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NURS 356 - EXAM #3 Questions And Correct Answers
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NURS 356 - EXAM #3 Questions And Correct AnswersWhat are the two layers of the skin?
Epidermis & Dermis
What is the epidermis?
top layer of skin
What is the dermis? Composed of?
Inner layer of skin, made of collagen
What is the dermal-epidermal junction?
Separates the dermis and epidermis?
What are the different types of pressure injuries?
Pressure ulcer, decubitus ulcer, or bed sore
What is the pathogenesis of pressure injuries?
Caused by pressure intensity of bony prominences and therefore causes tissue
ischemia and blanching
What are the risk factors for the development of pressure ulcers?
Impaired sensory perception, impaired mobility, alteration in LOC, shear, friction,
moisture
What are the stages of pressure injury?
Stage 1: Non-blanchable erythema of in-tact
Stage 2: Partial thickness skin loss with exposed dermis (adipose and deep tissue not
visible)
Stage 3: full thickness skin loss (granulated tissue + slough INVOLVED)
Stage 4: pressure injury: full-thickness skin and tissue loss (muscles, tendons, bones)
If there is eschar present in the wound what stage would it be?
UNSTAGEABLE
What is slough?
, soft yellow or white sticky substance that clings to the bed of the wound
What is eschar?
thick layer of dead dry tissue; black, brown, tan, necrotic-needs to be removed for
healing
UNSTAGEABLE as the depth of tissue loss is not visible
What is undermining?
area beneath the perimeter skin next to a pressure ulcer, eroded below the wound
edges tissues
What is tunneling?
Is an ulceration that has advanced to the stage of tunneling underneath the skin surface
What is granulation tissue? What does the presence of it mean?
Soft, red moist tissue made up of new blood vessels, presence indicates healing is
taking place
What is exudate?
fluid, cells, and other substances from cells or blood vessels that leaks through small
pores or breaks in cell membranes
What is serous exudate?
clear, watery plasma
What is serosanguinous exudate?
pale, pink, watery; mixture of clear/red fluid
What is purulent exudate?
thick, yellow, green or brown
What is sanguineous exudate?
Bright red; indicates active bleeding
What is healing by primary intention?
surgical incision, sutures, staples, minimal scarring, wound that is closed, heals by
epithelization
What is healing by secondary intention?
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