NUFT 204 Exam #2 Questions With Complete Solutions

Skin integrity/wound care, activity/immobility, assessment techniques, head/neck/neuro assessment & respiratory assessment define blanching: correct answer: pressure is placed on the skin to determine if coloration returns *blanch= become pale under applied pressure 3 factors that influence pathogenesis of pressure: correct answer: - pressure intensity (increased pressure) - pressure duration (length of pressure) - tissue tolerance (nutrition, age, hydration status) 3 layers of skin: correct answer: - epidermis (top layer) - dermis (inner layer) - epidermal junction (separates dermis/epidermis) what does blanchable mean? non-blanachable? correct answer: - skin turns pale when pressure is applied (indicates tissue perfusion) - skin remains red when pressure is applied (indicates high risk for ulcers) how can hydration be tested? what areas can be tested? correct answer: - pinching the skin; if it returns quickly, hydration is indicated - hand/clavicle ____ is the mechanical force exerted when skin is dragged across a coarse surface, such as bed linens correct answer: friction define shear: correct answer: force exerted parallel to skin _____ is pulling the bones of the pelvis in one direction and the skin in the opposite direction correct answer: shear can shear injury be examined? why? correct answer: no; happens beneath the skin stage 1 pressure ulcer: correct answer: intact skin with nonblanchable redness may include changes in skin temperature, tissue consistency, and/or sensation stage 2 pressure ulcer: correct answer: partial-thickness skin loss involving epidermis, dermis, or both stage 3 pressure ulcer: correct answer: full-thickness skin loss with visible fat (*with or without undermining and tunneling; drainage and infection common)