Skin Integrity and Wound Healing Nclex Test
Questions; with Answers
What does the Braden Scale evaluate?
A. Skin integrity at bony prominences, including any wounds
B. Risk factors that place the patient at risk for skin breakdown
C. The amount of repositioning that the patient can tolerate
D. The factors that place the patient at risk for poor healing - Answer B. Risk
factors that place the patient at risk for skin breakdown
The Braden Scale measures factors in six subscales that can predict the risk of
pressure ulcer development. It does not assess skin or wounds.
On assessing your patient's sacral pressure ulcer, you note that the tissue over the
sacrum is dark, hard, and adherent to the wound edge. What is the correct stage
for this patient's pressure ulcer?
A. Stage II
B. Stage IV
C. Unstageable
, D. Suspected deep tissue damage - Answer C. Unstageable
To determine the stage of a pressure ulcer you examine the depth of the tissue
involvement. Since the pressure ulcer assessed was covered with necrotic tissue,
the depth could not be determined. Thus this pressure ulcer cannot be staged.
When repositioning an immobile patient, the nurse notices redness over a bony
prominence. What is indicated when a reddened area blanches on fingertip touch?
A. A local skin infection requiring antibiotics
B. Sensitive skin that requires special bed linen
C. A stage III pressure ulcer needing the appropriate dressing
D. Blanching hyperemia, indicating the attempt by the body to overcome the
ischemic episode. - Answer D. Blanching hyperemia, indicating the attempt by the
body to overcome the ischemic episode.
When repositioning an immobile patient, it is important to assess all bony
prominences for the presence of redness, which can be the first sign of impaired
skin integrity. Pressing over the area compresses the blood vessels in the area;
and, if the integrity of the vessels is good, the area turns lighter in color and then
returns to the red color. However, if the area does not blanch when pressure is
applied, tissue damage is likely.
Which type of pressure ulcer is noted to have intact skin and may include changes
in one or more of the following: skin temperature (warmth or coolness), tissue
consistency (firm or soft), and/or pain?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV - Answer A. Stage I
Questions; with Answers
What does the Braden Scale evaluate?
A. Skin integrity at bony prominences, including any wounds
B. Risk factors that place the patient at risk for skin breakdown
C. The amount of repositioning that the patient can tolerate
D. The factors that place the patient at risk for poor healing - Answer B. Risk
factors that place the patient at risk for skin breakdown
The Braden Scale measures factors in six subscales that can predict the risk of
pressure ulcer development. It does not assess skin or wounds.
On assessing your patient's sacral pressure ulcer, you note that the tissue over the
sacrum is dark, hard, and adherent to the wound edge. What is the correct stage
for this patient's pressure ulcer?
A. Stage II
B. Stage IV
C. Unstageable
, D. Suspected deep tissue damage - Answer C. Unstageable
To determine the stage of a pressure ulcer you examine the depth of the tissue
involvement. Since the pressure ulcer assessed was covered with necrotic tissue,
the depth could not be determined. Thus this pressure ulcer cannot be staged.
When repositioning an immobile patient, the nurse notices redness over a bony
prominence. What is indicated when a reddened area blanches on fingertip touch?
A. A local skin infection requiring antibiotics
B. Sensitive skin that requires special bed linen
C. A stage III pressure ulcer needing the appropriate dressing
D. Blanching hyperemia, indicating the attempt by the body to overcome the
ischemic episode. - Answer D. Blanching hyperemia, indicating the attempt by the
body to overcome the ischemic episode.
When repositioning an immobile patient, it is important to assess all bony
prominences for the presence of redness, which can be the first sign of impaired
skin integrity. Pressing over the area compresses the blood vessels in the area;
and, if the integrity of the vessels is good, the area turns lighter in color and then
returns to the red color. However, if the area does not blanch when pressure is
applied, tissue damage is likely.
Which type of pressure ulcer is noted to have intact skin and may include changes
in one or more of the following: skin temperature (warmth or coolness), tissue
consistency (firm or soft), and/or pain?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV - Answer A. Stage I
