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2024 NUR 155 SKIN INTEGRITY AND WOUND CARE EXAM WITH CORRECT ANSWERS
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2024 NUR 155 SKIN INTEGRITY AND WOUND CARE EXAM WITH CORRECT ANSWERS
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2024 NUR 155 SKIN INTEGRITYAND WOUND CARE EXAM WITH
CORRECT ANSWERS
Stage 1 Pressure Ulcer - CORRECT-ANSWERSnonblanchable erythema of
intact skin
stage 2 pressure ulcer - CORRECT-ANSWERSPartial-thickness skin loss
involving epidermis or dermis, abrasion, blister, or shallow crater.
stage 3 pressure ulcer - CORRECT-ANSWERSFull-thickness pressure ulcer
extending into the subcutaneous tissue and resembling a crater. May see
subcutaneous fat but not muscle, bone, or tendon.
stage 4 pressure ulcer - CORRECT-ANSWERSFull-thickness tissue loss with
exposed bone, muscle, or tendon. This can have undermining
Unstageable/Unclassified Pressure Ulcer - CORRECT-ANSWERS•Full thickness
or tissue loss-depth is unknown
•The depth of the ulcer is obscured by slough ( this is yellow, tan, gray,
green, or brown) and/or ( this can be tan, brown, black)
yellow sclera indicates - CORRECT-ANSWERSliver disease
Generalized edema is most often an indication of impaired ___ circulation
and in some cases reflects cardiac dysfunction or venous abnormalities. -
CORRECT-ANSWERSvenous
pitting edema - CORRECT-ANSWERSdivide the depth of pitting in half to
determine the grading scale *2mm = 1+
Diaphoretic skin - CORRECT-ANSWERSsweaty
yellow nails indicate - CORRECT-ANSWERSPossible fungal infection
Skin lesions: macule, patch - CORRECT-ANSWERSFlat un-elevated change in
color
Skin lesions: Papule - CORRECT-ANSWERSCircumscribed Solid elevation of
skin
, warts, acne, pimples, elevated moles
Skin lesions: Plaque - CORRECT-ANSWERSLarger then 1cm
psoriasis, rubeola
Skin lesions: Nodule - CORRECT-ANSWERSElevated, solid, hard mass that
extends deeper into the dermis than a papule.
squamous cell carcinoma
Skin Lesions: Pustule - CORRECT-ANSWERSVesicle or bulla filled with puss
acne vulgaris, impetigo
skin lesions: vesicle, bulla - CORRECT-ANSWERScircumscribed, round or oval,
thin translucent mass filled with serous fluid or blood
Skin Lesions: cyst - CORRECT-ANSWERS1 cm or larger, elevated,
encapsulated fluid filled or semisolid mass
Skin Lesions: Wheal - CORRECT-ANSWERSA reddened localized collection of
edema fluid: irregular in shape
hives, mosquito bites, urticaria
Skin lesions: skin tag - CORRECT-ANSWERS
Skin Lesions: keloid - CORRECT-ANSWERS
Skin lesions: Striae - CORRECT-ANSWERS
Skin lesions: Vitiligo - CORRECT-ANSWERS
Nursing diagnoses - CORRECT-ANSWERS•Risk for Impaired Skin Integrity
•Impaired Skin Integrity
•Impaired Tissue Integrity
•Risk for Infection
•Acute Pain
Cold therapy - CORRECT-ANSWERS•promote vasoconstriction
•slows bacterial growth
•decreases inflammation
•used for sprains, fractures, and swelling
•The effects of cold are shivering.
• Cold applications can be in the form of cold packs, ice bags, ice gloves, and
ice collars.
Heat and Cold Therapy must have____ ______ - CORRECT-ANSWERSdoctors
orders
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