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Fundamentals of Nursing: Skin Integrity and Wound Care exam solved 100%

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Fundamentals of Nursing: Skin Integrity and Wound Care exam solved 100% The skin is the body's largest organ, accounting for ____ of the total body weight: -Correct Answer-15% Skin provides: -Correct Answer-- A protective barrier against disease-causing organisms - A sensory organ for pain, te...

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  • August 6, 2024
  • 14
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • Skin Integrity and Wound Care
  • Skin Integrity and Wound Care
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Fundamentals of Nursing: Skin Integrity
and Wound Care exam solved 100%
The skin is the body's largest organ, accounting for ____ of the total body weight: -Correct Answer-15%



Skin provides: -Correct Answer-- A protective barrier against disease-causing organisms

- A sensory organ for pain, temperature, and touch

- Vitamin D synthesis



The skin has two layers: -Correct Answer-- Epidermis

- Dermis



Epidermis -Correct Answer-Top layer of the skin



Dermis -Correct Answer-Inner layer of skin that provides tensile strength and mechanical support and
protection to underlying muscles, bones, and organs.

- Made of collagen, blood vessels, and nerves



Collagen -Correct Answer-Tough, fibrous protein

- Fibroblasts (which are responsible for collagen formation)



Pressure Ulcer -Correct Answer-Localized injury to the skin and underlying tissue over a bony
prominence as a result of pressure or pressure in combination of shear and/or friction.

Ex. sacrum, greater trochanter



Blanching -Correct Answer-Occurs when normal red tones of skin are absent.

*Does not occur in dark-skinned patients.*



Identify the pressure related factors that contribute to pressure ulcer development: (3) -Correct Answer--
Pressure intensity

, - Pressure duration

- Tissue tolerance



Identify risk factors that predispose a patient to pressure ulcer formation. -Correct Answer-- Impaired
sensory perception

- Impaired mobility

- Alteration in level of consciousness (LOC)

- Shear

- Friction

- Moisture



Any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary
incontinence, and/or poor nutrition is at risk for _________________________. -Correct Answer-
pressure ulcer development



Staging systems for pressure ulcers are based on the depth of tissue destroyed. Briefly describe each
stage. -Correct Answer-*Stage I:* Intact skin with non-blanchable redness

*Stage II:* Partial-thickness skin loss involving epidermis, dermis, or both

*Stage III:* Full thickness tissue loss with visible fat

*Stage IV:* Full-thickness tissue loss with exposed bone, muscle, or tendon

*Unstageable/Unclassified:* Full-thickness Skin or Tissue Loss (Depth Unknown)

*Suspected Deep-Tissue Injury* (Depth Unknown)



Stage I: Nonblanchable Redness -Correct Answer-- Intact skin presents with nonblanchable redness of a
localized area usually over a bony prominence.

- Discoloration of the skin, warmth, edema, hardness, or pain may also be present.

- Darkly pigmented skin may not have visible blanching but its coloring may differ from the surrounding
area.

- The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

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