NURS 247 Exam 2 Questions and Answers
100% Solved
Describe Stage 1 pressure ulcer -intact skin
-non-blanchable redness of localized area, usually over bony prominence
-darkly pigmented skin may not have visible blanching, it's color may differ from surrounding
area
Describe stage 2 pressure ulcer -partial thickness loss of dermis
-presents as shallow open ulcer
-red-pink wound bed w/out slough
-may also present as an intact or ruptured serum-filled blister
describe stage 3 pressure ulcer -full thickness tissue loss
-subcutaneous fat may be visible
-bone, tendon, muscle not exposed
-slough may be present, but does not obscure the depth of tissue loss
-may include undermining and tunneling
,describe stage 4 pressure ulcer -full thickness tissue loss
-bone, tendon, muscle are visible
-slough or eschar may be present on some parts of wound bed
-often include undermining and tunneling
what to palpate during derm assessment Temp
Moisture
Texture
Thickness
Edema
Mobility
Turgor
Assessment of mucous membranes should be intact, pink, and moist
, What is clubbing of the nails and what is the significance The skin and muscle around the
cuticle become 180 degrees and flat; this could indicate congenital cyanotic heart diseases, lung
cancer and pulmonary diseases
What is the importance of actinic keratosis It could develop into squamous cell
carcinoma
What is the significance of cap refill It tells about the status of the peripheral circulation
The skin changes associated with aging Liver sports (caused by chronic sun exposure) are
common and are usually on the hands, forearms, face, upper trunk, and shins
What are the normal ranges for hemoglobin in men and women men: 14-18
women: 12-16
what is the normal range for WBC count 5,000-10,000/mm3
How to assess for skin mobility and turgor 1. indication of dehydration
100% Solved
Describe Stage 1 pressure ulcer -intact skin
-non-blanchable redness of localized area, usually over bony prominence
-darkly pigmented skin may not have visible blanching, it's color may differ from surrounding
area
Describe stage 2 pressure ulcer -partial thickness loss of dermis
-presents as shallow open ulcer
-red-pink wound bed w/out slough
-may also present as an intact or ruptured serum-filled blister
describe stage 3 pressure ulcer -full thickness tissue loss
-subcutaneous fat may be visible
-bone, tendon, muscle not exposed
-slough may be present, but does not obscure the depth of tissue loss
-may include undermining and tunneling
,describe stage 4 pressure ulcer -full thickness tissue loss
-bone, tendon, muscle are visible
-slough or eschar may be present on some parts of wound bed
-often include undermining and tunneling
what to palpate during derm assessment Temp
Moisture
Texture
Thickness
Edema
Mobility
Turgor
Assessment of mucous membranes should be intact, pink, and moist
, What is clubbing of the nails and what is the significance The skin and muscle around the
cuticle become 180 degrees and flat; this could indicate congenital cyanotic heart diseases, lung
cancer and pulmonary diseases
What is the importance of actinic keratosis It could develop into squamous cell
carcinoma
What is the significance of cap refill It tells about the status of the peripheral circulation
The skin changes associated with aging Liver sports (caused by chronic sun exposure) are
common and are usually on the hands, forearms, face, upper trunk, and shins
What are the normal ranges for hemoglobin in men and women men: 14-18
women: 12-16
what is the normal range for WBC count 5,000-10,000/mm3
How to assess for skin mobility and turgor 1. indication of dehydration
