NUR 155 EXAM 3 TEST BANK /
300+ QUESTIONS AND CORRECT
ANSWERS 2025 GRADED A+
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1. What does not compromised skin mean ? ANSWER Not open, not wet
2. With diabetes what skin issues can we see? ANSWER Poor circulation, neuropathy
3. Skin Integrity ca...
NUR 155 EXAM 3 TEST BANK /
300+ QUESTIONS AND CORRECT
ANSWERS 2025 GRADED A+
LATEST UPDATE (BEST FOR
REVISION ) !!!
,1. What does not compromised skin mean ? ANSWER Not open, not wet
2. With diabetes what skin issues can we see? ANSWER Poor circulation, neuropathy
3. Skin Integrity can be affected by ANSWER Genetics/Heredity, Age,
Chronic Illness and their treatments Medications,
Poor nutrition
4. What chronic illnesses can affect skin integrity ANSWER Diabetes, Psoriasis
5. What are risk factors associated with skin integrity? ANSWER Friction and shearing Immobility
Poor Nutrition
Incontinence
Poor mental status Poor
sensation Excessive body heat
Advanced age
Chronic medical conditions
6. What are the types of wounds? ANSWER Clean Clean -
Contaminated
Contaminated Dirty/Infected
7. Clean Wounds are ANSWER uninfected wounds in which there is minimal inflammation and the respiratory,
gastrointestinal, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds.
8. Clean - Contaminated wounds are ANSWER surgical wounds in which the respiratory, gastrointestinal, genital,
or urinary tract has been entered. Such wounds show no evidence of infection
9. Contaminated wounds are ANSWER open, fresh, accidental wounds and surgical wounds involving a major break
in sterile technique or a large amount of spillage from the gastrointestinal tract. Contaminated wounds show evidence of
inflammation
10. Dirty or infected wounds are ANSWER wounds containing dead tissue and wounds with evidence of a clinical
infection, such as purulent drainage.
11. What are pressure ulcers ANSWER Injury to skin and or underlying tissue (usually) over a bony prominence
12. What causes pressure ulcers ANSWER decreased blood flow to the area
13. Why does decreased blood flow cause pressure ulcers ANSWER Lack of oxygen means tissue breakdown
and tissue death
14. Stage 1 Pressure ulcers are ANSWER nonblanchable, erythema (redness is not blanch- able and does not go away)
, 15. What is erythema ANSWER superficial redness
16. Incisions ANSWER Cause - Sharp instrument
Description - Open wound, deep or shallow
17. Contusion ANSWER Cause - blow from a blunt instrument Description - Closed
wound, skin looks bruised (ecchymotic)
18. Abrasion ANSWER Cause - Surface scrap Description -
Open wound involving the skin
19. Puncture ANSWER Cause - Penetration of the skin and often underlying tissues from a sharp instruments
Description - Open wound
20. Laceration ANSWER Cause - Tissues torn apart Description -
Open wound, edges are often jagged
21. Penetrating wound ANSWER Cause - Penetration of the skin and the underlying tissues (bullets, metal fragments)
Description - Open wound
22. Stage 2 Pressure Ulcer ANSWER Partial Thickness skin loss(loose top layer of skin), You can still regenerate and
heal with little harm.
23. Stage 3 Pressure ulcer ANSWER Full thickness skin loss, damage of necrosis of subq tissue that can extend to
the fascia
24. Stage 4 pressure ulcer ANSWER Full thickness with tissue loss (necrosis) or damage to muscle, bone, or
supporting structures
25. Unstageable or unclassified Pressure ulcer ANSWER Full thickness or tissue loss depth is unknown, The
depth of the ulcer is obscured by slough
26. Suspected deep tissue injury ANSWER Depth unknown, purple or maroon localized area of discolored intact
skin or blood filled blister to underlying soft tissue from pressure and or sheer
27. A low Braden Scale Score means ANSWER The patient is at a higher risk for pressure ulcers
28. A high Braden Scale Score means ANSWER The patient is at a lower risk for pressure ulcers
29. Poor nutrition can affect the patients risk of pressure ulcers ANSWER Hypoproteine- mia causes edema, that
increases the risk for pressure sores
30. Phases of wound healing ANSWER Inflammatory Phase
Proliferative Phase
Maturation Phase
31. Inflammation Phase ANSWER Hemostasis occurs - blood vessels constrict to control bleeding
Macrophages are activated and phagocytosis takes place - getting rid of bacteria
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