Review Practice Exercise 2

Inflammation And Wound Healing > Adult Health

Exam Review

Practice Exercise 2

Share This Link

Share on social media

Facebook

Messager

WhatsApp

Share URL
Copy

We are excited to announce the release of a NEW VERSION OF THE SYSTEM! To benefit from the latest features, improvements, and component updates, please switch to the new system as soon as possible.

Visit Latest Version

Total Questions : 5

Showing 5 questions, Sign in for more

Question 1:

Select all the modifiable risk factors for the development of pressure ulcers. Select all that apply

A. Immobility B. Age C. Incontinence D. Nutritional status E. Sensory perception deficits

Answer and Explanation

Choice A:

Immobility: Regular repositioning, mobility exercises, and assistive devices can significantly reduce ulcer risk.

Choice B:

Age: Older adults are more susceptible due to thinner skin and comorbidities, but age itself cannot be changed.

Choice C:

Incontinence: Moisture from urine or feces breaks down skin; managing continence and protecting the skin can prevent ulcers.

Choice D:

Nutritional status: Adequate nutrition supports skin integrity and wound healing; deficiencies increase ulcer susceptibility.Rationale for incorrect answers:

Choice E:

Sensory perception deficits: Conditions like neuropathy reduce the ability to feel pressure, but the underlying deficit cannot be reversed (though compensatory measures can help).

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 2:

The primary etiological factor in the development of a pressure ulcer is:

A. Shear force, which is the stretching of the blood vessels. B. Friction, which is the rubbing of skin against a surface. C. Compression of soft tissue between a bony prominence and an external surface. D. Moisture, which leads to skin maceration. E. Sensory perception deficits

Answer and Explanation

Choice A:

Shear force, which is the stretching of the blood vessels: Shear exacerbates injury by distorting tissues and damaging blood vessels, but it is secondary to direct pressure.

Choice B:

Friction, which is the rubbing of skin against a surface: Friction removes superficial skin layers, increasing vulnerability but does not directly cause deep tissue ischemia.

Choice C:

Compression of soft tissue between a bony prominence and an external surface: Continuous pressure obstructs blood supply, depriving tissues of oxygen and nutrients, which leads to ischemia and necrosis.Rationale for incorrect answers:

Choice D:

Moisture, which leads to skin maceration: Moisture weakens the skin and increases susceptibility to pressure injury but is not the initiating cause.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 3:

A nurse assesses a patient's sacral area and observes a shallow, open ulcer with a red-pink wound bed and no slough. This ulcer is best described as a:

A. Stage 1 pressure ulcer. B. Stage 2 pressure ulcer. C. Stage 3 pressure ulcer. D. Unstageable pressure ulcer.

Answer and Explanation

Choice A:

Stage 1 pressure ulcer: Involves non-blanchable erythema of intact skin, without ulceration or open wound.

Choice B:

Stage 2 pressure ulcer: Defined by partial-thickness skin loss involving the epidermis and/or dermis, presenting with a red-pink wound bed without slough.Rationale for incorrect answers:

Choice C:

Stage 3 pressure ulcer: Involves full-thickness skin loss with possible exposure of subcutaneous fat but no bone, tendon, or muscle.

Choice D:

Unstageable pressure ulcer: The wound base is obscured by slough or eschar, preventing accurate staging until debridement.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 4:

A nurse assesses a pressure ulcer that is completely covered by thick, black eschar. Which of the following statements are true regarding this type of ulcer?

A. The true stage of the ulcer cannot be determined. B. The wound bed is likely to be a Stage 2 or 3 ulcer beneath the eschar. C. Debridement is necessary to determine the stage. D. The wound is likely to heal by secondary intention.

Answer and Explanation

Choice A:

The true stage of the ulcer cannot be determined: The eschar blocks visibility of the wound base, making staging impossible until removal.

Choice B:

The wound bed is likely to be a Stage 2 or 3 ulcer beneath the eschar: The actual depth could range from Stage 3 to Stage 4; it cannot be assumed without direct visualization.

Choice C:

Debridement is necessary to determine the stage: Without removing the necrotic tissue, the extent of damage cannot be assessed.

Choice D:

The wound is likely to heal by secondary intention: This type of wound closes gradually through granulation tissue formation, contraction, and epithelialization.Rationale for incorrect answer:

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Question 5:

A nurse is using the Braden Scale to assess a patient's risk for developing a pressure ulcer. A lower score on the Braden Scale indicates:

A. Lower risk for pressure ulcer development. B. Higher risk for pressure ulcer development. C. The patient's skin is intact. D. The patient is fully mobile.

Answer and Explanation

Choice A:

Lower risk for pressure ulcer development: A higher, not lower, Braden score indicates reduced risk.

Choice B:

Higher risk for pressure ulcer development: Scores of 18 or lower typically signal increased risk, with lower numbers indicating more severe risk factors.Rationale for incorrect answers:

Choice C:

The patient's skin is intact: Skin status is assessed separately; intact skin does not guarantee a low risk for ulcers.

Choice D:

The patient is fully mobile: Mobility is one factor in the scale, but the total score considers multiple risk factors.

Discussion Section

Posting as Anonymous or Login Here

0 Pulse Checks

No comments

Sign Up or Login to view all the 5 Questions on this Exam

Join over 100,000+ nursing students using Naxlex’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.

Exam Review

Practice Exercise 2 Share this Share This Link Share on social media Facebook Messager WhatsApp Share URL Copy Close

Total Questions : 5

Sign Up or Login to view all the 5 Questions on this Exam

Practice Exercise 2

Share This Link

Share on social media

Facebook

Messager

WhatsApp

Share URL
Copy