Factors Affecting Skin Integrity and Pressure Ulcers
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Questions and Answers

Which factor does NOT affect skin integrity according to the text?

  • Age
  • Genetics
  • Types of wounds (correct)
  • Chronic illnesses

What is the largest organ in the body according to the text?

  • Heart
  • Liver
  • Lung
  • Skin (correct)

Which factor can impair skin integrity?

  • Good nutrition
  • Young age
  • Corticosteroids medication (correct)
  • Regular physical activity

What is one of the functions of intact skin according to the text?

<p>Maintaining health (D)</p> Signup and view all the answers

Which condition makes skin on the legs damage more easily?

<p>Impaired peripheral arterial circulation (D)</p> Signup and view all the answers

What type of wound is caused by accidental trauma?

<p><strong>Unintentional</strong> wound (B)</p> Signup and view all the answers

Skin color and allergies are examples of factors related to which aspect of skin integrity?

<p><strong>Genetics &amp; heredity</strong> (D)</p> Signup and view all the answers

What is the impact of poor nutrition on skin integrity?

<p><strong>Impairs skin integrity</strong> (B)</p> Signup and view all the answers

In what way do chronic illnesses affect skin integrity?

<p><strong>Impair peripheral arterial circulation</strong> (C)</p> Signup and view all the answers

What is the main purpose of understanding factors affecting skin integrity for nurses?

<p><strong>To prevent injury</strong> (A)</p> Signup and view all the answers

What are some measures mentioned in the text to promote optimal skin condition?

<p>Understanding factors affecting skin integrity (D)</p> Signup and view all the answers

Which medication is specifically highlighted in the text as affecting skin integrity?

<p>Corticosteroids (A)</p> Signup and view all the answers

What is the maximum score on the Braden Scale?

<p>23 points (C)</p> Signup and view all the answers

What does a Braden Scale score of ≤ 18 points indicate?

<p>High risk (B)</p> Signup and view all the answers

Which of the following is NOT one of the subscales in the Braden Scale?

<p>Moisture (D)</p> Signup and view all the answers

What is the main purpose of a Risk Assessment Tool in pressure ulcer prevention?

<p>To identify individuals at risk for pressure ulcers (C)</p> Signup and view all the answers

What does a Norton Scale score between 14-10 indicate?

<p>High risk (D)</p> Signup and view all the answers

In nursing management, what is assessed during the diagnosing phase related to skin integrity?

<p>Color of the wound bed (A)</p> Signup and view all the answers

What is recommended for preventing pressure ulcers regarding skin hygiene?

<p>Avoid hot water (C)</p> Signup and view all the answers

What is a common nursing intervention for preventing pressure ulcers related to repositioning?

<p>Providing supportive devices like mattresses and pillows (B)</p> Signup and view all the answers

What should be done at each dressing change when treating a pressure ulcer?

<p>Clean the ulcer and surrounding skin with surgical asepsis (B)</p> Signup and view all the answers

What should be considered for medication in the treatment of pressure ulcers?

<p>Consider systemic antibiotics for evidence of infection (B)</p> Signup and view all the answers

What does a Norton Scale score > 18 indicate?

<p>Low risk (D)</p> Signup and view all the answers

What is essential in assessing pressure ulcers regarding nursing management?

<p>Color of the wound bed and location of necrosis (D)</p> Signup and view all the answers

Which type of wound involves accidental wounds and surgical wounds with a major break in sterile technique?

<p>Contaminated wounds (D)</p> Signup and view all the answers

What does an 'Incision' type of wound involve?

<p>Open wound with deep or shallow tissue penetration by a sharp instrument (A)</p> Signup and view all the answers

Which position is considered common for pressure ulcers?

<p>Supine position (C)</p> Signup and view all the answers

What is the defining characteristic of Stage I pressure ulcers?

<p>Non blanchable erythema (A)</p> Signup and view all the answers

Which type of wound involves tissue torn apart and often occurs from accidents?

<p>Laceration (C)</p> Signup and view all the answers

What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?

<p>Visible slough that obscures the depth of tissue loss (B)</p> Signup and view all the answers

What causes Pressure Ulcers?

<p>Localized ischemia due to blood supply deficiency (B)</p> Signup and view all the answers

'Dirty or infected wounds' are characterized by:

<p>Evidence of infection like purulent drainage (C)</p> Signup and view all the answers

Why is it important for nurses to understand the factors affecting skin integrity?

<p>To promote optimal skin condition and prevent injury (B)</p> Signup and view all the answers

Which factor does NOT affect skin integrity according to the text?

<p>Medication administration (C)</p> Signup and view all the answers

How do chronic illnesses affect skin integrity?

<p>They impair peripheral arterial circulation leading to easy skin damage (C)</p> Signup and view all the answers

What aspect of skin integrity do skin color and allergies fall under?

<p>Genetics &amp; heredity (A)</p> Signup and view all the answers

What should be done at each dressing change when treating a pressure ulcer?

<p>Document the wound's progress (B)</p> Signup and view all the answers

What is the impact of poor nutrition on skin integrity?

<p>It delays wound healing and impairs skin regeneration (D)</p> Signup and view all the answers

What type of wound is characterized by open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique?

<p>Contaminated wounds (A)</p> Signup and view all the answers

In the context of wound classification, which wound type typically involves tissues that are torn apart and often occurs from accidents?

<p>Laceration (D)</p> Signup and view all the answers

What does a 'Partial-thickness' wound involve?

<p>Loss of epidermis and dermis (D)</p> Signup and view all the answers

Which position is NOT considered common as a pressure site leading to pressure ulcers?

<p>Supine position (A)</p> Signup and view all the answers

What is the characteristic of a Stage II pressure ulcer?

<p>Partial-thickness loss of epidermis and dermis (D)</p> Signup and view all the answers

What does 'Iatrogenesis' refer to in the context of describing wounds?

<p>How the wounds were acquired (D)</p> Signup and view all the answers

What is the maximum score on the Norton Scale for assessing pressure ulcers?

<p>20 points (D)</p> Signup and view all the answers

Which subscale is NOT part of the Braden Scale for pressure ulcer risk assessment?

<p>Pain Perception (C)</p> Signup and view all the answers

In the context of pressure ulcers, what does 'Unstageable' mean?

<p>Depth of ulcer obscured by slough or eschar (C)</p> Signup and view all the answers

What is the primary factor considered in determining a client's risk level according to the Norton Scale?

<p>Mobility (C)</p> Signup and view all the answers

What is the significance of a Braden Scale score of 18 points?

<p>Low risk for developing pressure ulcers (B)</p> Signup and view all the answers

What should be the first step in any pressure ulcer prevention model according to the text?

<p>Using risk assessment tools (A)</p> Signup and view all the answers

How does the Norton Scale categorize individuals with scores between 14-10 points?

<p>High risk for pressure ulcers (D)</p> Signup and view all the answers

Which factor is NOT mentioned as affecting skin integrity in the text?

<p>Blood type (C)</p> Signup and view all the answers

What is the defining characteristic of a Stage II pressure ulcer according to the text?

<p>Partial-thickness wound with a loss of dermis (B)</p> Signup and view all the answers

In what way do chronic illnesses impact skin integrity according to the text?

<p>By making the skin on the legs prone to damage (A)</p> Signup and view all the answers

What type of wound is characterized by open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique?

<p>Contaminated wound (C)</p> Signup and view all the answers

Which wound description involves an open wound penetrating the skin and often the underlying tissues by a sharp instrument?

<p>Puncture (C)</p> Signup and view all the answers

What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?

<p>Skin loss with necrosis or damage to tendon, muscle, or bone (D)</p> Signup and view all the answers

What is the maximum score on the Norton Scale for assessing pressure ulcers?

<p>20 points (A)</p> Signup and view all the answers

What is the main purpose of using risk assessment tools in pressure ulcer prevention?

<p>Identifying clients at risk (C)</p> Signup and view all the answers

What does 'Suspected deep tissue injury' in pressure ulcers refer to?

<p>Purple or maroon area with intact skin (A)</p> Signup and view all the answers

What is an essential aspect of nursing intervention in treating pressure ulcers?

<p>Repositioning the client regularly (C)</p> Signup and view all the answers

What is the maximum score on the Norton Scale for assessing pressure ulcers?

<p>20 points (C)</p> Signup and view all the answers

In the Braden Scale, what is the significance of a score of 18 points?

<p>At risk for pressure ulcers (A)</p> Signup and view all the answers

What is the primary factor considered in determining a client's risk level according to the Norton Scale?

<p>General physical condition (D)</p> Signup and view all the answers

What is a common nursing intervention for preventing pressure ulcers related to repositioning?

<p>Providing smooth and wrinkle-free foundation (A)</p> Signup and view all the answers

What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?

<p>Loss of skin or tissue depth unknown (D)</p> Signup and view all the answers

What factors can affect skin integrity, as discussed in the text?

<p>Chronic illnesses and medications like corticosteroids (A)</p> Signup and view all the answers

Why is it important for nurses to understand the factors affecting skin integrity?

<p>To promote optimal skin condition and prevent injuries (B)</p> Signup and view all the answers

Which aspect of skin is impacted by poor nutrition according to the text?

<p>Skin color and allergies (C)</p> Signup and view all the answers

How are 'clean-contaminated wounds' described in the text?

<p>Uninfected wounds with minimal inflammation (D)</p> Signup and view all the answers

What is the characteristic of a 'Contusion' injury as described in the text?

<p>It is a closed wound resulting in ecchymosis (bruising) (C)</p> Signup and view all the answers

Which factor contributes to Pressure Ulcers according to the text?

<p>Decreased mobility (C)</p> Signup and view all the answers

What is the significance of a Braden Scale score of 23 points?

<p>Low risk of developing pressure ulcers (D)</p> Signup and view all the answers

In the context of nursing management, what does 'Risk for Infection' imply?

<p>The client is immunocompromised and prone to infection (B)</p> Signup and view all the answers

What is the main purpose of 'Preventing PUs' as mentioned in the text?

<p>To implement strategies to avoid pressure ulcer development (C)</p> Signup and view all the answers

Which component is NOT part of the Braden Scale for assessing pressure ulcer risk?

<p>Presence of slough or eschar (A)</p> Signup and view all the answers

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