306 Exam (final Chapters)

Question 1

Top sites for pressure injury risks

Answer 1

Heels
Ankles
Hips
Sacral area
Elbows
Shoulders
Inside of knees
Occipital
Ears.

Question 2

What 6 things does the Braden scale assess In pressure injuries

Answer 2

Sensory
Moisture
Activity
Mobility
Nutrition
Friction and shear

Question 3

If a patient score a 9 or less on the Braden scale what does that mean?

Answer 3

They are at a very high risk of getting a pressure injury

Question 4

If a patient scores in between 19-23 on the Braden scale what does it mean?

Answer 4

Not much of a risk at all of getting a pressure injury

Question 5

How many layers deep is the epidermis over the palms of hands and soles of feet?
Over the rest of the body?

Answer 5

5 layers over palms of hands and soles of feet.
4 layers over the rest of the body

Question 6

Which layer of skin consists of the papillary layer and the reticular layer?

(This layer also contains the hair follicles and eccrine sweat glands)

Answer 6

The dermis.

Question 7

What layer of skin contains nerves, arteries and veins.
It also contains adipose tissue.

Answer 7

Subcutaneous tissue

Question 8

What internal factors can influence the appearance of skin and skin integrity?

Answer 8

Age
Genetics
Individuals underlying health

Question 9

What is vernix caseosa ?

Answer 9

The protective covering on newborn skin in utero.

Question 10

Excessive body heat increases the metabolic rate and the cells need for oxygen. T/f

Answer 10

True. And it puts client T risk for pressure injuries.

Question 11

What laboratory test should you anticipate being prescribed for a patient with a stage 3 pressure injury that reports pain at the site which has developed a yellow-white exudate?

Answer 11

Complete blood count.
This would indicate if there was an elevated white blood count which would point to a possible infection and used to determine the degree of inflammation.

Question 12

What dressing would you use for a pressure wound with deep exudate that will form a gel when in contact with the wound exudate?

Answer 12

Alginate dressings form a gel when in contact with wound exudate.

Question 13

Should bony prominences be massaged to help prevent pressure wounds?

Answer 13

No.

Question 14

What is Granulex?

Answer 14

A product that increases blood supply to the intact skin of stage 1 pressure injury. It toughens skin, adds moisture, and contains trypsin to aid in removal of necrotic tissue.

Question 15

Petroleum lotions or ointments should be avoided. T/f?

Answer 15

True

Question 16

Even slight weight shift of only 10-15 degrees every 15-30 minutes can help promote circulation. T/f?

Answer 16

True

Question 17

What does larval therapy do for a pressure ulcer?

Answer 17

They decrease bacterial growth and break down necrotic tissue while keeping healthy tissue intact.

Question 18

What kind of debridement causes the least damage to healthy and healing tissue surrounding the pressure injury?

Answer 18

Autolytic debridement

Question 19

A patient with diabetes mellitis has a blister on the left heel caused by Ill fitting shoes. What stage should you document this injury to be?

Answer 19

Stage 2

Question 20

A patient has a pressure injury over the sacrum. What assessment finding would indicate that this is a stage 3 injury?

Answer 20

Necrosis of subcutaneous tissue.

Question 21

What assessment finding of a wound would indicate it as a stage 4 injury?

Answer 21

Exposed muscle and bone.

Question 22

For patients who are confined to bed, what kind of support surface should be used?

Answer 22

A kinetic bed that provides oscillation therapy.

Question 23

If a patient presents with a lower limb that is dusky red colored when the limb is lowered, what does this suggest

Answer 23

Arterial insufficiency

Question 24

If a patient has cool skin to the touch and mild edema, and dependent rubor. What would this suggest.

Answer 24

Arterial insufficiency

Question 25

A blood lactic acid level is commonly measured to identify what?

Answer 25

Possible sepsis

Question 26

Impetigo is an infectious bacteria skin condition.
T/f

Answer 26

True

Question 27

A superficial skin infection common in children that presents as an itchy rash with clusters of fluid filled vesicles that rupture easily. Common on face, arms, and legs.

Answer 27

Impetigo

Question 28

Otoacoustic emissions testing is for what?

Answer 28

Newborn and infant hearing screening.

Question 29

Risk factors for cataracts

Answer 29

Age
Genetics
Sunlight exposure
Smoking
Alcohol
Eye trauma
Diabetes
Corticosteroids

Question 30

Primary prevention

Answer 30

Methods designed to focus on health promotion and illness prevention

Question 31

Secondary prevention

Answer 31

Methods that focus on the diagnosis and treatment of disease.

Question 32

Tertiary prevention

Answer 32

Methods that focus on restoration of health following an Illness or accident. Like rehab or palliative services.

Question 33

What is the relationship of nutrition to pressure injury development

Answer 33

Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure injuries.

Question 34

A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. What stage is this?

Answer 34

UNSTAGEABLE.
(A stage 4 pressure wound may be covered in eschar but cannot be evaluated if wound bed is obscured with extensive tissue damage)
Eschar is not present in stage 2.
Stage 3 might have eschar with tissue damage limited to subcutaneous tissue.

Question 35

A patient has a localized purple discoloration that does not blanch over the coccyx. What pressure injury would be suspected?

Answer 35

Deep tissue injury
(Does not blanch. Skin intact. Thin blister or eschar can develop very quickly)