Skin Integrity and Wound Care Exam
Questions; with Answers
What are some nursing diagnoses related to skin integrity and wound care? - Answer
impaired tissue integrity related to sacral pressure ulcer, impaired skin integrity related
to surgical incision, risk for infection related to impaired skin integrity
Which term would the nurse use to document wound drainage that is thick, odorous,
and green? - Answer purulent
What are the three layers of the skin? - Answer epidermis, dermis, subcutaneous tissue
What are the functions of the skin? - Answer protection, temperature regulation,
psychosocial, sensation, vitamin D production, immunological, absorption, elimination
How does skin protect? - Answer acts as a barrier, prevents infection and injury, loss of
moisture; first line of defense; any breech decreases protection
What affects skin integrity? - Answer developmental level, circulation, mobility, state of
health, medical interventions
What are the developmental factors in infants? - Answer skin is thinner, weaker, more
susceptible to infection
What are developmental factors in older adults? - Answer thinner, dryer skin; delayed
healing time, less elastic
, How does circulation affect skin integrity? - Answer promotes long skin cell life;
immobility decreases circulation to tissues; decreased circulation leads to inadequate
cell nutrition
How does state of health affect skin integrity? - Answer Physical stature: very thin and
obese; reduced sensation: temp, pressure, friction; dehydration/malnutrition:
adequately nourished/hydrated skin cells are more resistant to injury; diseases:
decreased sensation/increased risk of skin complication; mental status: may affect
sensation, ability understand instructions; skin moisture: diaphoresis, incontinence
What are the types of wounds? - Answer Intentional, unintentional, open, closed, acute,
chronic
What are the phases of wound healing? - Answer hemostasis, inflammatory phase,
proliferation phase, maturation phase
Describe hemostasis - Answer occurs immediately after tissue injury; blood vessels
constrict, clotting begins; capillary permeability increases; exudate causes swelling/pain;
increased perfusion causes redness and heat
Describe the inflammatory phase - Answer 4-6 days, phagocytosis of bacteria and
cellular debris; macrophages release growth factors for new cells
Describe the proliferation phase - Answer fibroblastic, regenerative, connective tissue
phase; several weeks; synthesize collagen and produce growth factors to form blood
vessels and endothelial cells; capillaries grow across wound; granulation tissues
Describe the maturation phase - Answer ~day 21; collagen is remodeled to make wound
stronger, new collagen deposited, compresses blood vessels
Questions; with Answers
What are some nursing diagnoses related to skin integrity and wound care? - Answer
impaired tissue integrity related to sacral pressure ulcer, impaired skin integrity related
to surgical incision, risk for infection related to impaired skin integrity
Which term would the nurse use to document wound drainage that is thick, odorous,
and green? - Answer purulent
What are the three layers of the skin? - Answer epidermis, dermis, subcutaneous tissue
What are the functions of the skin? - Answer protection, temperature regulation,
psychosocial, sensation, vitamin D production, immunological, absorption, elimination
How does skin protect? - Answer acts as a barrier, prevents infection and injury, loss of
moisture; first line of defense; any breech decreases protection
What affects skin integrity? - Answer developmental level, circulation, mobility, state of
health, medical interventions
What are the developmental factors in infants? - Answer skin is thinner, weaker, more
susceptible to infection
What are developmental factors in older adults? - Answer thinner, dryer skin; delayed
healing time, less elastic
, How does circulation affect skin integrity? - Answer promotes long skin cell life;
immobility decreases circulation to tissues; decreased circulation leads to inadequate
cell nutrition
How does state of health affect skin integrity? - Answer Physical stature: very thin and
obese; reduced sensation: temp, pressure, friction; dehydration/malnutrition:
adequately nourished/hydrated skin cells are more resistant to injury; diseases:
decreased sensation/increased risk of skin complication; mental status: may affect
sensation, ability understand instructions; skin moisture: diaphoresis, incontinence
What are the types of wounds? - Answer Intentional, unintentional, open, closed, acute,
chronic
What are the phases of wound healing? - Answer hemostasis, inflammatory phase,
proliferation phase, maturation phase
Describe hemostasis - Answer occurs immediately after tissue injury; blood vessels
constrict, clotting begins; capillary permeability increases; exudate causes swelling/pain;
increased perfusion causes redness and heat
Describe the inflammatory phase - Answer 4-6 days, phagocytosis of bacteria and
cellular debris; macrophages release growth factors for new cells
Describe the proliferation phase - Answer fibroblastic, regenerative, connective tissue
phase; several weeks; synthesize collagen and produce growth factors to form blood
vessels and endothelial cells; capillaries grow across wound; granulation tissues
Describe the maturation phase - Answer ~day 21; collagen is remodeled to make wound
stronger, new collagen deposited, compresses blood vessels
