tendon
-tunneling/underminning
◉ Unstageable Pressure Ulcer.
Answer: -Full thickness tissue loss in which the base of the ulcer is
covered by slough (yellow, tan, gray, green or brown) and/or eschar
(tan, brown or black) in the wound bed.
-cannot be measured/depth unknown
◉ Suspected Deep Tissue Injury.
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.
-depth unknown
◉ Primary Wound Healing.
Answer: -wound that is closed
-surgical incision
-wound that is sutured or stapled
, -heals quickly with minimal scar formation
◉ Secondary Wound Healing.
Answer: -wound edges not approximated
-pressure ulcers, surgical wounds that have tissue loss or
contamination
-wounds heal by granulation tissue formation
◉ Tertiary Wound Healing.
Answer: -wound that is left open to air for several days, then wound
edges are approximated
-wounds that are contaminated and require observation for signs of
infection
-closure of wound is delayed until risk of infection is resolved
◉ Acute Wound.
Answer: -wound that proceeds through an orderly and timely
reparative process
-ex: trauma, surgical incision
-wound edges are clean and intact
◉ Chronic Wound.
