301 Test 2 wounds

Question 1

Intact skin with non-blanchable redness (erythema) of a localized area usually over a bony prominence

Answer 1

stage 1

Question 2

Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area

Answer 2

stage 1

Question 3

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

Answer 3

stage 1

Question 4

A localized area of redness from pressure is observed over the right iliac crest of an elder male patient.

The skin surface is intact.

The reddened area of skin is nonblanchable.

Answer 4

stage 1

Question 5

an area of reddened skin on the right heel.

The alteration in skin color persists under applied light pressure.

There is no break in the skin surface.

Answer 5

stage 1

Question 6

The skin is reddened.

The area of redness does not blanch under applied light pressure.

The epidermis remains intact.

No blistering of the skin is observed.

Answer 6

stage 1

Question 7

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough

Answer 7

stage 2

Question 8

may also present as an intact or open/ruptured serum-filled or serosangineous-filled blister

Answer 8

stage 2

Question 9

The pressure ulcer is approximately 2 cm in length and 1.5 cm in width.

Tissue loss extends into the dermis.

There is no slough in the wound bed.

Answer 9

stage 2

Question 10

Area of epidermal and dermal skin loss noted over the left buttock.

No alteration in skin integrity was observed over the right buttock or perineum.

Answer 10

stage 2

Question 11

This wound is shallow. Tissue loss extends into the dermis.

The wound bed is reddish. No slough is observed.

Answer 11

stage 2

Question 12

Full thickness tissue loss

Answer 12

stage 3

Question 13

Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed

Answer 13

stage 3

Question 14

stage 3 MIGHT include 3 things:

Answer 14

slough, undermining, tunneling

Question 15

Subcutaneous tissue is visible in the wound bed. Muscle, tendon, and bone are not exposed.

Answer 15

stage 3

Question 16

Tissue loss extends through the dermis to subcutaneous tissue.

Not cartilage or bone is visualized.

Answer 16

stage 3

Question 17

Subcutaneous tissue is visible in the wound bed. Muscle, tendon, and bone are not evident.

A small amount of slough is present.

Answer 17

stage 3

Question 18

Full thickness tissue loss with exposed bone, tendon, or muscle

Answer 18

stage 4

Question 19

These ulcers often include undermining and tunneling

Answer 19

stage 4

Question 20

exposed muscle is observed in this very large pressure ulcer.

Slough/eschar are present.

Undermining is noted at the superior wound edge.

Answer 20

stage 4

Question 21

Full thickness tissue loss in which the base of the ulcer is completely covered by slough

Answer 21

unstageable

Question 22

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear

Answer 22

Suspected Deep Tissue Injury (sDTI)

Question 23

A wound caused by shear, friction, and/or blunt force resulting in separation of skin layers.

Answer 23

Skin Tears

Question 24

partial thickness wound is stage

Answer 24

2

Question 25

full thickness wound is stage

Answer 25

3 or 4