76 Questions
Which factor does NOT affect skin integrity according to the text?
Types of wounds
What is the largest organ in the body according to the text?
Skin
Which factor can impair skin integrity?
Corticosteroids medication
What is one of the functions of intact skin according to the text?
Maintaining health
Which condition makes skin on the legs damage more easily?
Impaired peripheral arterial circulation
What type of wound is caused by accidental trauma?
Unintentional wound
Skin color and allergies are examples of factors related to which aspect of skin integrity?
Genetics & heredity
What is the impact of poor nutrition on skin integrity?
Impairs skin integrity
In what way do chronic illnesses affect skin integrity?
Impair peripheral arterial circulation
What is the main purpose of understanding factors affecting skin integrity for nurses?
To prevent injury
What are some measures mentioned in the text to promote optimal skin condition?
Understanding factors affecting skin integrity
Which medication is specifically highlighted in the text as affecting skin integrity?
Corticosteroids
What is the maximum score on the Braden Scale?
23 points
What does a Braden Scale score of ≤ 18 points indicate?
High risk
Which of the following is NOT one of the subscales in the Braden Scale?
Moisture
What is the main purpose of a Risk Assessment Tool in pressure ulcer prevention?
To identify individuals at risk for pressure ulcers
What does a Norton Scale score between 14-10 indicate?
High risk
In nursing management, what is assessed during the diagnosing phase related to skin integrity?
Color of the wound bed
What is recommended for preventing pressure ulcers regarding skin hygiene?
Avoid hot water
What is a common nursing intervention for preventing pressure ulcers related to repositioning?
Providing supportive devices like mattresses and pillows
What should be done at each dressing change when treating a pressure ulcer?
Clean the ulcer and surrounding skin with surgical asepsis
What should be considered for medication in the treatment of pressure ulcers?
Consider systemic antibiotics for evidence of infection
What does a Norton Scale score > 18 indicate?
Low risk
What is essential in assessing pressure ulcers regarding nursing management?
Color of the wound bed and location of necrosis
Which type of wound involves accidental wounds and surgical wounds with a major break in sterile technique?
Contaminated wounds
What does an 'Incision' type of wound involve?
Open wound with deep or shallow tissue penetration by a sharp instrument
Which position is considered common for pressure ulcers?
Supine position
What is the defining characteristic of Stage I pressure ulcers?
Non blanchable erythema
Which type of wound involves tissue torn apart and often occurs from accidents?
Laceration
What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?
Visible slough that obscures the depth of tissue loss
What causes Pressure Ulcers?
Localized ischemia due to blood supply deficiency
'Dirty or infected wounds' are characterized by:
Evidence of infection like purulent drainage
Why is it important for nurses to understand the factors affecting skin integrity?
To promote optimal skin condition and prevent injury
Which factor does NOT affect skin integrity according to the text?
Medication administration
How do chronic illnesses affect skin integrity?
They impair peripheral arterial circulation leading to easy skin damage
What aspect of skin integrity do skin color and allergies fall under?
Genetics & heredity
What should be done at each dressing change when treating a pressure ulcer?
Document the wound's progress
What is the impact of poor nutrition on skin integrity?
It delays wound healing and impairs skin regeneration
What type of wound is characterized by open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique?
Contaminated wounds
In the context of wound classification, which wound type typically involves tissues that are torn apart and often occurs from accidents?
Laceration
What does a 'Partial-thickness' wound involve?
Loss of epidermis and dermis
Which position is NOT considered common as a pressure site leading to pressure ulcers?
Supine position
What is the characteristic of a Stage II pressure ulcer?
Partial-thickness loss of epidermis and dermis
What does 'Iatrogenesis' refer to in the context of describing wounds?
How the wounds were acquired
What is the maximum score on the Norton Scale for assessing pressure ulcers?
20 points
Which subscale is NOT part of the Braden Scale for pressure ulcer risk assessment?
Pain Perception
In the context of pressure ulcers, what does 'Unstageable' mean?
Depth of ulcer obscured by slough or eschar
What is the primary factor considered in determining a client's risk level according to the Norton Scale?
Mobility
What is the significance of a Braden Scale score of 18 points?
Low risk for developing pressure ulcers
What should be the first step in any pressure ulcer prevention model according to the text?
Using risk assessment tools
How does the Norton Scale categorize individuals with scores between 14-10 points?
High risk for pressure ulcers
Which factor is NOT mentioned as affecting skin integrity in the text?
Blood type
What is the defining characteristic of a Stage II pressure ulcer according to the text?
Partial-thickness wound with a loss of dermis
In what way do chronic illnesses impact skin integrity according to the text?
By making the skin on the legs prone to damage
What type of wound is characterized by open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique?
Contaminated wound
Which wound description involves an open wound penetrating the skin and often the underlying tissues by a sharp instrument?
Puncture
What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?
Skin loss with necrosis or damage to tendon, muscle, or bone
What is the maximum score on the Norton Scale for assessing pressure ulcers?
20 points
What is the main purpose of using risk assessment tools in pressure ulcer prevention?
Identifying clients at risk
What does 'Suspected deep tissue injury' in pressure ulcers refer to?
Purple or maroon area with intact skin
What is an essential aspect of nursing intervention in treating pressure ulcers?
Repositioning the client regularly
What is the maximum score on the Norton Scale for assessing pressure ulcers?
20 points
In the Braden Scale, what is the significance of a score of 18 points?
At risk for pressure ulcers
What is the primary factor considered in determining a client's risk level according to the Norton Scale?
General physical condition
What is a common nursing intervention for preventing pressure ulcers related to repositioning?
Providing smooth and wrinkle-free foundation
What does 'Full-thickness Tissue Loss' involve in the context of pressure ulcers?
Loss of skin or tissue depth unknown
What factors can affect skin integrity, as discussed in the text?
Chronic illnesses and medications like corticosteroids
Why is it important for nurses to understand the factors affecting skin integrity?
To promote optimal skin condition and prevent injuries
Which aspect of skin is impacted by poor nutrition according to the text?
Skin color and allergies
How are 'clean-contaminated wounds' described in the text?
Uninfected wounds with minimal inflammation
What is the characteristic of a 'Contusion' injury as described in the text?
It is a closed wound resulting in ecchymosis (bruising)
Which factor contributes to Pressure Ulcers according to the text?
Decreased mobility
What is the significance of a Braden Scale score of 23 points?
Low risk of developing pressure ulcers
In the context of nursing management, what does 'Risk for Infection' imply?
The client is immunocompromised and prone to infection
What is the main purpose of 'Preventing PUs' as mentioned in the text?
To implement strategies to avoid pressure ulcer development
Which component is NOT part of the Braden Scale for assessing pressure ulcer risk?
Presence of slough or eschar
Learn about the factors influencing skin integrity, identification of clients at risk for pressure ulcers, types of wounds, and the four stages of pressure ulcer development. Explore how to apply the nursing process to patients with skin issues.
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