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CCBC Nursing 153: Exam Two Prep | Questions and Answers Latest {} A+ Graded | 100% Verified
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CCBC Nursing 153: Exam Two Prep | Questions and Answers Latest {} A+ Graded | 100% Verified
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CCBC Nursing 153: Exam Two Prep | Questions and Answers Latest {2024- 2025} A+Graded | 100% Verified
What are the 5 functions of the skin? - **Think PTSSD**
1. Protection (1st line of defense)
2. Thermoregulation
3. Sensation (heat, cold, pressure, pain, contact)
4. Secretion/Excretion
5. Vitamin D formation
What are 9 factors that affect skin integrity? - 1. Age
2. Mobility
3. Moisture of the skin
4. Nutrition and Hydration
5. Diminished Sensation or Cognition (ex, a diabetic patient who doesn't understand the disease
process)
6. Impaired Circulation
7. Fever
8. Lifestyle
9. Medications
When it comes to skin integrity, any break in the skin can lead to infection. What are the 2 focuses of the
nurse regarding the skin? - 1. Protecting the skin.
2. Maintaining skin integrity.
What are the 3 factors that can cause a break in skin integrity? - 1. Traumatic injuries.
2. Surgery.
3. Pressure.
,What are the 3 layers that make up normal skin? - 1. Epidermis
2. Dermis
3. Subcutaneous Fat Layer
Top layer, avascular, receives nutrition from the dermis, epithelial cells on this layer are constantly being
replaced to protect against pathogens. - Epidermis
2nd layer, provides strength and mechanical support. - Dermis
Fatty tissue that provides cushioning. - Subcutaneous
When performing a skin assessment, what are the 9 factors that should be evaluated? - 1. Color: pallor,
erythema (redness), jaundice, cyanosis.
2. Temperature: Warm or Cold.
3. Moisture
4. Odor
5. Turgor
6. Vascularity
7. Edema
8. Lesions
9. Texture/thickness
There are two types of wounds in regards to skin INTEGRITY, what are they? - 1. Closed wound
2. Open wound
When the epidermis and dermis remain intact. Ex, a bruise or contusion. - Closed wound
,When there is a break in the skin or mucous membrane. - Open Wound
What are 3 types of open wounds? - 1. Laceration
2. Abrasion.
3. Puncture
A tearing injury, usually with irregular wound edges. These wounds are usually contaminated with
debris, dirt, or bacteria. Ex, a scratch. - Laceration
SUPERFICIAL, involves the scraping or rubbing of superficial layers of the skin. Ex, a skinned knee. -
Abrasion
a PENETRATING injury due to a pointed object without a blade; depth is greater than length. Ex, an ice
pick puncture wound - Puncture
In regards to skin integrity, what is the term used to describe a closed, intentional surgical incision? - An
APPROXIMATED incision
In regards to the HEALING TIME of a wound, what are the two types of wounds? - 1. Acute Wound
2. Chronic Wound
This wound heals on its own over a short duration, proceeds through an orderly and timely reparative
process, and in a healthy person it usually heals w/o complications. This wound can be a result of
trauma or a surgical incision. - Acute Wound
This wound takes a lonngggg time to heal and usually exceeds the expected length of recovery. It fails to
proceed through an orderly and timely reparative process, and healing is usually interrupted due to
, infection, continued trauma, ischemia, or edema. Ex, pressure, arterial, venous, and diabetic ulcers. -
Chronic Wound
In regards to WOUND CONTAMINATION, what are the 3 types of wounds? - 1. Clean
2. Clean Contaminated
3. Contaminated
UNCONTAMINATED. This wound contains no pathogenic organisms and does not include areas going
into the GI, GU, respiratory, or oral-pharyngeal cavities. - Clean
A wound made under ASEPTIC CONDITIONS, but involving a body cavity that normally harbors
microorganisms so it DOES include the GI, GU, respiratory, and oral-pharyngeal cavities. - Clean
Contaminated
Involves a MAJOR BREAK in aseptic technique; open traumatic wounds not under controlled conditions.
Ex, spillage from GI tract or a ruptured appendix - Contaminated
In regards to the DEPTH of wounds, what are the two types? - 1. Partial-thickness
2. Full-thickness
Wounds that are SHALLOW, involving loss of the epidermis and possibly partial loss of the dermis. This
wound type heals be REGENERATION. Ex, Stage II wounds. - Partial-thickness
Wounds that extend into the DERMIS and into deeper tissues (subcutaneous fat and muscle). This
wound type heals by SCAR FORMATION because deep skin structures do not regenerate. - Full-thickness
What are the 3 different PROCESSES of wound healing? - 1. Primary Intention
2. Secondary Intention
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