NR 329 ACTUAL UPDATED QUESTIONS AND SOLUTIONS
RATED A+
✔✔Patch - ✔✔a flat, discolored area on the skin larger than 1 cm
✔✔papule - ✔✔small (less then 1 cm), solid, raised lesion on surface of the skin
wart, elevated nevus
✔✔Plaque - ✔✔solid, raised lesion on surface of the skin (larger then 1 cm)
✔✔Wheals - ✔✔Superficial, raised, transient and erythematous (Allergic reaction)
✔✔Urticaria (hives) - ✔✔wheals coalesce (start touching each other) to form extensive
reaction, intensely pruritic
✔✔Bulla - ✔✔a large blister that is usually more than 1 cm in diameter
✔✔vesicle - ✔✔blister, less then 1 cm
✔✔Secondary lesion - ✔✔skin lesion that evolves from a primary lesion or that is
caused by external forces, such as infection, scratching, trauma, or the healing process
✔✔Crust and Scale - ✔✔debris on skin surfaces
✔✔Keloid - ✔✔hypertrophic scar, elevated beyond site of original injury
✔✔Excoriation - ✔✔Skin sore or abrasion produced by scratching or scraping
✔✔Fissure - ✔✔Narrow, slitlike opening
✔✔Erosion skin - ✔✔Scooped out but shallow depression. Superficial; epidermis lost;
moist but no bleeding
✔✔Ulcer - ✔✔a deeper loss of epidermis and dermis
✔✔annular/circular - ✔✔circular shape to skin lesion
✔✔discrete - ✔✔distinct, individual lesions that remain separate
✔✔Confluent - ✔✔skin lesions that run together
✔✔grouped - ✔✔clusters of lesions
, ✔✔linear - ✔✔a scratch, streak, line, or stripe
✔✔Target/iris - ✔✔resembles iris of eye/bullseye, concentric rings of color in lesions
✔✔Zosteriform - ✔✔linear arrangement along a unilateral nerve route (herpes zoster)
✔✔Braden Scale - ✔✔sensory perception, moisture, activity, mobility, nutrition, friction
and shear
✔✔Pressure Ulcer increased Risk - ✔✔Immobile
Poor Nutrition (Protein, Vitamin C, Zinc)
Decreased Blood Circulation
✔✔Pressure Injuries: Stage 1 - ✔✔non-blanchable erythema of intact skin
✔✔Pressure Injuries: Stage 2 - ✔✔partial thickness skin loss with exposed dermis
✔✔Pressure Injuries: Stage 3 - ✔✔Full-thickness skin loss
•Extends into subcutaneous tissue, resembles crater
•Fat, granulation tissue and rolled edges seen
•No bone, tendon or muscle visible
✔✔Pressure Injuries: Stage 4 - ✔✔Full-thickness tissue loss with exposed bone,
tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.
Often includes undermining and tunneling.
✔✔Deep Tissue Pressure Injury (DTPI) - ✔✔persistent non-blanchable deep red,
maroon, or purple discoloration (egg plant)
✔✔Non-stageable pressure ulcer - ✔✔obscured by slough/eschar
✔✔Slough - ✔✔viscous fibrinous tissue that can appear loosely or firmly attached to the
wound bed.
✔✔Tunneling - ✔✔channel of tissue loss extending in any direction through soft tissue
and muscle
measure a cotton tipped applicator
✔✔Assessing Pressure Ulcers - ✔✔-location of the lesion
- size of lesion in cm (measure length, width, & depth)
- stage of ulcer
- color of the wound bed & location of necrosis or eschar
- condition of wound margins
- integrity of surrounding skin
RATED A+
✔✔Patch - ✔✔a flat, discolored area on the skin larger than 1 cm
✔✔papule - ✔✔small (less then 1 cm), solid, raised lesion on surface of the skin
wart, elevated nevus
✔✔Plaque - ✔✔solid, raised lesion on surface of the skin (larger then 1 cm)
✔✔Wheals - ✔✔Superficial, raised, transient and erythematous (Allergic reaction)
✔✔Urticaria (hives) - ✔✔wheals coalesce (start touching each other) to form extensive
reaction, intensely pruritic
✔✔Bulla - ✔✔a large blister that is usually more than 1 cm in diameter
✔✔vesicle - ✔✔blister, less then 1 cm
✔✔Secondary lesion - ✔✔skin lesion that evolves from a primary lesion or that is
caused by external forces, such as infection, scratching, trauma, or the healing process
✔✔Crust and Scale - ✔✔debris on skin surfaces
✔✔Keloid - ✔✔hypertrophic scar, elevated beyond site of original injury
✔✔Excoriation - ✔✔Skin sore or abrasion produced by scratching or scraping
✔✔Fissure - ✔✔Narrow, slitlike opening
✔✔Erosion skin - ✔✔Scooped out but shallow depression. Superficial; epidermis lost;
moist but no bleeding
✔✔Ulcer - ✔✔a deeper loss of epidermis and dermis
✔✔annular/circular - ✔✔circular shape to skin lesion
✔✔discrete - ✔✔distinct, individual lesions that remain separate
✔✔Confluent - ✔✔skin lesions that run together
✔✔grouped - ✔✔clusters of lesions
, ✔✔linear - ✔✔a scratch, streak, line, or stripe
✔✔Target/iris - ✔✔resembles iris of eye/bullseye, concentric rings of color in lesions
✔✔Zosteriform - ✔✔linear arrangement along a unilateral nerve route (herpes zoster)
✔✔Braden Scale - ✔✔sensory perception, moisture, activity, mobility, nutrition, friction
and shear
✔✔Pressure Ulcer increased Risk - ✔✔Immobile
Poor Nutrition (Protein, Vitamin C, Zinc)
Decreased Blood Circulation
✔✔Pressure Injuries: Stage 1 - ✔✔non-blanchable erythema of intact skin
✔✔Pressure Injuries: Stage 2 - ✔✔partial thickness skin loss with exposed dermis
✔✔Pressure Injuries: Stage 3 - ✔✔Full-thickness skin loss
•Extends into subcutaneous tissue, resembles crater
•Fat, granulation tissue and rolled edges seen
•No bone, tendon or muscle visible
✔✔Pressure Injuries: Stage 4 - ✔✔Full-thickness tissue loss with exposed bone,
tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.
Often includes undermining and tunneling.
✔✔Deep Tissue Pressure Injury (DTPI) - ✔✔persistent non-blanchable deep red,
maroon, or purple discoloration (egg plant)
✔✔Non-stageable pressure ulcer - ✔✔obscured by slough/eschar
✔✔Slough - ✔✔viscous fibrinous tissue that can appear loosely or firmly attached to the
wound bed.
✔✔Tunneling - ✔✔channel of tissue loss extending in any direction through soft tissue
and muscle
measure a cotton tipped applicator
✔✔Assessing Pressure Ulcers - ✔✔-location of the lesion
- size of lesion in cm (measure length, width, & depth)
- stage of ulcer
- color of the wound bed & location of necrosis or eschar
- condition of wound margins
- integrity of surrounding skin
