Ch. 23 Patients w/ Skin Problems

Question 1

At what elevation should the HOB be to prevent pressure injuries?

Answer 1

< 30 degrees

Question 2

Stage 1 Pressure Injury

Answer 2

Intact skin w/ localized area of non-blanch able erythema

Question 3

Stage 2 Pressure Injury

Answer 3

Partial-thickness loss of skin w/ exposed dermis

Wound bed is viable, pink or red, and moist

Looks like intact or ruptured serum-filled blister

Question 4

Stage 3 Pressure Injury

Answer 4

Full thickness skin loss w/ adipose visible in injury

Granulation tissue and rolled wound edges

Slough and/or eschar

Subcutaneous tissues may be damaged or necrotic

Question 5

Stage 4 Pressure Injury

Answer 5

Full-thickness skin loss w/ exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone

May have slough or eschar

Rolled edges, undermining, or tunneling may be present

Question 6

If slough or scar obscures the extent of tissue loss, what is it considered as?

Answer 6

Unstageable pressure injury

Question 7

Deep Tissue Injury

Answer 7

Intact or non-intact skin w/ a localized area

Persistent non-blanch able, deep red, maroon, purple, or discoloration

Epidermal separation revealing a dark wound bed or blood filled blister

Question 8

Herpes Simplex 1

Answer 8

Contact and standard precautions until lesions are dry and crusted

Question 9

Smoke-Related Burn

Answer 9

Occurs on inhalation and can cause edema that impairs breathing (ABC priority)

Question 10

What is the priority with any respiratory burn?

Answer 10

AIRWAY (ABCs)

Question 11

Respiratory Patients w/ Severe Inhalation Injuries

Answer 11

Rapid destruction that w/in a short time they cannot force air through narrowed airways

Wheezing sounds may disappear

Indicates airway obstruction and requires immediate intubation

Question 12

Inhalation Injury

Answer 12

Inhalation