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Skin Integrity and Pressure Ulcers Quiz

Test your knowledge on factors affecting skin integrity, identifying clients at risk for pressure ulcers, different types of wounds, and the four stages of pressure ulcer development. Learn how to apply the nursing process to patients with skin issues.

Created by
@Darling talent
1/31
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Questions and Answers

Which type of wound involves surgical wounds in which the respiratory, alimentary, genital, and urinary tracts have been entered but shows no evidence of infection?

Clean-contaminated wounds

What type of wound involves a blow from a blunt instrument causing the skin to appear ecchymosed?

Contusion

Which position is considered a common pressure site leading to pressure ulcers?

Supine position

What does reactive hyperemia indicate in the context of pressure ulcers?

<p>Increased blood supply to the area</p> Signup and view all the answers

Which stage of pressure ulcers involves non-blanchable erythema but intact skin?

<p>Stage I</p> Signup and view all the answers

In which type of wound are the edges often uneven, and tissues are torn apart?

<p>Laceration</p> Signup and view all the answers

Which term describes a combination of friction and pressure resulting in skin injury?

<p>Shearing force</p> Signup and view all the answers

What is the depth described in a wound that involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone?

<p>Full thickness</p> Signup and view all the answers

Which type of wound results from skin injury over bony prominences due to force alone or in combination with movement?

<p>Pressure ulcer</p> Signup and view all the answers

What type of wound involves a skin injury that usually affects bony prominences due to localized ischemia?

<p>Pressure ulcer</p> Signup and view all the answers

Which type of wound shows evidence of inflammation and may contain dead tissue and purulent drainage?

<p>Dirty wound</p> Signup and view all the answers

What characterizes Full-thickness skin loss in Pressure Ulcers?

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

What is the maximum score in the Norton Scale risk assessment tool?

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

Which scale includes subscales like sensory perception, moisture, and activity?

<p>Braden Scale</p> Signup and view all the answers

What is considered at risk according to the Braden Scale?

<p>Scores ≤ 18 points</p> Signup and view all the answers

Which nursing intervention is recommended for preventing pressure ulcers?

<p>Repositioning every 2 hours</p> Signup and view all the answers

What is the main purpose of assessing the location of an ulcer in relation to a bony prominence?

<p>To assess pressure distribution</p> Signup and view all the answers

Which nursing diagnosis may be related to trauma or immobility?

<p>Impaired Tissue Integrity</p> Signup and view all the answers

What should be used to clean wounds during each dressing change?

<p>Surgical asepsis</p> Signup and view all the answers

What should be avoided when maintaining skin hygiene to prevent pressure ulcers?

<p>'Babypowder' for friction</p> Signup and view all the answers

Which organ is referred to as the largest in the body?

<p>Skin</p> Signup and view all the answers

What refers to the presence of normal skin uninterrupted by wounds?

<p>Intact skin</p> Signup and view all the answers

Which factor affecting skin integrity includes sensitivity to sunlight?

<p>Genetics</p> Signup and view all the answers

What is a type of wound that can occur unintentionally due to accidents?

<p>Traumatic wound</p> Signup and view all the answers

Which factor can lead to impaired peripheral arterial circulation affecting skin on the legs?

<p>Chronic illnesses</p> Signup and view all the answers

What is a common medication that might affect skin integrity?

<p>Corticosteroids</p> Signup and view all the answers

Pressure ulcers are often linked to prolonged:

<p>Periods of sitting or lying down</p> Signup and view all the answers

In the context of skin integrity, what does poor nutrition contribute to?

<p>Wound healing complications</p> Signup and view all the answers

What physiological impact does activity level have on skin integrity?

<p>Improved circulation</p> Signup and view all the answers

What plays a role in the color of an individual's skin?

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

What type of medication can compromise the body's immune response, affecting skin health?

<p>Corticosteroids</p> Signup and view all the answers

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