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NSG 3023 CHAPTER 37 QUIZ
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NSG 3023 CHAPTER 37 QUIZChapter 37: Skin Integrity and Wound Care
Potter: Essentials for Nursing Practice, 8th Edition
MULTIPLE CHOICE
1. An elderly patient is admitted to the hospital for a bowel obstruction. The patient is
immobile and the nurse notices that there is a reddened area on the right heel. When the
nurse presses on the area it does not turn lighter in color. How should the nurse document
the tissue condition?
a. Reactive hyperemia
b. Blanchable hyperemia
c. Nonblanchable hyperemia
d. Tissue ischemia
ANS: C
Nonblanchable hyperemia is redness that persists after palpation and indicates tissue
damage. When you press a finger against the red or purple area, it does not turn lighter in
color. Deep tissue damage is present and is commonly the first stage of pressure ulcer
development. Reactive hyperemia is a redness of the skin resulting from dilation of the
superficial capillaries. Reactive hyperemia blanches. In blanchable hyperemia, the area that
appears red and warm will blanch (turn lighter in color) following fingertip palpation.
Tissue ischemia, decreased blood flow to tissue, usually results in tissue death and occurs
when capillary blood flow is obstructed, as in the case of pressure.
PTS: 1 DIF: Cognitive Level: Applying (Application)
REF: 1062 OBJ: Describe risk factors for pressure ulcer development.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
2. The student nurse asks a nursing assistive personnel (NAP) to help move a patient up in bed.
The student nurse instructs the NAP to position the patient in bed to avoid which of the
following factors that would contribute to pressure ulcer formation?
a. Friction
b. Shear
c. Moisture
d. Tunneling
ANS: B
, Shear is the force exerted against the skin while the skin remains stationary and the bony
structures move. For example, when the head of the bed is elevated, gravity causes the bony
skeleton to pull toward the foot of the bed, while the skin remains against the sheets.
Friction is surface damage caused by the skin rubbing against another surface that often
results in an abrasion. Friction would result if the patient is dragged across the sheets. Skin
moisture increases the risk for ulcer formation as moisture softens the skin and reduces its
resistance to other physical factors such as pressure or shear. Moisture comes from many
sources such as wound drainage, perspiration, and/or fecal and urinary incontinence. With
continuous pressure over the area, deep tissue destruction continues, which often results in
larger pockets of necrotic tissue beneath the opening of the main wound that resemble a
tunnel; this is referred to as tunneling.
PTS: 1 DIF: Cognitive Level: Applying (Application)
REF: 1062 | 1063 OBJ: Describe risk factors for pressure ulcer development.
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
3. An elderly patient has been admitted to the hospital for pneumonia. Which factor could put
this patient at risk for a pressure ulcer?
a. A diet low in protein
b. Braden Scale results of 22
c. Primary health care provider orders that read “activity as tolerated”
d. Being repositioned every 2 hours
ANS: A
Poor nutrition, specifically severe protein deficiency, causes soft tissue to become
susceptible to breakdown. Low protein levels cause edema or swelling, which contributes to
problems with the transportation of oxygen and nutrients. A hospitalized adult with a score
of 16 or below and an older adult at 18 or below are at risk for pressure ulcer development;
a score of 22 does not place the patient at risk. A patient with decreased mobility,
inadequate nutrition, excessive skin moisture, decreased sensory perception, or decreased
activity is at risk for pressure ulcer development. Repositioning a patient every 2 hours will
help prevent pressure ulcers. Activity as tolerated will help prevent pressure ulcers.
PTS: 1 DIF: Cognitive Level: Analyzing (Analysis)
REF: 1063 OBJ: Describe risk factors for pressure ulcer development.
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
4. A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open
with exposed bone. The nurse should document this pressure ulcer at what stage?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: D
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar
may be present; often includes undermining and tunneling
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