Skin Integrity: Assess and Recognize Cues Exam Questions With 100% Correct Answers Guaranteed Pass.

Which reasoning explains why a nurse measures wound size during an initial wound assessment? - correct answer - To help assess progression of wound healing Measuring wound size helps assess the progression of wound healing. As the wound heals, it becomes smaller. Which cues related to skin integrity may reflect an overall health problem? - correct answer - Cracking Extreme dryness or cracking adversely affects skin integrity, indicating an overall health problem. - Tenting Tenting indicates the patient is dehydrated and reflects an overall health problem. - Pathogens Identified A wound with pathogens indicates an infection, which is an overall health problem. Which term would the nurse use to describe excessive moisture on the patient's skin? - correct answer - Diaphoresis Diaphoresis is excessive moisture on the patient's skin, and it is usually visible to the nurse and patient. Match the type of wound drainage to the color of fluid the nurse would observe on a patient's dressing: Clear and watery Pink to pale red Bright red Greenish, yellow - correct answer Clear and watery: Serous Pink to pale red: Serosanguineous Bright red: Sanguineous Greenish, yellow: Purulent Which factors may impact the development of pressure injuries or nonhealing wounds? - correct answer - Smoking - Diabetes - Urinary Incontinence Which statements by the nurse caring for a postoperative patient who suffered a spinal cord injury indicate correct understanding about assessment tools? - correct answer - "The Norton Scale is used to assess for pressure injury risk." The Norton Scale is a tool used to assess risk for developing pressure injuries, and it indicates a correct understanding about assessment tools. - "When assessing for open wounds, I can use the Wound Characteristic Instrument." Wound Characteristic Instrument is a tool used to assess open wounds and to track wound healing. Which type of fluid would the nurse likely observe if the patient was hemorrhaging? - correct answer - Sanguineous Sanguineous fluid is bright red, and it indicates bleeding that is observed in hemorrhaging. Which interpretation would the nurse make about a patient's wound culture that is positive? - correct answer - It is infected. Match the unexpected skin assessment finding to its description: Blue skin Pinpoint, flat, red spots Red skin Bruise - correct answer Blue skin: Cyanosis Pinpoint, flat, red spots: Petechiae Red skin: Erythema Bruise: Ecchymosis Which factors can place a patient at risk for a pale, dry wound? - correct answer - Anemia When a wound bed is pale or dry, it can indicate anemia, which is when the blood does not contain enough red blood cells. - Diabetes Diabetes can contribute to a nonhealing wound that presents with a pale, dry wound bed. - Vascular Disease Vascular disease can be a contributing factor that presents with a pale, dry wound bed because of the decreased perfusion to the wound. - Nutritional Deficiencies Nutritional deficiencies can cause a wound bed to be dry and pale. Nutritional deficiencies can delay wound healing. Which cues would the nurse observe for a patient with an infected lateral malleolus wound? - correct answer -Erythema noted on the superior portion of the wound -Purulent, malodorous drainage -Temperature of 102°F (38.9°C) Which Braden Scale score range would alert the nurse that a patient is at moderate risk for pressure injury development? Record your answer as whole numbers separated by a hyphen. __ - correct answer 13-14 Which patient is likely at risk for developing a pressure injury? - correct answer - Patient with unrelieved pressure who has a fractured hip The patient with unrelieved pressure is most at risk for developing a pressure injury, because tissue ischemia can form and lead to pressure injuries. Which steps would the nurse take to measure the dimensions of a sacral pressure injury? - correct answer - Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. - Measure the width laterally from left to right at the widest portion of the wound. - Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. - Measure the length vertically from the top to the bottom at the widest open area of the wound. Which assessment technique indicates the nurse properly determined if the patient's incision is healing or is becoming infected? - correct answer - Palpating the area of induration around the incision line Palpating the area of induration is an effective way to assess if an incision is healing or becoming infected; an infected incision will have induration (hardness) around the incision. Which patient situations are of immediate concern? - correct answer A patient is experiencing shock. A patient is profusely bleeding from a wound. A patient has an eviscerated wound. Match the wound bed condition to its cues. 1. Pale, soft, wrinkled 2. Beefy red, shiny, moist 3. Black, hard, dry 4. Purulent yellow - correct answer Pale, soft, wrinkled: Macerated Beefy red, shiny, moist: Granulated Black, hard, dry: Necrotic Purulent yellow: Infected