WCU NURS 100 ASSESSMENT 4
EXAM 2025 QUESTIONS AND
ANSWERS
FUNCTIONS OF THE SKIN - ....ANSWER ...-• Protective barrier
• Thermoregulation
• Perception
• Elimination
• Vitamin D synthesis
WOUND - ....ANSWER ...-injury to the skin
PRESSURE INJURY - ....ANSWER ...-tissue injury from unrelieved
pressure
Chronic hypoperfusion and prolonged pressure can result in -
....ANSWER ...-tissue breakdown in less than 2 hours
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,RISK FAC TORS FOR IMPAIRED SKININTEGRITY - ....ANSWER ...-
• Immature skin
• Degenerative changes
• Chronic illness
• Prolonged pressure, shear, friction
• Excessive moisture
• Decreased moisture
• Poor perfusion• Irritants
• Mechanical force
•Impaired sensation
• Tightly knitted braids
• Trauma
• Sun exposure
• Infection
• Radiation
• Vasopressors
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 2
,arterial ulcer - ....ANSWER ...-an open wound on the lower legs or feet
caused by poor arterial blood flow
venous ulcer - ....ANSWER ...-Brownish discoloration and scaling of the
skin, warm skin, edema, varicose veins.
Neuropathic ulcer - ....ANSWER ...-Symmetrical sensory loss, dry, scaly,
skin, decreased reflexes, wound goes unknown because of a lack of feeling.
SKIN ASSESSMENT - ....ANSWER ...-During admission, daily, or once
per shift
BRADEN SC ALE - ....ANSWER ...-6 ELEMENTS
Sensory perception 4 points
Moisture 4 points
Activity 4 points
Mobility 4 points
Nutrition 4 points
Friction and shear 3 points
lower score higher risk
Score Interpretation - ....ANSWER ...-No risk 19 to 23
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 3
, Mild risk 15 to 18
Moderate risk 13 to 14
High risk 10 to 12
Severe risk 6 to 9
SIGNIFIC ANT FINDINGS - ....ANSWER ...-erythema
Localized hypothermia or hyperthermia
Edema
Pain at pressure point
Lacerations
Skin tears
Surgical wounds
Moisture associated skin damage
Chronic wounds
Exudates
EX PECTED FINDINGS IN A SURGIC ALWOU ND - ....ANSWER ...-•
Intact, well-approximated edges• AFTER 4 DAYS - epithelial closure• AFTER 5
DAYS - resolution of edema and exudate• AFTER 9 to 14 DAYS - removal of
sutures and staples
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 4
EXAM 2025 QUESTIONS AND
ANSWERS
FUNCTIONS OF THE SKIN - ....ANSWER ...-• Protective barrier
• Thermoregulation
• Perception
• Elimination
• Vitamin D synthesis
WOUND - ....ANSWER ...-injury to the skin
PRESSURE INJURY - ....ANSWER ...-tissue injury from unrelieved
pressure
Chronic hypoperfusion and prolonged pressure can result in -
....ANSWER ...-tissue breakdown in less than 2 hours
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 1
,RISK FAC TORS FOR IMPAIRED SKININTEGRITY - ....ANSWER ...-
• Immature skin
• Degenerative changes
• Chronic illness
• Prolonged pressure, shear, friction
• Excessive moisture
• Decreased moisture
• Poor perfusion• Irritants
• Mechanical force
•Impaired sensation
• Tightly knitted braids
• Trauma
• Sun exposure
• Infection
• Radiation
• Vasopressors
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 2
,arterial ulcer - ....ANSWER ...-an open wound on the lower legs or feet
caused by poor arterial blood flow
venous ulcer - ....ANSWER ...-Brownish discoloration and scaling of the
skin, warm skin, edema, varicose veins.
Neuropathic ulcer - ....ANSWER ...-Symmetrical sensory loss, dry, scaly,
skin, decreased reflexes, wound goes unknown because of a lack of feeling.
SKIN ASSESSMENT - ....ANSWER ...-During admission, daily, or once
per shift
BRADEN SC ALE - ....ANSWER ...-6 ELEMENTS
Sensory perception 4 points
Moisture 4 points
Activity 4 points
Mobility 4 points
Nutrition 4 points
Friction and shear 3 points
lower score higher risk
Score Interpretation - ....ANSWER ...-No risk 19 to 23
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 3
, Mild risk 15 to 18
Moderate risk 13 to 14
High risk 10 to 12
Severe risk 6 to 9
SIGNIFIC ANT FINDINGS - ....ANSWER ...-erythema
Localized hypothermia or hyperthermia
Edema
Pain at pressure point
Lacerations
Skin tears
Surgical wounds
Moisture associated skin damage
Chronic wounds
Exudates
EX PECTED FINDINGS IN A SURGIC ALWOU ND - ....ANSWER ...-•
Intact, well-approximated edges• AFTER 4 DAYS - epithelial closure• AFTER 5
DAYS - resolution of edema and exudate• AFTER 9 to 14 DAYS - removal of
sutures and staples
....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 4
