Chapter 48: Skin Integrity and Wound
Care Practice questions And All Correct
Answers.
1. The nurse is working on a medical-surgical unit that has been participating in a research project
associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to
pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain. - Answer ANS: B
Patients who are confused or disoriented or who have changing levels of consciousness are unable to
protect themselves. The patient may feel the pressure but may not understand what to do to relieve the
discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception,
impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath,
muscular pain, and a diet low in calories and fat are not included among the predisposing factors.
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient
sustained a head injury and is unconscious. The nurse is able to identify that the major element involved
in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight. - Answer ANS: A
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to
pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the
intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel,
causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure
over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging
effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages
acquire skin breakdown) are not major causes of pressure ulcers.
3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?
,a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds. - Answer ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation by making it
susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or
urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown
because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for
nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised
red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin,
which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin
breakdown, but this capillary response is within normal limits.
4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient
with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How
would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer - Answer ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is
labeled with the words "healing stage." Once an ulcer has been staged, the stage endures even as the
ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage such as stage I or II. This
ulcer is healing, so it is no longer labeled a stage III.
5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes
a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged
as stage
a. I.
b. II.
c. III.
d. IV. - Answer ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving
epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or
, shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III
pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage
IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the
following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light - Answer ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete
the first step in assessment—inspection—and the whole assessment process. Natural light or a halogen
light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and
can interfere with an accurate assessment. Other items that could possibly be used during the
assessment include gloves for infection control, a disposable measuring device to measure the size of the
wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first
item used.
7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer
takes time to heal and is an example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention. - Answer ANS: C
Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation
because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-
thickness repair has three phases: inflammatory, proliferative, and remodeling. A wound heals by
primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are
approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-
thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis.
These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when
a wound is left open for several days, and then the wound edges approximated. Wound closure is
delayed until risk of infection is resolved.
