WCU NURS 100 ASSESSMENT 4 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+||BRAND NEW
FUNCTIONS OF THE SKIN Ans✓✓✓ • Protective barrier
• Thermoregulation
• Perception
• Elimination
• Vitamin D synthesis
WOUND Ans✓✓✓ injury to the skin
PRESSURE INJURY Ans✓✓✓ tissue injury from unrelieved pressure
Chronic hypoperfusion and prolonged pressure can result in Ans✓✓✓
tissue breakdown in less than 2 hours
RISK FAC TORS FOR IMPAIRED SKININTEGRITY Ans✓✓✓ •
Immature skin
• Degenerative changes
• Chronic illness
• Prolonged pressure, shear, friction
• Excessive moisture
• Decreased moisture
• Poor perfusion• Irritants
,• Mechanical force
•Impaired sensation
• Tightly knitted braids
• Trauma
• Sun exposure
• Infection
• Radiation
• Vasopressors
arterial ulcer Ans✓✓✓ an open wound on the lower legs or feet caused
by poor arterial blood flow
venous ulcer Ans✓✓✓ Brownish discoloration and scaling of the skin,
warm skin, edema, varicose veins.
Neuropathic ulcer Ans✓✓✓ Symmetrical sensory loss, dry, scaly, skin,
decreased reflexes, wound goes unknown because of a lack of feeling.
SKIN ASSESSMENT Ans✓✓✓ During admission, daily, or once per
shift
BRADEN SC ALE Ans✓✓✓ 6 ELEMENTS
Sensory perception 4 points
Moisture 4 points
, Activity 4 points
Mobility 4 points
Nutrition 4 points
Friction and shear 3 points
lower score higher risk
Score Interpretation Ans✓✓✓ No risk 19 to 23
Mild risk 15 to 18
Moderate risk 13 to 14
High risk 10 to 12
Severe risk 6 to 9
SIGNIFIC ANT FINDINGS Ans✓✓✓ erythema
Localized hypothermia or hyperthermia
Edema
Pain at pressure point
Lacerations
Skin tears
Surgical wounds
Moisture associated skin damage
Chronic wounds
Exudates
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+||BRAND NEW
FUNCTIONS OF THE SKIN Ans✓✓✓ • Protective barrier
• Thermoregulation
• Perception
• Elimination
• Vitamin D synthesis
WOUND Ans✓✓✓ injury to the skin
PRESSURE INJURY Ans✓✓✓ tissue injury from unrelieved pressure
Chronic hypoperfusion and prolonged pressure can result in Ans✓✓✓
tissue breakdown in less than 2 hours
RISK FAC TORS FOR IMPAIRED SKININTEGRITY Ans✓✓✓ •
Immature skin
• Degenerative changes
• Chronic illness
• Prolonged pressure, shear, friction
• Excessive moisture
• Decreased moisture
• Poor perfusion• Irritants
,• Mechanical force
•Impaired sensation
• Tightly knitted braids
• Trauma
• Sun exposure
• Infection
• Radiation
• Vasopressors
arterial ulcer Ans✓✓✓ an open wound on the lower legs or feet caused
by poor arterial blood flow
venous ulcer Ans✓✓✓ Brownish discoloration and scaling of the skin,
warm skin, edema, varicose veins.
Neuropathic ulcer Ans✓✓✓ Symmetrical sensory loss, dry, scaly, skin,
decreased reflexes, wound goes unknown because of a lack of feeling.
SKIN ASSESSMENT Ans✓✓✓ During admission, daily, or once per
shift
BRADEN SC ALE Ans✓✓✓ 6 ELEMENTS
Sensory perception 4 points
Moisture 4 points
, Activity 4 points
Mobility 4 points
Nutrition 4 points
Friction and shear 3 points
lower score higher risk
Score Interpretation Ans✓✓✓ No risk 19 to 23
Mild risk 15 to 18
Moderate risk 13 to 14
High risk 10 to 12
Severe risk 6 to 9
SIGNIFIC ANT FINDINGS Ans✓✓✓ erythema
Localized hypothermia or hyperthermia
Edema
Pain at pressure point
Lacerations
Skin tears
Surgical wounds
Moisture associated skin damage
Chronic wounds
Exudates
