Questions and Verified Answers
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What are 3 pressure related factors that contribute to pressure ulcer
development? - 🧠 ANSWER ✔✔1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
,How does pressure lead to tissue ischemia? - 🧠 ANSWER ✔✔If pressure
applied over a capillary exceeds normal capillary pressure and the vessel is
occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - 🧠 ANSWER ✔✔tissue
death
Does blanching occur in dark skinned patients? - 🧠 ANSWER ✔✔No,
blanching does not occur but color, texture and temp may differ from
surrounding area
What does pressure duration assess? - 🧠 ANSWER ✔✔Low and extended
pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue
death
What is tissue tolerance? - 🧠 ANSWER ✔✔the ability of tissue to endure
pressure which is dependent on the integrity of the tissue and supporting
structures
,What are risk factors of pressure injuries? - 🧠 ANSWER ✔✔◦Impaired
sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - 🧠
ANSWER ✔✔Wound location, staging, type and approximate percentage
of tissue in wound bed, wound dimensions (sinus tracts and tunneling),
exudate description and condition of surrounding skin
stage 1 pressure injury - 🧠 ANSWER ✔✔Intact skin with nonblanchable
redness
stage 2 pressure injury - 🧠 ANSWER ✔✔partial thickness skin loss
involving epidermis, dermis or both and, shallow abrasion or open blister
looking
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, stage 3 pressure injury - 🧠 ANSWER ✔✔full thickness skin loss extending
to SQ, crater looking
stage 4 pressure injury - 🧠 ANSWER ✔✔full thickness with exposed bone,
muscle or tendon and may have eschar
What characteristics does stage 3 and 4 pressure injuries share? - 🧠
ANSWER ✔✔They may have slough, undermining and tunneling present
A nurse states slough is present in a stage 3 pressure injury. What should
the student nurse expect to see? - 🧠 ANSWER ✔✔A yellow or white,
stringy substance attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should
the student nurse expect to see? - 🧠 ANSWER ✔✔brown or black necrotic
tissue
Unstageable/Unclassified Pressure Ulcer - 🧠 ANSWER ✔✔Tissue loss but
depth unknown because wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and
states "it will heal on its own". What education should the nurse provide? -