Exam 1: NSG316 / NSG 316 (Latest Update ) Health Assessment Exam | Questions and Verified Answers | 100% Correct | Grade A - GCU Question: Pressure Ulcers Answer: Stage I - non-blanchable erythema - intact skin is red but unbroken. localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure. dark skin appears darker but does not blanch. may have changes in sensation, temperature, or firmness Stage II - partial -thickness skin loss - loss of epidermis and exposed dermis. superficial ulcer looks shallow like an abrasion or open blister with a red -pink wound bed. no visible fat or deeper tissue Stage III - full-thickness skin loss - PI extends into subcutaneous tissue and resembles a crater. see subcutaneous fat, granulation tissue, and rolled edges, but not muscle, bone, or tendon Stage IV - full-thickness skin/tissue loss - PI involves all skin layers and extends into supporting tissue. exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue), rolled edge s, and tunneling Question: Stage I Pressure Ulcers Answer: non-blanchable erythema - intact skin is red but unbroken. localized redness in lightly pigmented skin does not blanch (turn light with fingertip pressure. dark skin appears darker but does not blanch. may have changes in sensation, temperature, or firmne ss Question: Stage II Pressure Ulcers Answer: partial -thickness skin loss - loss of epidermis and exposed dermis. superficial ulcer looks shallow like an abrasion or open blister with a red -pink wound bed. no visible fat or deeper tissue Question: Stage III Pressure Ulcer Answer: full-thickness skin loss - PI extends into subcutaneous tissue and resembles a crater. see subcutaneous fat, granulation tissue, and rolled edges, but not muscle, bone, or tendon Question: Stage IV Pressure Ulcer Answer: full-thickness skin/tissue loss - PI involves all skin layers and extends into supporting tissue. exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue), rolled edges, and tun neling Question: Stages of Bruising Answer: 1) Pink and red - immediately after a blow, such as banging your shin on a step or your arm on the door; area is swollen and tender to touch 2) Blue and dark purple - within a day or so of impact; caused by both low oxygen supplies and swelling at the bruising site 3) Pale green - around the sixth day → sign of hemoglobin breaking down; also means the healing process has begun 4) Yellow and brown - seventh day from the time of injury → last stage of your body's re -absorption process; bruise won't change color again, it will gradually fade away 5) Brown to disappearing Question: Nociceptive pain Answer: a. Develops when function and intact nerve fibers in the periphery and the CNS are stimulated b. Is triggered by events outside the nervous system from actual or potential tissue damage c. Nociception can be divided into four phases: transduction, transmission, perception, and modulation Question: Transduction Answer: Noxious stimuli
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