NURS 121 21-2.1 Tissue Impairment Exam
Study Set 2025
A client asks what effect nutrition has on skin integrity. Which response should the
nurse make that explains the relationship of nutrition to pressure injury development?
A.
"Increased dietary intake of protein can cause pressure injuries."
B.
"Increased dietary intake of carbohydrates and minerals can cause pressure injuries."
C.
"Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure
injuries."
D.
"Poor dietary intake of primarily fatty foods can increase the risk of pressure injuries." -
ANSWER C.
"Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure
injuries."
A client has a pressure injury on the right elbow that is covered with eschar and
extensive tissue damage. Which stage should the nurse document this ulcer to be?
A.Stage 4
B.unstageable
C.Stage 3
D.Stage 2 - ANSWER B.unstageable
The charge nurse receives report for all clients on the unit. Which client should the
nurse consider as being at risk for the development of pressure injuries? (Select all that
apply.)
A.Client admitted to an acute care unit
B.Client with type 1 diabetes mellitus
C.Client who is 92-years-old
, D.Client with a history of anorexia nervosa
E.Client on bedrest - ANSWER B.Client with type 1 diabetes mellitus
C.Client who is 92-years-old
D.Client with a history of anorexia nervosa
E.Client on bedrest
A client who has been sedated and on mechanical ventilation for several days is on a
low-air-loss bed; however, the client has a localized purple area of discoloration over
the coccyx that does not blanch. Which pressure injury should the nurse suspect for this
client?
A.Suspected deep tissue injury
B.Stage 3 pressure injury
C.Stage 1 pressure injury
D.Bruising - ANSWER A.Suspected deep tissue injury
A client is in the high- Fowler position to facilitate breathing. Which body pressure area
should the nurse be most concerned about?
A.Heels
B.Zygomatic bone
C.Ilium
D.Knee - ANSWER A.Heels
A client has a follow-up appointment for treatment of a pressure injury. Which client
outcome should indicate to the nurse that treatment goals have been met? (Select all
that apply.)
A.There is greenish exudate on the dressing.
B.The wound has decreased in size.
C.The client's BMI is 16, and the weight is down by 4 pounds.
D.The client and family demonstrate an understanding of preventive care measures.
E.The client has enrolled in a smoking cessation program. - ANSWER B.The wound has
decreased in size.
D.The client and family demonstrate an understanding of preventive care measures.
E.The client has enrolled in a smoking cessation program.
Study Set 2025
A client asks what effect nutrition has on skin integrity. Which response should the
nurse make that explains the relationship of nutrition to pressure injury development?
A.
"Increased dietary intake of protein can cause pressure injuries."
B.
"Increased dietary intake of carbohydrates and minerals can cause pressure injuries."
C.
"Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure
injuries."
D.
"Poor dietary intake of primarily fatty foods can increase the risk of pressure injuries." -
ANSWER C.
"Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure
injuries."
A client has a pressure injury on the right elbow that is covered with eschar and
extensive tissue damage. Which stage should the nurse document this ulcer to be?
A.Stage 4
B.unstageable
C.Stage 3
D.Stage 2 - ANSWER B.unstageable
The charge nurse receives report for all clients on the unit. Which client should the
nurse consider as being at risk for the development of pressure injuries? (Select all that
apply.)
A.Client admitted to an acute care unit
B.Client with type 1 diabetes mellitus
C.Client who is 92-years-old
, D.Client with a history of anorexia nervosa
E.Client on bedrest - ANSWER B.Client with type 1 diabetes mellitus
C.Client who is 92-years-old
D.Client with a history of anorexia nervosa
E.Client on bedrest
A client who has been sedated and on mechanical ventilation for several days is on a
low-air-loss bed; however, the client has a localized purple area of discoloration over
the coccyx that does not blanch. Which pressure injury should the nurse suspect for this
client?
A.Suspected deep tissue injury
B.Stage 3 pressure injury
C.Stage 1 pressure injury
D.Bruising - ANSWER A.Suspected deep tissue injury
A client is in the high- Fowler position to facilitate breathing. Which body pressure area
should the nurse be most concerned about?
A.Heels
B.Zygomatic bone
C.Ilium
D.Knee - ANSWER A.Heels
A client has a follow-up appointment for treatment of a pressure injury. Which client
outcome should indicate to the nurse that treatment goals have been met? (Select all
that apply.)
A.There is greenish exudate on the dressing.
B.The wound has decreased in size.
C.The client's BMI is 16, and the weight is down by 4 pounds.
D.The client and family demonstrate an understanding of preventive care measures.
E.The client has enrolled in a smoking cessation program. - ANSWER B.The wound has
decreased in size.
D.The client and family demonstrate an understanding of preventive care measures.
E.The client has enrolled in a smoking cessation program.
