Name: Score:
28 Multiple choice questions
,Term 1 of 28
For which patient hypotheses would the nurse select turning and positioning as a solution?
Select all that apply.
Impaired Skin Integrity
Risk for Pressure Ulcer/Injury
Malignant Wound
Impaired Tissue Integrity
Risk for Impaired Skin Integrity
Correct
A patient is experiencing shock.A patient experiencing shock is of immediate concern
because the condition is life-threatening.
Correct
A patient is profusely bleeding from a wound.A patient who is bleeding profusely is of
immediate concern because the situation is life-threatening.
A patient has an infected wound.A patient with an infected wound is of urgent concern,
but not an immediate concern because an infected wound is not life-threatening.
Correct
A patient has an eviscerated wound.A patient who has an eviscerated wound is of
immediate concern because the situation is a medical emergency.
A patient has a stage 4 pressure injury.A patient with a stage 4 pressure injury is not of
immediate concern because a stage 4 pressure injury is not life-threatening.
Correct
Impaired Skin IntegrityTurning and positioning is a solution for Impaired Skin Integrity.
Correct
Risk for Pressure Ulcer/InjuryTurning and positioning is a solution for Risk for Pressure
Ulcer/Injury.
Malignant WoundTurning and positioning is not a solution for Malignant Wound; specific
wound care is needed.
Correct
Impaired Tissue IntegrityTurning and positioning is a solution for Impaired Tissue
Integrity.
Correct
,Risk for Impaired Skin IntegrityTurning and positioning is a solution for Risk for Impaired
Skin Integrity.
Correct
SmokingSmoking can contribute to development of a nonhealing wound by causing
vasoconstriction.
Correct
DiabetesDiabetes alters circulation of blood, oxygen, and nutrients to skin and body
tissues, and it can contribute to nonhealing wounds.
Specific genderA specific gender has no effect on either pressure injuries or a
nonhealing wound. All genders can be affected by pressure injuries and nonhealing
wounds.
Correct
Urinary incontinenceUrinary incontinence may cause skin breakdown and lead to the
development of pressure injuries. Skin should always be kept clean and dry.
Skin toneSkin tone is not a factor that impacts the development of pressure injuries or
nonhealing wounds.
Correct
Low prealbumin levelsLow prealbumin level is a cue for Impaired Skin Integrity because
it can affect healing.
Correct
ImmobilityImmobility is a cue for Impaired Skin Integrity because it can lead to
prolonged pressure.
Inexperience with wound careInexperience with wound care is a cue for inadequate
knowledge of wound care, not Impaired Skin Integrity.
Correct
Stage 2 pressure injuryA stage 2 pressure injury is a cue for Impaired Skin Integrity
because it affects the epidermal and dermal layers of the skin.
Stage 4 pressure injuryA stage 4 pressure injury is a cue for Impaired Tissue Integrity,
not Impaired Skin Integrity, because it affects subcutaneous tissue and underlying tissue
of bone, tendon, muscle, and cartilage.
, Term 2 of 28
Which factors may impact the development of pressure injuries or nonhealing wounds?
Select all that apply.
Smoking
Diabetes
Specific gender
Urinary incontinence
Skin tone
Correct
AnemiaWhen a wound bed is pale or dry, it can indicate anemia, which is when the blood
does not contain enough red blood cells.
Correct
DiabetesDiabetes can contribute to a nonhealing wound that presents with a pale, dry
wound bed.
Wound infectionWound infection would not result in a pale, dry wound bed. Warmth,
redness, and increased drainage may be present.
Correct
Vascular diseaseVascular disease can be a contributing factor that presents with a pale,
dry wound bed because of the decreased perfusion to the wound.
Correct
Nutritional deficienciesNutritional deficiencies can cause a wound bed to be dry and
pale. Nutritional deficiencies can delay wound healing.
Correct
BoneBone is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity
would be appropriate.
Correct
TendonTendon is tissue and it would be damaged. The hypothesis Impaired Tissue
Integrity would be appropriate.
Correct
MuscleMuscle is tissue and it would be damaged. The hypothesis Impaired Tissue
Integrity would be appropriate.
DermisDermis is skin, and it would not be a primary area that would be damaged. Dermis
is damaged in Impaired Skin Integrity, not Impaired Tissue Integrity.
28 Multiple choice questions
,Term 1 of 28
For which patient hypotheses would the nurse select turning and positioning as a solution?
Select all that apply.
Impaired Skin Integrity
Risk for Pressure Ulcer/Injury
Malignant Wound
Impaired Tissue Integrity
Risk for Impaired Skin Integrity
Correct
A patient is experiencing shock.A patient experiencing shock is of immediate concern
because the condition is life-threatening.
Correct
A patient is profusely bleeding from a wound.A patient who is bleeding profusely is of
immediate concern because the situation is life-threatening.
A patient has an infected wound.A patient with an infected wound is of urgent concern,
but not an immediate concern because an infected wound is not life-threatening.
Correct
A patient has an eviscerated wound.A patient who has an eviscerated wound is of
immediate concern because the situation is a medical emergency.
A patient has a stage 4 pressure injury.A patient with a stage 4 pressure injury is not of
immediate concern because a stage 4 pressure injury is not life-threatening.
Correct
Impaired Skin IntegrityTurning and positioning is a solution for Impaired Skin Integrity.
Correct
Risk for Pressure Ulcer/InjuryTurning and positioning is a solution for Risk for Pressure
Ulcer/Injury.
Malignant WoundTurning and positioning is not a solution for Malignant Wound; specific
wound care is needed.
Correct
Impaired Tissue IntegrityTurning and positioning is a solution for Impaired Tissue
Integrity.
Correct
,Risk for Impaired Skin IntegrityTurning and positioning is a solution for Risk for Impaired
Skin Integrity.
Correct
SmokingSmoking can contribute to development of a nonhealing wound by causing
vasoconstriction.
Correct
DiabetesDiabetes alters circulation of blood, oxygen, and nutrients to skin and body
tissues, and it can contribute to nonhealing wounds.
Specific genderA specific gender has no effect on either pressure injuries or a
nonhealing wound. All genders can be affected by pressure injuries and nonhealing
wounds.
Correct
Urinary incontinenceUrinary incontinence may cause skin breakdown and lead to the
development of pressure injuries. Skin should always be kept clean and dry.
Skin toneSkin tone is not a factor that impacts the development of pressure injuries or
nonhealing wounds.
Correct
Low prealbumin levelsLow prealbumin level is a cue for Impaired Skin Integrity because
it can affect healing.
Correct
ImmobilityImmobility is a cue for Impaired Skin Integrity because it can lead to
prolonged pressure.
Inexperience with wound careInexperience with wound care is a cue for inadequate
knowledge of wound care, not Impaired Skin Integrity.
Correct
Stage 2 pressure injuryA stage 2 pressure injury is a cue for Impaired Skin Integrity
because it affects the epidermal and dermal layers of the skin.
Stage 4 pressure injuryA stage 4 pressure injury is a cue for Impaired Tissue Integrity,
not Impaired Skin Integrity, because it affects subcutaneous tissue and underlying tissue
of bone, tendon, muscle, and cartilage.
, Term 2 of 28
Which factors may impact the development of pressure injuries or nonhealing wounds?
Select all that apply.
Smoking
Diabetes
Specific gender
Urinary incontinence
Skin tone
Correct
AnemiaWhen a wound bed is pale or dry, it can indicate anemia, which is when the blood
does not contain enough red blood cells.
Correct
DiabetesDiabetes can contribute to a nonhealing wound that presents with a pale, dry
wound bed.
Wound infectionWound infection would not result in a pale, dry wound bed. Warmth,
redness, and increased drainage may be present.
Correct
Vascular diseaseVascular disease can be a contributing factor that presents with a pale,
dry wound bed because of the decreased perfusion to the wound.
Correct
Nutritional deficienciesNutritional deficiencies can cause a wound bed to be dry and
pale. Nutritional deficiencies can delay wound healing.
Correct
BoneBone is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity
would be appropriate.
Correct
TendonTendon is tissue and it would be damaged. The hypothesis Impaired Tissue
Integrity would be appropriate.
Correct
MuscleMuscle is tissue and it would be damaged. The hypothesis Impaired Tissue
Integrity would be appropriate.
DermisDermis is skin, and it would not be a primary area that would be damaged. Dermis
is damaged in Impaired Skin Integrity, not Impaired Tissue Integrity.
