Blanchable - Study guides, Class notes & Summaries

Exam 2: NSG122/ NSG 122 (Latest 2024/ 2025 Update) Nursing Fundamental Concepts Exam Review| Questions and Verified Answers| 100% Correct| Grade A- Herzing Q: This scale evaluates: - Skin integrity at bony prominences, including any wounds - Risk factors that place pt at risk for skin breakdown - Amount of repositioning that the pt can tolerate - Factors that place the pt at risk for poor healing Answer: Braden Scale Q: Signs of a healthy wound Answer: Edges of a health...

NUFT 204 Exam 2 (Latest ) Actual Questions and Answers 100% Correct 1. define blanching: Answer: pressure is placed on the skin to determine if colorationreturns *blanch= become pale under applied pressure 2. 3 factors that influence pathogenesis of pressure: Answer: - pressure intensity (in-creased pressure) - pressure duration (length of pressure) - tissue tolerance (nutrition, age, hydration status) 3. 3 layers of skin: Answer: - epidermis (top layer) - dermis (inner layer) - ...

NURS 221 - Final Exam What is wound dehiscence? A partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers What is a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers called? Dehiscence What is wound evisceration? A dehiscence that involves the protrusion of visceral organs through a wound opening What is a dehiscence that involves the protrusion of visceral organs thro...

NR 224 QUIZ 2 ACTUAL EXAM LATEST UPDATED QUESTIONS AND CORRECTLY HIGHLIGHTED ANSWERS ALREADY GRADED A+… What is the rule regarding pressure injuries and clients with dark pigmented skin? - ANSWER- - cannot be assessed for pressure injuries risk by inspected the skin alone What is a stage 1 Pressure ulcer called? - ANSWER- - Non-blanchable erythema What are the characteristics of a stage 1 pressure ulcer? - ANSWER- - intact skin - non-blanchable redness What are some characte...

tissue integrity -:- the ability of body tissues to regenerate and/or repair to maintain normal physiological processes interventions to maintain tissue integrity -:- reposition turning adequate nutrition skin assessments blanching test -:- A test of the rate of capillary refill; blanching means to cause to become pale by applying digital pressure. Non-blanchable -:- skins stay very red even with finger pressure; indicates severe skin injury Stage 1 pressure ulcer -:- intact sk...

Ischemic lesions of the skin and tissues caused by unrelieved pressure that interferes with blood and lymph flow - correct answer pressure ulcers dead tissue - correct answer necrosis A nurse identifies that a client has a pressure ulcer on the sacrum. Which assessment finding indicates that this is a stage III pressure ulcer? A. Non-blanchable erythema of intact skin B. Damage identifies to muscle and bone C. Skin loss to the dermis D. Necrosis of subcutaneous tissue - correct answe...

Stage 3 Pressure Injury - ️️Full thickness loss of skin, adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. Pressure - ️️Pressure is the force (per unit area) exerted ...

Layers of skin epidermis Dermal-epidermal junction Dermis Subcutaneous layer Pressure injuries pathogenesis pressure intensity (tissue ischemia, blanching), pressure duration, tissue tolerance Pressure injuries risk factors impaired sensory perception, impaired mobility, alteration in loc, shear, friction, moisture Inability to perceive pressure, incontinence/moisture, decreased activity level, inability to reposition, poor nutritional intake, friction and shear Stage 1 pressure injury non-b...

Wound Stages Answer Stage 1: - intact skin with non-blanchable redness of a localized area usually over a bony prominence. -Area may be painful, firm, soft, warmer or cooler as composed to adjacent tissue. Stage 2: -Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough - may also be present as an intact or open/ ruptured serum filled blister Stage 3: - full-thickness loss and subcutaneous fat may be visible but bone, tendon o...

NUR 134 EXAM 3 REVIEW QUESTIONS AND ANSWERS, GRADED A+/ VERIFIED. Abrasion - -Scarping or rubbing away of epidermis; may result in localized bleeding and later weeping of serous fluid Approximated - -to come close together, as in the edges of a wound Blanchable hyperemia - -Redness of the skin caused by dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color. Blanching - - Debridement - -Removal of foreign matter or dea...