Fundamentals of Nursing: Skin Integrity
and Wound Care exam solved 100%
The skin is the body's largest organ, accounting for ____ of the total body weight: -Correct Answer-15%
Skin provides: -Correct Answer-- A protective barrier against disease-causing organisms
- A sensory organ for pain, temperature, and touch
- Vitamin D synthesis
The skin has two layers: -Correct Answer-- Epidermis
- Dermis
Epidermis -Correct Answer-Top layer of the skin
Dermis -Correct Answer-Inner layer of skin that provides tensile strength and mechanical support and
protection to underlying muscles, bones, and organs.
- Made of collagen, blood vessels, and nerves
Collagen -Correct Answer-Tough, fibrous protein
- Fibroblasts (which are responsible for collagen formation)
Pressure Ulcer -Correct Answer-Localized injury to the skin and underlying tissue over a bony
prominence as a result of pressure or pressure in combination of shear and/or friction.
Ex. sacrum, greater trochanter
Blanching -Correct Answer-Occurs when normal red tones of skin are absent.
*Does not occur in dark-skinned patients.*
Identify the pressure related factors that contribute to pressure ulcer development: (3) -Correct Answer--
Pressure intensity
, - Pressure duration
- Tissue tolerance
Identify risk factors that predispose a patient to pressure ulcer formation. -Correct Answer-- Impaired
sensory perception
- Impaired mobility
- Alteration in level of consciousness (LOC)
- Shear
- Friction
- Moisture
Any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary
incontinence, and/or poor nutrition is at risk for _________________________. -Correct Answer-
pressure ulcer development
Staging systems for pressure ulcers are based on the depth of tissue destroyed. Briefly describe each
stage. -Correct Answer-*Stage I:* Intact skin with non-blanchable redness
*Stage II:* Partial-thickness skin loss involving epidermis, dermis, or both
*Stage III:* Full thickness tissue loss with visible fat
*Stage IV:* Full-thickness tissue loss with exposed bone, muscle, or tendon
*Unstageable/Unclassified:* Full-thickness Skin or Tissue Loss (Depth Unknown)
*Suspected Deep-Tissue Injury* (Depth Unknown)
Stage I: Nonblanchable Redness -Correct Answer-- Intact skin presents with nonblanchable redness of a
localized area usually over a bony prominence.
- Discoloration of the skin, warmth, edema, hardness, or pain may also be present.
- Darkly pigmented skin may not have visible blanching but its coloring may differ from the surrounding
area.
- The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.
and Wound Care exam solved 100%
The skin is the body's largest organ, accounting for ____ of the total body weight: -Correct Answer-15%
Skin provides: -Correct Answer-- A protective barrier against disease-causing organisms
- A sensory organ for pain, temperature, and touch
- Vitamin D synthesis
The skin has two layers: -Correct Answer-- Epidermis
- Dermis
Epidermis -Correct Answer-Top layer of the skin
Dermis -Correct Answer-Inner layer of skin that provides tensile strength and mechanical support and
protection to underlying muscles, bones, and organs.
- Made of collagen, blood vessels, and nerves
Collagen -Correct Answer-Tough, fibrous protein
- Fibroblasts (which are responsible for collagen formation)
Pressure Ulcer -Correct Answer-Localized injury to the skin and underlying tissue over a bony
prominence as a result of pressure or pressure in combination of shear and/or friction.
Ex. sacrum, greater trochanter
Blanching -Correct Answer-Occurs when normal red tones of skin are absent.
*Does not occur in dark-skinned patients.*
Identify the pressure related factors that contribute to pressure ulcer development: (3) -Correct Answer--
Pressure intensity
, - Pressure duration
- Tissue tolerance
Identify risk factors that predispose a patient to pressure ulcer formation. -Correct Answer-- Impaired
sensory perception
- Impaired mobility
- Alteration in level of consciousness (LOC)
- Shear
- Friction
- Moisture
Any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary
incontinence, and/or poor nutrition is at risk for _________________________. -Correct Answer-
pressure ulcer development
Staging systems for pressure ulcers are based on the depth of tissue destroyed. Briefly describe each
stage. -Correct Answer-*Stage I:* Intact skin with non-blanchable redness
*Stage II:* Partial-thickness skin loss involving epidermis, dermis, or both
*Stage III:* Full thickness tissue loss with visible fat
*Stage IV:* Full-thickness tissue loss with exposed bone, muscle, or tendon
*Unstageable/Unclassified:* Full-thickness Skin or Tissue Loss (Depth Unknown)
*Suspected Deep-Tissue Injury* (Depth Unknown)
Stage I: Nonblanchable Redness -Correct Answer-- Intact skin presents with nonblanchable redness of a
localized area usually over a bony prominence.
- Discoloration of the skin, warmth, edema, hardness, or pain may also be present.
- Darkly pigmented skin may not have visible blanching but its coloring may differ from the surrounding
area.
- The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.
