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NURSADN2 Test #1: Study Guide (Questions & Complete Answers)
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NURSADN2 Test #1: Study Guide (Questions &Complete Answers)
Covering integumentary system, wounds, pain physiology, perioperative care,
infection cycle and immunizations
What are the functions of skin? Right Ans - Protection, sensation, fluid
balance, temperature regulation, vitamin production, immune response
function, absorption, elimination
What is vitamin D? Right Ans - Cholecalciferol; a fat soluble vitamin that
helps the body absorb calcium and phosphorus
Vitamin D is particularly helpful in *preventing* which of the following?
A. COVID
B. Osteoporosis
C. Scurvy
D. Anorexia Right Ans - B. Osteoporosis
What role does vitamin D play in the integument? Right Ans - Enables the
body to properly absorb and use calcium, the element needed for proper bone
development and maintenance. Vitamin D also promotes rapid healing of the
skin.
How can one obtain vitamin D? Right Ans - Sun exposure, fortified milk,
fortified cereal, and fatty fish such as salmon, mackerel and sardines.
How does the skin protect the body? Right Ans - It acts as a physical
barrier, prevents fluid loss, prevents the invasion of microorganisms and
protects against UV damage
How does the skin regulate body temperature? Right Ans - Insulation
(hypodermis),
Constriction or Dialation of dermal blood vessels,
Sweating or shivering
,What are the layers of the skin? Right Ans - Epidermis, dermis,
subcutaneous
What are pressure ulcers? Right Ans - Localized area of cellular necrosis
resulting from pressure between any boney prominence and with an external
object.
*Blanchable* redness is considered a what in regard to pressure wounds?
Right Ans - Warning sign
There are 4 stages of pressure wounds, 1 being the least severe. Which stage
would be characterized by *full thickness tissue loss with visible fat/adipose
tissue?* Right Ans - Stage 3
There are 4 stages of pressure wounds, 1 being the least severe. Which stage
would be characterized by *partial thickness skin loss involving epidermis,
dermis, or both?* Right Ans - Stage 2
There are 4 stages of pressure wounds, 1 being the least severe. Which stage
would be characterized by *non-blanchable redness?* Right Ans - Stage 1
There are 4 stages of pressure wounds, 1 being the least severe. Which stage
would be characterized by *full-thickness tissue loss with exposed bone,
muscle, or tendon?* Right Ans - Stage 4
There are 4 stages of pressure wounds, 1 being the least severe. Which stage
would be characterized by *full-thickness skin and tissue loss in which the
extent of tissue damage within the ulcer cannot be confirmed because it is
obscured by slough or eschar*? Right Ans - Unstageable
There are 4 stages of pressure wounds, 1 being the least severe. Which stage
would be characterized by *intact or non-intact skin with localized area of
persistent non-blanchable deep red, maroon, purple discoloration
orepidermal separation revealing a dark wound bed or bloodfilled blister*?
Right Ans - Deep Tissue Injury
What is the Braden scale? Right Ans - Scale that assesses the risk in
numerical scoring based on sensory perception, moisture, activity, mobility,
nutrition, and friction or shearing.
,When assessing for pressure wounds, a nurse should assess what qualities of
the wound? Right Ans - Type, location, thickness, stage, size, length, width,
depth, tunneling (if applicable), drainage/exudate (with amount), odor, tissue
adherence/type, edges, epibole, and presence of tubes or drains
Which of the following is *not* a wound drain?
A. Penrose
B. Hemovac
C. Jackson-Pratt
D. Wound Vac
E. Yankauer Right Ans - E. Yankauer
Penrose drain: Right Ans - A flat, thin, rubber tube inserted into a wound to
allow for fluid to flow from the wound; it has an open end that drains onto a
dressing
Hemovac Drain: Right Ans - A closed drainage system in which a soft drain
is attached to a springlike suction device
Wound Vac: Right Ans - A medical device that applies negative pressure to
a wound to promote healing and prevent infections.
Jackson-Pratt drain: Right Ans - Drainage system that uses a compressed
bulb, applies slight suction within the wound
All of the following need to be a part of a nursing assessment in regard to
wound management, except:
- Evaluate mobility
- GCS Scale Score
- Evaluate circulatory status
- Evaluate neurologic status
- Evaluate nutrition/hydration
- Braden Scale Score Right Ans - GCS Scale Score
, The Braden scale evaluates *what characteristics* of the patient to measure
pressure injury risk? Right Ans - Sensory perception, moisture, activity,
mobility, nutrition, friction and shear
With the Braden scale, the *lower* the score, the... Right Ans - higher the
patient is at risk
A patient is considered *high risk* for impaired skin integrity if the Braden
scale is:
A. 13-14
B. 19+
C. 15-18
D. 10-12 Right Ans - D. 10-12
*True or False?:*
Moist skin can help prevent the occurrence of dermatological injury. Right
Ans - False
Which nutrient is responsible for collagen synthesis?
A. Vitamin A
B. Vitamin C
C. Water
D. Zinc Right Ans - B. Vitamin C
(Remember Vitamin *C*ollagen!)
Which layer of the skin consists of several layers of *stratified squamous
epithelium*? Right Ans - Epidermis
Which cells give *pigment* to the skin? Right Ans - Melanocytes
The skin acts as a host for _______________ flora.
A. Dangerous
B. Harmful
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