NSG 300 Topic 4 Review Questions and
Answers
Pressure Injury ✅impaired skin integrity related to unrelieved, prolonged pressure
Skin microbiome affecting skin integrity ✅temperature, humidity, airflow, nutrition,
perfusion, comorbidities, and condition of soft tissue.
At risk for pressure injury... ✅decreased mobility, decreased sensory perception, fecal
or urinary incontinence, poor nutrition, and altered LOC
Shear ✅the sliding movement of skin and subcutaneous tissue while the underlying
muscle and bone are stationary
Shear Occurs when ✅the head of the bed is elevated, and the sliding of the skeleton
starts but the skin is fixed because of friction with the bed
Friction ✅The force of two surfaces moving across one another such as the
mechanical force exerted when skin is dragged across a coarse surface such as bed
linens. Can be referred to as sheet burn
Friction effects the... ✅epidermis (top layer of the skin)/superficial skin loss
sources of moisture include... ✅wound drainage, urine, stool, perspiration, wound
exudate, mucus, or saliva
Stage 1 Pressure injury ✅non-blanchable erythema of intact skin
stage 2 pressure injury ✅partial-thickness skin loss with exposed dermis
stage 4 pressure injury ✅full-thickness skin and tissue loss
unstageable pressure injury ✅full-thickness skin and tissue loss but extent of damage
cannot be confirmed due to slough or eschar. Stage 3 or 4 will be revealed.
Deep-tissue pressure injury ✅intact or non-intact skin with persistent non-blanchable
deep red, maroon, or purple discoloration or blood filled blister. May evolve rapidly or
resolve. Can be classified as unstageable, stage 3, or stage 4.
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