NURS EXAM|SKIN INTEGRITY AND WOULD CARE
QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023
Pressure is the main element that causes pressure ulcers. Three pressure-related factors
contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue
tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32
mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds.
High pressure over a short time and low pressure over a long time cause skin breakdown.
Resistance (the ability to remain unaltered by the damaging effect of something), stress
(worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin
breakdown) are not major causes of pressure ulcers.
DIF: Remember REF: 1177-1178
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Assessment MSC: Physiological Integrity: Reduction of Risk Potential
Which nursing observation would indicate that the patient was at risk for pressure ulcer
formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient’s capillary refill is less than 2 seconds.
ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation by
making it susceptible to injury. Moisture can originate from wound drainage, excessive
perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can
enhance the opportunity for skin breakdown 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.
DIF: Understand REF: 1177-1178
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Implementation
MSC: Physiological Integrity: Reduction of Risk Potential
,NURS EXAM|SKIN INTEGRITY AND WOULD CARE
QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023
The wound care nurse visits a patient in the long-term care unit. The nurse is
monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and
healthy tissue is observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same
stage and is labeled with the words “healing stage.” Once an ulcer has been staged, the
stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return
to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a
stage III.
DIF: Remember REF: 1178-1179 OBJ: Describe the pressure ulcer staging system.
TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation
The nurse is admitting an older patient from a nursing home. During the assessment,
the nurse notes a shallow open ulcer without slough on the right heel of the patient. This
pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV.
ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss
involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an
abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over
a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but
bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss
with exposed bone, tendon, or muscle.
DIF: Remember REF: 1178-1179 OBJ: Describe the pressure ulcer staging system.
TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation
, NURS EXAM|SKIN INTEGRITY AND WOULD CARE
QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023
The nurse is completing a skin assessment on a patient with darkly pigmented skin.
Which of the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to
accurately complete the first step in assessment—inspection—and the whole assessment
process. Natural light or a halogen light is recommended. Fluorescent light sources can
produce blue tones on darkly pigmented skin and can interfere with an accurate
assessment. Other items that could possibly be used during the assessment include gloves
for infection 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.
DIF: Understand REF: 1179 OBJ: Describe the pressure ulcer staging system.
TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation
The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a
pressure ulcer takes time to heal and is an example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.
ANS: C
Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar
formation because the deeper structures do not regenerate, hence the need for full-
thickness repair. The full-thickness repair has three phases: inflammatory, proliferative,
and remodeling. A wound heals by primary intention when wounds such as surgical
wounds have little tissue loss; the skin 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
QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023
Pressure is the main element that causes pressure ulcers. Three pressure-related factors
contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue
tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32
mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds.
High pressure over a short time and low pressure over a long time cause skin breakdown.
Resistance (the ability to remain unaltered by the damaging effect of something), stress
(worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin
breakdown) are not major causes of pressure ulcers.
DIF: Remember REF: 1177-1178
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Assessment MSC: Physiological Integrity: Reduction of Risk Potential
Which nursing observation would indicate that the patient was at risk for pressure ulcer
formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient’s capillary refill is less than 2 seconds.
ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation by
making it susceptible to injury. Moisture can originate from wound drainage, excessive
perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can
enhance the opportunity for skin breakdown 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.
DIF: Understand REF: 1177-1178
OBJ: Discuss the risk factors that contribute to pressure ulcer formation.
TOP: Implementation
MSC: Physiological Integrity: Reduction of Risk Potential
,NURS EXAM|SKIN INTEGRITY AND WOULD CARE
QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023
The wound care nurse visits a patient in the long-term care unit. The nurse is
monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and
healthy tissue is observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same
stage and is labeled with the words “healing stage.” Once an ulcer has been staged, the
stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return
to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a
stage III.
DIF: Remember REF: 1178-1179 OBJ: Describe the pressure ulcer staging system.
TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation
The nurse is admitting an older patient from a nursing home. During the assessment,
the nurse notes a shallow open ulcer without slough on the right heel of the patient. This
pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV.
ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss
involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an
abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over
a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but
bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss
with exposed bone, tendon, or muscle.
DIF: Remember REF: 1178-1179 OBJ: Describe the pressure ulcer staging system.
TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation
, NURS EXAM|SKIN INTEGRITY AND WOULD CARE
QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023
The nurse is completing a skin assessment on a patient with darkly pigmented skin.
Which of the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to
accurately complete the first step in assessment—inspection—and the whole assessment
process. Natural light or a halogen light is recommended. Fluorescent light sources can
produce blue tones on darkly pigmented skin and can interfere with an accurate
assessment. Other items that could possibly be used during the assessment include gloves
for infection 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.
DIF: Understand REF: 1179 OBJ: Describe the pressure ulcer staging system.
TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation
The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a
pressure ulcer takes time to heal and is an example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.
ANS: C
Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar
formation because the deeper structures do not regenerate, hence the need for full-
thickness repair. The full-thickness repair has three phases: inflammatory, proliferative,
and remodeling. A wound heals by primary intention when wounds such as surgical
wounds have little tissue loss; the skin 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
