Chapter 37: Skin Integrity and Wound Care

Chapter 37: Skin Integrity and Wound Care

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. An elderly patient is admitted to the hospital for a bowel obstruction. The patient is immobile and the nurse notices that there is a reddened area on the right heel. When the nurse presses on the area it does not turn lighter in color. How should the nurse document the tissue condition?

a.	Reactive hyperemia
b.	Blanchable hyperemia
c.	Nonblanchable hyperemia
d.	Tissue ischemia

 

 

ANS:   C

Nonblanchable hyperemia is redness that persists after palpation and indicates tissue damage. When you press a finger against the red or purple area, it does not turn lighter in color. Deep tissue damage is present and is commonly the first stage of pressure ulcer development. Reactive hyperemia is a redness of the skin resulting from dilation of the superficial capillaries. Reactive hyperemia blanches. In blanchable hyperemia, the area that appears red and warm will blanch (turn lighter in color) following fingertip palpation. Tissue ischemia, decreased blood flow to tissue, usually results in tissue death and occurs when capillary blood flow is obstructed, as in the case of pressure.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    1062                OBJ:    Describe risk factors for pressure ulcer development.

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity

 

2. The student nurse asks a nursing assistive personnel (NAP) to help move a patient up in bed. The student nurse instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation?

a.	Friction
b.	Shear
c.	Moisture
d.	Tunneling

 

 

ANS:   B

Shear is the force exerted against the skin while the skin remains stationary and the bony structures move. For example, when the head of the bed is elevated, gravity causes the bony skeleton to pull toward the foot of the bed, while the skin remains against the sheets. Friction is surface damage caused by the skin rubbing against another surface that often results in an abrasion. Friction would result if the patient is dragged across the sheets. Skin moisture increases the risk for ulcer formation as moisture softens the skin and reduces its resistance to other physical factors such as pressure or shear. Moisture comes from many sources such as wound drainage, perspiration, and/or fecal and urinary incontinence. With continuous pressure over the area, deep tissue destruction continues, which often results in larger pockets of necrotic tissue beneath the opening of the main wound that resemble a tunnel; this is referred to as tunneling.

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    1062 | 1063     OBJ:    Describe risk factors for pressure ulcer development.

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Safe and Effective Care Environment

 

3. An elderly patient has been admitted to the hospital for pneumonia. Which factor could put this patient at risk for a pressure ulcer?

a.	A diet low in protein
b.	Braden Scale results of 22
c.	Primary health care provider orders that read “activity as tolerated”
d.	Being repositioned every 2 hours

 

 

ANS:   A

Poor nutrition, specifically severe protein deficiency, causes soft tissue to become susceptible to breakdown. Low protein levels cause edema or swelling, which contributes to problems with the transportation of oxygen and nutrients. A hospitalized adult with a score of 16 or below and an older adult at 18 or below are at risk for pressure ulcer development; a score of 22 does not place the patient at risk. A patient with decreased mobility, inadequate nutrition, excessive skin moisture, decreased sensory perception, or decreased activity is at risk for pressure ulcer development. Repositioning a patient every 2 hours will help prevent pressure ulcers. Activity as tolerated will help prevent pressure ulcers.

 

PTS:    1                      DIF:    Cognitive Level: Analyzing (Analysis)

REF:    1063                OBJ:    Describe risk factors for pressure ulcer development.

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

 

4. A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone. The nurse should document this pressure ulcer at what stage?

a.	Stage I
b.	Stage II
c.	Stage III
d.	Stage IV

 

 

ANS:   D

Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling

Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence

Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister

Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling

 

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    1063

OBJ:    List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Physiological Integrity