Potter-Perry Chapter 48 Skin Integrity and Wound Care-
remake UPDATED ACTUAL Questions and
CORRECT Answers
1. The nurse is working on a medical-surgical unit that ANS: B
has been participating in a research project associated Patients who are confused or disoriented or who have changing levels of
with pressure ulcers. The nurse recognizes that the risk consciousness are unable to protect themselves. The patient may feel the
factors that predispose a patient to pressure ulcer pressure but may not understand what to do to relieve the discomfort or to
development include communicate that he or she is feeling discomfort. Impaired sensory perception,
a. A diet low in calories and fat. impaired mobility, shear, friction, and moisture are other predisposing factors.
b. Alteration in level of consciousness. Shortness of breath, muscular pain, and a diet low in calories and fat are not
c. Shortness of breath. included among the predisposing factors.
d. Muscular pain.
2. The nurse is caring for a patient who was involved in ANS: A
an automobile accident 2 weeks ago. The patient Pressure is the main element that causes pressure ulcers. Three pressure-
sustained a head injury and is unconscious. The nurse is related factors contribute to pressure ulcer development: pressure intensity,
able to identify that the major element involved in the pressure duration, and tissue tolerance. When the intensity of the pressure
development of a decubitus ulcer is exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel,
a. Pressure. causing ischemic injury to the tissues it normally feeds. High pressure over a
b. Resistance. short time and low pressure over a long time cause skin breakdown. Resistance
c. Stress. (the ability to remain unaltered by the damaging effect of something), stress
d. Weight. (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire
skin breakdown) are not major causes of pressure ulcers.
, 3. Which nursing observation would indicate that the ANS: B
patient was at risk for pressure ulcer formation? The presence and duration of moisture on the skin increase the risk of ulcer
a. The patient ate two thirds of breakfast. formation by making it susceptible to injury. Moisture can originate from wound
b. The patient has fecal incontinence. drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria
c. The patient has a raised red rash on the right shin. and enzymes in the stool can enhance the opportunity for skin breakdown
d. The patient's capillary refill is less than 2 seconds. 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.
4. The wound care nurse visits a patient in the long- ANS: C
term care unit. The nurse is monitoring a patient with a When a pressure ulcer has been staged and is beginning to heal, the ulcer
stage III pressure ulcer. The wound seems to be keeps the same stage and is labeled with the words "healing stage." Once an
healing, and healthy tissue is observed. How would the ulcer has been staged, the stage endures even as the ulcer heals. This ulcer
nurse stage this ulcer? was labeled a stage III, it cannot return to a previous stage such as stage I or II.
a. Stage I pressure ulcer This ulcer is healing, so it is no longer labeled a stage III.
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer
5. The nurse is admitting an older patient from a nursing ANS: B
home. During the assessment, the nurse notes a shallow This would be a stage II pressure ulcer because it presents as partial-thickness
open ulcer without slough on the right heel of the skin loss involving epidermis, dermis, or both. The ulcer is superficial and
patient. This pressure ulcer would be staged as stage presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin
a. I. with nonblanchable redness over a bony prominence. With a Stage III pressure
b. II. ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not
c. III. exposed. Stage IV involves full-thickness tissue loss with exposed bone,
d. IV. tendon, or muscle.
6. The nurse is completing a skin assessment on a ANS: D
patient with darkly pigmented skin. Which of the When assessing a patient with darkly pigmented skin, proper lighting is
following would be used first to assist in staging an essential to accurately complete the first step in assessment—inspection—and
ulcer on this patient? the whole assessment process. Natural light or a halogen light is
a. Cotton-tipped applicator recommended. Fluorescent light sources can produce blue tones on darkly
b. Disposable measuring tape pigmented skin and can interfere with an accurate assessment. Other items that
c. Sterile gloves could possibly be used during the assessment include gloves for infection
d. Halogen light 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
not the first item used.
7. The nurse is caring for a patient with a stage IV ANS: C
pressure ulcer. The nurse recalls that a pressure ulcer Pressure ulcers are full-thickness wounds that extend into the dermis and heal
takes time to heal and is an example of by scar formation because the deeper structures do not regenerate, hence the
a. Primary intention. need for full-thickness repair. The full-thickness repair has three phases:
b. Partial-thickness wound repair. inflammatory, proliferative, and remodeling. A wound heals by primary
c. Full-thickness wound repair. intention when wounds such as surgical wounds have little tissue loss; the skin
d. Tertiary intention. edges are approximated or closed, and the risk for infection is low. Partial-
thickness repairs are done on partial-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 then the
wound edges approximated. Wound closure is delayed until risk of infection is
resolved.
remake UPDATED ACTUAL Questions and
CORRECT Answers
1. The nurse is working on a medical-surgical unit that ANS: B
has been participating in a research project associated Patients who are confused or disoriented or who have changing levels of
with pressure ulcers. The nurse recognizes that the risk consciousness are unable to protect themselves. The patient may feel the
factors that predispose a patient to pressure ulcer pressure but may not understand what to do to relieve the discomfort or to
development include communicate that he or she is feeling discomfort. Impaired sensory perception,
a. A diet low in calories and fat. impaired mobility, shear, friction, and moisture are other predisposing factors.
b. Alteration in level of consciousness. Shortness of breath, muscular pain, and a diet low in calories and fat are not
c. Shortness of breath. included among the predisposing factors.
d. Muscular pain.
2. The nurse is caring for a patient who was involved in ANS: A
an automobile accident 2 weeks ago. The patient Pressure is the main element that causes pressure ulcers. Three pressure-
sustained a head injury and is unconscious. The nurse is related factors contribute to pressure ulcer development: pressure intensity,
able to identify that the major element involved in the pressure duration, and tissue tolerance. When the intensity of the pressure
development of a decubitus ulcer is exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel,
a. Pressure. causing ischemic injury to the tissues it normally feeds. High pressure over a
b. Resistance. short time and low pressure over a long time cause skin breakdown. Resistance
c. Stress. (the ability to remain unaltered by the damaging effect of something), stress
d. Weight. (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire
skin breakdown) are not major causes of pressure ulcers.
, 3. Which nursing observation would indicate that the ANS: B
patient was at risk for pressure ulcer formation? The presence and duration of moisture on the skin increase the risk of ulcer
a. The patient ate two thirds of breakfast. formation by making it susceptible to injury. Moisture can originate from wound
b. The patient has fecal incontinence. drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria
c. The patient has a raised red rash on the right shin. and enzymes in the stool can enhance the opportunity for skin breakdown
d. The patient's capillary refill is less than 2 seconds. 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.
4. The wound care nurse visits a patient in the long- ANS: C
term care unit. The nurse is monitoring a patient with a When a pressure ulcer has been staged and is beginning to heal, the ulcer
stage III pressure ulcer. The wound seems to be keeps the same stage and is labeled with the words "healing stage." Once an
healing, and healthy tissue is observed. How would the ulcer has been staged, the stage endures even as the ulcer heals. This ulcer
nurse stage this ulcer? was labeled a stage III, it cannot return to a previous stage such as stage I or II.
a. Stage I pressure ulcer This ulcer is healing, so it is no longer labeled a stage III.
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer
5. The nurse is admitting an older patient from a nursing ANS: B
home. During the assessment, the nurse notes a shallow This would be a stage II pressure ulcer because it presents as partial-thickness
open ulcer without slough on the right heel of the skin loss involving epidermis, dermis, or both. The ulcer is superficial and
patient. This pressure ulcer would be staged as stage presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin
a. I. with nonblanchable redness over a bony prominence. With a Stage III pressure
b. II. ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not
c. III. exposed. Stage IV involves full-thickness tissue loss with exposed bone,
d. IV. tendon, or muscle.
6. The nurse is completing a skin assessment on a ANS: D
patient with darkly pigmented skin. Which of the When assessing a patient with darkly pigmented skin, proper lighting is
following would be used first to assist in staging an essential to accurately complete the first step in assessment—inspection—and
ulcer on this patient? the whole assessment process. Natural light or a halogen light is
a. Cotton-tipped applicator recommended. Fluorescent light sources can produce blue tones on darkly
b. Disposable measuring tape pigmented skin and can interfere with an accurate assessment. Other items that
c. Sterile gloves could possibly be used during the assessment include gloves for infection
d. Halogen light 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
not the first item used.
7. The nurse is caring for a patient with a stage IV ANS: C
pressure ulcer. The nurse recalls that a pressure ulcer Pressure ulcers are full-thickness wounds that extend into the dermis and heal
takes time to heal and is an example of by scar formation because the deeper structures do not regenerate, hence the
a. Primary intention. need for full-thickness repair. The full-thickness repair has three phases:
b. Partial-thickness wound repair. inflammatory, proliferative, and remodeling. A wound heals by primary
c. Full-thickness wound repair. intention when wounds such as surgical wounds have little tissue loss; the skin
d. Tertiary intention. edges are approximated or closed, and the risk for infection is low. Partial-
thickness repairs are done on partial-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 then the
wound edges approximated. Wound closure is delayed until risk of infection is
resolved.
