NR 226 CH APTER 48 QUIZ Chapter 48: Skin Integrity and Wound Care Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is working on a medical -surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development? a. Decreased level of c onsciousness b. Adequate dietary intake c. Shortness of breath d. Muscular pain ANS: A Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feelin g discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and an adequate dietary intake are not included among the predisposing factors. DIF: Understand (comprehension) REF: 1186 OBJ: Discuss the risk factors that contribute to pressure ulcer formation. TOP: Assessment MSC: Reduction of Risk Potential 2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus u lcer? a. Resistance b. Pressure c. Weight d. Stress ANS: B Pressure is the mai n element that causes pressure ulcers. Three pressure -related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers. DIF: Understand (comprehension) REF: 1185 -1186 OBJ: Discuss the risk factors that contribute to pressure ulcer formation. TOP: Planning MSC: Reduction of Risk Potential 3. Which nursing observation will indicate the patient is at risk for pressure ulcer fo rmation? a. The patient has fecal incontinence. b. The patient ate two thirds of breakfast. c. The patient has a raised red rash on the right shin. d. The patient’s capillary refill is less than 2 seconds. ANS: A The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the st ool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits. DIF: Understand (comprehension) REF: 1187 OBJ: Discuss the risk factors that contribute to pressure ulcer formation. TOP: Assessment MSC: Reduction of Risk Potential 4. The wound care nurse visits a patient in the long -term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient’s me dical record? a. Stage I pressure ulcer b. Healing Stage II pressure ulcer c. Healing Stage III pressure ulcer d. Stage III pressure ulcer ANS: C When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words “healing stage ” or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage III, and it cannot return to a previous stage such as Stage I or II. This ulcer is healing, so it is no longer labeled a Stage III. DIF: Understand (comprehension) REF: 1187 OBJ: Describe the pressure ulcer staging system. TOP : Implementation MSC: Physiological Adaptation 5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse s tage this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV ANS: B This would be a Stage II pressure ulcer because it presents as partial -thickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bo ny prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full -thickness tissue loss with exposed bone, tendon, or muscle. DIF: Apply (application) REF: 1187 -1188 OBJ: Describe the pressure ulcer staging system. TOP: Assessment MSC: Physiological Adaptation 6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on thi s patient? a. Disposable measuring tape b. Cotton -tipped applicator c. Sterile gloves d. Halogen light ANS: D When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment —inspection —and the entire assessment process. Natural light or a halogen light is recommended. Fluorescent light sources c an produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound , and a cotton -tipped applicator to measure the depth of the wound, but these items are not the first items used. DIF: Understand (comprehension) REF: 1186 OBJ: Describe the pressure ulcer staging system. TOP: Assessment MSC: Health Promotion and Maintenance 7. The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? a. Partial -thickness wound repair b. Full-thickness wound repair c. Primary intention d. Tertiary intention ANS: B Stage IV pressure ulcers are full -thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full -
thickness repair. The full -thickness repair has four phases: hemostasis, infl ammatory, proliferative, and maturation. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial -thickness repairs are done on par tial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and th en the wound edges are approximated. Wound closure is delayed until risk of infection is resolved. DIF: Apply (application) REF: 1187 | 1190
thickness repair. The full -thickness repair has four phases: hemostasis, infl ammatory, proliferative, and maturation. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial -thickness repairs are done on par tial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and th en the wound edges are approximated. Wound closure is delayed until risk of infection is resolved. DIF: Apply (application) REF: 1187 | 1190
