NUR 205 EXAM 2 Questions and Correct Answers |
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Largest Organ of the body Ans: The Skin
Two layers of the skin Ans: Epidermis and Dermis
Epidermis Ans: top layer of skin
Stratum Corneum Ans: Outermost layer of the epidermis, which consists
of flattened, keratinized cells
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Define Pressure Ulcers Ans: Described as impaired skin integrity related
to unrelieved, prolonged pressure, usually over a boney prominence
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Pressure Ulcer Risk Factors Ans: -decreased mobility
-decreased sensory perception
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-fecal or urinary incontinence
-poor nutrition
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Individuals at risk for pressure ulcers Ans: -older adults that have
experienced a trauma
-those with spinal cord injuries
-those who have sustained a fractured hip
-those in long-term homes or community care, the acutely ill
-individuals with diabetes
-patients in critical care settings (ICU)
Dermis Ans: inner layer of skin, provides tensile strength, mechanical
support, and protection for the underlying muscles, bones, and organs
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Tissue Ischemia Ans: Pressure applied over a capillary exceeds the
normal capillary pressure, and the vessel is occluded for a prolonged
period of time.
dermal-epidermal junction Ans: separates dermis and epidermis
3 pressure related factors that contribute to pressure ulcer development
Ans: -pressure intensity
-pressure duration
-tissue tolerance
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Non-blanchable hyperemia Ans: redness that persists after palpation and
indicates tissue damage
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Stage 1 Pressure Ulcer Ans: -intact skin with nonblanchable redness
-warm to touch, edema, can be a hardened area
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Stage 2 Pressure Ulcer Ans: -partial thickness skin loss
-shallow but open
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-no slough or drainage
-red/pink wound bed
Stage 3 Pressure ulcer Ans: -full thickness tissue loss with visible
underlying fat
-NO bone, muscle or tendon is visible
-can have slough
-underminning/tunneling
Stage 4 Pressure ulcer Ans: -full thickness tissue loss WITH visible
muscle, bone or tendon