NUR 2400 Skin Integrity and Wound Care
Exam UPDATED QUESTIONS AND
CORRECT ANSWERS
Skin - CORRECT ANSWER largest organ of the body
Composed of 2 layers
Skin ph 4.5-5.5
Functions of the skin - CORRECT ANSWER Protection, Thermoregulation, Cutaneous
Sensation, Vitamin D synthesis, Blood Reservoir, Excretion and Absorption.
What is a wound - CORRECT ANSWER disruption of the integrity and function of tissues in
the body
How are wounds classified - CORRECT ANSWER 1. Onset and duration
- acute (burns, surgical trauma)
-chronic (non healing wounds, venous ulcers, arterial ulcers, neuropathic ulcers)
2. Extent of tissue damage
-partial thickness (loss of epidermis and superficial dermis, ex: skin tears, abrasions)
-full thickness (skin loss and extends below dermis and may involve muscle and supporting structures
ex: stage 3 pressure injury)
3. Healing process
-primary intention (ex. Surgical incision, predictable healing process)
-secondary intention (wound edges are not approximated; prolonged healing process)
-tertiary intention (contaminated wound left open do drain before wound closure occurs)
, 4 phases of wound healing - CORRECT ANSWER 1. Hemostasis (upon injury)
-blood vessels constrict; platelet activation
2. Inflammation (1-3 days)
-vasodilation (allows WBC to get to wound)
3. Proliferation (3-24 days)
-granulation (new cell tissue)
-epithelialization (cells migrate)
-wound contraction (decrease size)
4. Maturation (24 days-2 years)
-collagen reorganization providing scar strength
Factors affecting wound healing: systemic factors - CORRECT ANSWER Age: decrease cell
function and inflammatory phase
Body Build
Tissue perfusion: need good blow flow
Chronic disease: medications
Nutritional Status: vitamin A and C-needed for epithelialization and collagen synthesis, zinc-
proliferation of cells, iron carries O2
Smoking: vasoconstrictor, increase platelet adhesiveness
Immunosuppression and radiation therapy: reduces inflammatory response and healing cascade,
radiation weakens surrounding skin
Factors that affect wound healing: local - CORRECT ANSWER pressure: interferes with blood
flow
Dry wound environment: cells cannot migrate
Infection
Trauma
Edema: reduces blood flow
Necrosis
- slough: yellow, moist, loose stringy,
- eschar: black, brown, dry, leathery
Exam UPDATED QUESTIONS AND
CORRECT ANSWERS
Skin - CORRECT ANSWER largest organ of the body
Composed of 2 layers
Skin ph 4.5-5.5
Functions of the skin - CORRECT ANSWER Protection, Thermoregulation, Cutaneous
Sensation, Vitamin D synthesis, Blood Reservoir, Excretion and Absorption.
What is a wound - CORRECT ANSWER disruption of the integrity and function of tissues in
the body
How are wounds classified - CORRECT ANSWER 1. Onset and duration
- acute (burns, surgical trauma)
-chronic (non healing wounds, venous ulcers, arterial ulcers, neuropathic ulcers)
2. Extent of tissue damage
-partial thickness (loss of epidermis and superficial dermis, ex: skin tears, abrasions)
-full thickness (skin loss and extends below dermis and may involve muscle and supporting structures
ex: stage 3 pressure injury)
3. Healing process
-primary intention (ex. Surgical incision, predictable healing process)
-secondary intention (wound edges are not approximated; prolonged healing process)
-tertiary intention (contaminated wound left open do drain before wound closure occurs)
, 4 phases of wound healing - CORRECT ANSWER 1. Hemostasis (upon injury)
-blood vessels constrict; platelet activation
2. Inflammation (1-3 days)
-vasodilation (allows WBC to get to wound)
3. Proliferation (3-24 days)
-granulation (new cell tissue)
-epithelialization (cells migrate)
-wound contraction (decrease size)
4. Maturation (24 days-2 years)
-collagen reorganization providing scar strength
Factors affecting wound healing: systemic factors - CORRECT ANSWER Age: decrease cell
function and inflammatory phase
Body Build
Tissue perfusion: need good blow flow
Chronic disease: medications
Nutritional Status: vitamin A and C-needed for epithelialization and collagen synthesis, zinc-
proliferation of cells, iron carries O2
Smoking: vasoconstrictor, increase platelet adhesiveness
Immunosuppression and radiation therapy: reduces inflammatory response and healing cascade,
radiation weakens surrounding skin
Factors that affect wound healing: local - CORRECT ANSWER pressure: interferes with blood
flow
Dry wound environment: cells cannot migrate
Infection
Trauma
Edema: reduces blood flow
Necrosis
- slough: yellow, moist, loose stringy,
- eschar: black, brown, dry, leathery
