Fundamentals Of Nursing Chapter 48: Skin Integrity and Wound Care
Practice Questions and Answers
1. The nurse is working on a medical-surgical and weight (individuals of all sizes, shapes, and
unit that has been participating in a research ages acquire skin breakdown) are not major
project associated with pressure ulcers. The causes of pressure ulcers.
nurse recognizes that the risk factors that
predispose a patient to pressure ulcer
development include 3. Which nursing observation would indicate that
a. A diet low in calories and fat. the patient was at risk for pressure ulcer
b. Alteration in level of consciousness. formation?
c. Shortness of breath. a. The patient ate two thirds of breakfast.
d. Muscular pain. - - ANS: B b. The patient has fecal incontinence.
Patients who are confused or disoriented or who c. The patient has a raised red rash on the right
have changing levels of consciousness are shin.
unable to protect themselves. The patient may d. The patient's capillary refill is less than 2
feel the pressure but may not understand what to seconds. - - ANS: B
do to relieve the discomfort or to communicate The presence and duration of moisture on the
that he or she is feeling discomfort. Impaired skin increase the risk of ulcer formation by
sensory perception, impaired mobility, shear, making it susceptible to injury. Moisture can
friction, and moisture are other predisposing originate from wound drainage, excessive
factors. Shortness of breath, muscular pain, and perspiration, and fecal or urinary incontinence.
a diet low in calories and fat are not included Bacteria and enzymes in the stool can enhance
among the predisposing factors. the opportunity for skin breakdown because the
skin is moistened and softened, causing
maceration. Eating a balanced diet is important
2. The nurse is caring for a patient who was for nutrition, but eating just two thirds of the meal
involved in an automobile accident 2 weeks ago. does not indicate that the individual is at risk. A
The patient sustained a head injury and is raised red rash on the leg again is a concern and
unconscious. The nurse is able to identify that can affect the integrity of the skin, but it is located
the major element involved in the development of on the shin, which is not a high-risk area for skin
a decubitus ulcer is breakdown. Pressure can influence capillary refill,
a. Pressure. leading to skin breakdown, but this capillary
b. Resistance. response is within normal limits.
c. Stress.
d. Weight. - - ANS: A
Pressure is the main element that causes 4. The wound care nurse visits a patient in the
pressure ulcers. Three pressure-related factors long-term care unit. The nurse is monitoring a
contribute to pressure ulcer development: patient with a stage III pressure ulcer. The wound
pressure intensity, pressure duration, and tissue seems to be healing, and healthy tissue is
tolerance. When the intensity of the pressure observed. How would the nurse stage this ulcer?
exerted on the capillary exceeds 12 to 32 mm a. Stage I pressure ulcer
Hg, this occludes the vessel, causing ischemic b. Healing stage II pressure ulcer
injury to the tissues it normally feeds. High c. Healing stage III pressure ulcer
pressure over a short time and low pressure over d. Stage III pressure ulcer - - ANS: C
a long time cause skin breakdown. Resistance When a pressure ulcer has been staged and is
(the ability to remain unaltered by the damaging beginning to heal, the ulcer keeps the same
effect of something), stress (worry or anxiety), stage and is labeled with the words "healing
, Fundamentals Of Nursing Chapter 48: Skin Integrity and Wound Care
Practice Questions and Answers
stage." Once an ulcer has been staged, the possibly be used during the assessment include
stage endures even as the ulcer heals. This ulcer gloves for infection control, a disposable
was labeled a stage III, it cannot return to a measuring device to measure the size of the
previous stage such as stage I or II. This ulcer is wound, and a cotton-tipped applicator to measure
healing, so it is no longer labeled a stage III. the depth of the wound, but these items not the
first item used.
5. The nurse is admitting an older patient from a
nursing home. During the assessment, the nurse 7. The nurse is caring for a patient with a stage
notes a shallow open ulcer without slough on the IV pressure ulcer. The nurse recalls that a
right heel of the patient. This pressure ulcer pressure ulcer takes time to heal and is an
would be staged as stage example of
a. I. a. Primary intention.
b. II. b. Partial-thickness wound repair.
c. III. c. Full-thickness wound repair.
d. IV. - - ANS: B d. Tertiary intention. - - ANS: C
This would be a stage II pressure ulcer because Pressure ulcers are full-thickness wounds that
it presents as partial-thickness skin loss involving
extend into the dermis and heal by scar formation
epidermis, dermis, or both. The ulcer is because the deeper structures do not regenerate,
superficial and presents clinically as an abrasion,
hence the need for full-thickness repair. The full-
blister, or shallow crater. Stage I is intact skin
thickness repair has three phases: inflammatory,
with nonblanchable redness over a bony proliferative, and remodeling. A wound heals by
prominence. With a Stage III pressure ulcer, primary intention when wounds such as surgical
subcutaneous fat may be visible, but bone, wounds have little tissue loss; the skin edges are
tendon, and muscles are not exposed. Stage IV approximated or closed, and the risk for infection
involves full-thickness tissue loss with exposed is low. Partial-thickness repairs are done on
bone, tendon, or muscle. partial-thickness wounds that are shallow,
involving loss of the epidermis and maybe partial
loss of the dermis. These wounds heal by
6. The nurse is completing a skin assessment on regeneration because the epidermis regenerates.
a patient with darkly pigmented skin. Which of Tertiary intention is seen when a wound is left
the following would be used first to assist in open for several days, and then the wound edges
staging an ulcer on this patient? approximated. Wound closure is delayed until
a. Cotton-tipped applicator risk of infection is resolved.
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light - - ANS: D 8. The nurse is caring for a patient with a large
When assessing a patient with darkly pigmented abrasion from a motorcycle accident. The nurse
skin, proper lighting is essential to accurately recalls that if the wound is kept moist, it can
complete the first step in assessment— resurface in _____ day(s).
inspection—and the whole assessment process. a. 4
Natural light or a halogen light is recommended. b. 2
Fluorescent light sources can produce blue tones c. 1
on darkly pigmented skin and can interfere with d. 7 - - ANS: A
an accurate assessment. Other items that could A partial-thickness wound repair has three
Practice Questions and Answers
1. The nurse is working on a medical-surgical and weight (individuals of all sizes, shapes, and
unit that has been participating in a research ages acquire skin breakdown) are not major
project associated with pressure ulcers. The causes of pressure ulcers.
nurse recognizes that the risk factors that
predispose a patient to pressure ulcer
development include 3. Which nursing observation would indicate that
a. A diet low in calories and fat. the patient was at risk for pressure ulcer
b. Alteration in level of consciousness. formation?
c. Shortness of breath. a. The patient ate two thirds of breakfast.
d. Muscular pain. - - ANS: B b. The patient has fecal incontinence.
Patients who are confused or disoriented or who c. The patient has a raised red rash on the right
have changing levels of consciousness are shin.
unable to protect themselves. The patient may d. The patient's capillary refill is less than 2
feel the pressure but may not understand what to seconds. - - ANS: B
do to relieve the discomfort or to communicate The presence and duration of moisture on the
that he or she is feeling discomfort. Impaired skin increase the risk of ulcer formation by
sensory perception, impaired mobility, shear, making it susceptible to injury. Moisture can
friction, and moisture are other predisposing originate from wound drainage, excessive
factors. Shortness of breath, muscular pain, and perspiration, and fecal or urinary incontinence.
a diet low in calories and fat are not included Bacteria and enzymes in the stool can enhance
among the predisposing factors. the opportunity for skin breakdown because the
skin is moistened and softened, causing
maceration. Eating a balanced diet is important
2. The nurse is caring for a patient who was for nutrition, but eating just two thirds of the meal
involved in an automobile accident 2 weeks ago. does not indicate that the individual is at risk. A
The patient sustained a head injury and is raised red rash on the leg again is a concern and
unconscious. The nurse is able to identify that can affect the integrity of the skin, but it is located
the major element involved in the development of on the shin, which is not a high-risk area for skin
a decubitus ulcer is breakdown. Pressure can influence capillary refill,
a. Pressure. leading to skin breakdown, but this capillary
b. Resistance. response is within normal limits.
c. Stress.
d. Weight. - - ANS: A
Pressure is the main element that causes 4. The wound care nurse visits a patient in the
pressure ulcers. Three pressure-related factors long-term care unit. The nurse is monitoring a
contribute to pressure ulcer development: patient with a stage III pressure ulcer. The wound
pressure intensity, pressure duration, and tissue seems to be healing, and healthy tissue is
tolerance. When the intensity of the pressure observed. How would the nurse stage this ulcer?
exerted on the capillary exceeds 12 to 32 mm a. Stage I pressure ulcer
Hg, this occludes the vessel, causing ischemic b. Healing stage II pressure ulcer
injury to the tissues it normally feeds. High c. Healing stage III pressure ulcer
pressure over a short time and low pressure over d. Stage III pressure ulcer - - ANS: C
a long time cause skin breakdown. Resistance When a pressure ulcer has been staged and is
(the ability to remain unaltered by the damaging beginning to heal, the ulcer keeps the same
effect of something), stress (worry or anxiety), stage and is labeled with the words "healing
, Fundamentals Of Nursing Chapter 48: Skin Integrity and Wound Care
Practice Questions and Answers
stage." Once an ulcer has been staged, the possibly be used during the assessment include
stage endures even as the ulcer heals. This ulcer gloves for infection control, a disposable
was labeled a stage III, it cannot return to a measuring device to measure the size of the
previous stage such as stage I or II. This ulcer is wound, and a cotton-tipped applicator to measure
healing, so it is no longer labeled a stage III. the depth of the wound, but these items not the
first item used.
5. The nurse is admitting an older patient from a
nursing home. During the assessment, the nurse 7. The nurse is caring for a patient with a stage
notes a shallow open ulcer without slough on the IV pressure ulcer. The nurse recalls that a
right heel of the patient. This pressure ulcer pressure ulcer takes time to heal and is an
would be staged as stage example of
a. I. a. Primary intention.
b. II. b. Partial-thickness wound repair.
c. III. c. Full-thickness wound repair.
d. IV. - - ANS: B d. Tertiary intention. - - ANS: C
This would be a stage II pressure ulcer because Pressure ulcers are full-thickness wounds that
it presents as partial-thickness skin loss involving
extend into the dermis and heal by scar formation
epidermis, dermis, or both. The ulcer is because the deeper structures do not regenerate,
superficial and presents clinically as an abrasion,
hence the need for full-thickness repair. The full-
blister, or shallow crater. Stage I is intact skin
thickness repair has three phases: inflammatory,
with nonblanchable redness over a bony proliferative, and remodeling. A wound heals by
prominence. With a Stage III pressure ulcer, primary intention when wounds such as surgical
subcutaneous fat may be visible, but bone, wounds have little tissue loss; the skin edges are
tendon, and muscles are not exposed. Stage IV approximated or closed, and the risk for infection
involves full-thickness tissue loss with exposed is low. Partial-thickness repairs are done on
bone, tendon, or muscle. partial-thickness wounds that are shallow,
involving loss of the epidermis and maybe partial
loss of the dermis. These wounds heal by
6. The nurse is completing a skin assessment on regeneration because the epidermis regenerates.
a patient with darkly pigmented skin. Which of Tertiary intention is seen when a wound is left
the following would be used first to assist in open for several days, and then the wound edges
staging an ulcer on this patient? approximated. Wound closure is delayed until
a. Cotton-tipped applicator risk of infection is resolved.
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light - - ANS: D 8. The nurse is caring for a patient with a large
When assessing a patient with darkly pigmented abrasion from a motorcycle accident. The nurse
skin, proper lighting is essential to accurately recalls that if the wound is kept moist, it can
complete the first step in assessment— resurface in _____ day(s).
inspection—and the whole assessment process. a. 4
Natural light or a halogen light is recommended. b. 2
Fluorescent light sources can produce blue tones c. 1
on darkly pigmented skin and can interfere with d. 7 - - ANS: A
an accurate assessment. Other items that could A partial-thickness wound repair has three
