Fundamentals Exam #2: Part 1

State risk factors that contribute to pressure ulcer formation.

• Immobility, poor nutrition, and decreased sensation

• Frequent repositioning and good hydration

• Regular exercise and balanced diet

• High levels of physical activity

Impaired sensory perception (i.e. neuropathy) is a risk factor for what condition related to skin integrity?

• Pressure ulcer formation

• Psoriasis

• Eczema

• Acne

Alterations in LOC is a risk factor for what condition related to skin integrity?

• Pressure ulcer formation

• Eczema

• Psoriasis

• Acne

Tags

NGSS.HS-LS1-3

Shearing is a risk factor for what condition related to skin integrity?

• Pressure ulcer formation

• Eczema

• Psoriasis

• Cellulitis

The pressure ulcer staging system is used to:

• Classify the severity of tissue damage in pressure ulcers

• Measure blood pressure in patients with ulcers

• Diagnose the cause of pressure ulcers

• Determine the type of bacteria in ulcers

Stage 1 of pressure ulcer is characterized by ________.

• intact skin with non-blanchable redness

• open wound with exposed bone

• blister with serous fluid

• necrotic tissue with eschar

Stage 2 of pressure ulcer is characterized by ________.

• partial thickness skin loss involving epidermis, dermis, or both

• full thickness skin loss with damage to or necrosis of subcutaneous tissue

• intact skin with non-blanchable redness

• exposed bone, tendon, or muscle

Stage 3 of pressure ulcer is characterized by ________.

• full thickness tissue loss with visible fat

• non-blanchable erythema of intact skin

• partial thickness loss of dermis presenting as a shallow open ulcer

• exposed bone, tendon, or muscle

Stage 4 of pressure ulcer is characterized by ________.

• full thickness tissue loss with exposed bone, muscle, or tendon

• full thickness non-blanchable erythema of intact skin

• partial thickness loss of dermis presenting as a shallow open ulcer

• full-thickness tissue loss with localized area of non-blanchable deep red, maroon, or purple discoloration

An unstageable pressure ulcer is characterized by ________.

• full thickness tissue loss in which the base of the ulcer is covered by eschar/necrosis in the wound bed

• full thickness loss of dermis presenting as a shallow open ulcer

• full thickness tissue loss in which the base of the ulcer is covered by erythema/petechiae in the wound bed

• full thickness tissue loss with exposed bone, tendon, or muscle in the wound bed