Scales

Question 1

Pulse scale:

Not palpable

Answer 1

0

Question 2

Pulse scale:

Difficult to palpate, weak, thready

Answer 2

1+

Question 3

Pulse scale:

Weak, light pressure causes it to disappear

Answer 3

2+

Question 4

Pulse scale:

Normal, easily felt

Answer 4

3+

Question 5

Pulse scale:

Bounding

Answer 5

4+

Question 6

What is normal on pulse scale

Answer 6

3+

Question 7

Reflex scale:

Absent

Answer 7

0

Question 8

Reflex scale:

Weak

Answer 8

1+

Question 9

Reflex scale:

normal

Answer 9

2+

Question 10

Reflex scale:

hyperactive

Answer 10

3+

Question 11

Reflex scale:

Clonus

Answer 11

4+

Question 12

Pitting edema scale:

barely detectable

Answer 12

1+

Question 13

Pitting edema scale:

skin takes 15 sec or less to return to normal

Answer 13

2+

Question 14

Pitting edema scale:

skin takes 16-30 seconds to return to normal

Answer 14

3+

Question 15

Pitting edema scale:

skin takes 30+ seconds to return to normal

Answer 15

4+

Question 16

Stage of lymphedema:

no edema

Answer 16

Stage 0

Question 17

Stage of lymphedema:

Pitting edema, reduces with elevation

Answer 17

Stage 1

Question 18

Stage of lymphedema:

Irreversible edema

Answer 18

Stage 2

Question 19

Stage of lymphedema:

Positive Stemmer’s sign

Answer 19

Stage 2

Question 20

Stage of lymphedema:

Elephant like skin

Answer 20

Stage 3

Question 21

Burn Scale:

Minimal pain, dry, no blisters

Answer 21

First degree

Question 22

Burn Scale:

Blistering, web, moderate edema/pain

Answer 22

2nd degree superficial partial thickness

Question 23

Burn scale:

mixed red with pale areas. web, blisters. insensitive to light touch, sensate to pressure

Answer 23

2nd degree deep partial thickness

Question 24

Burn Scale:

white, charred, gray, dry, marked edema, insensate

Answer 24

3rd degree

Question 25

Burn Scale:

charred, black, exposed bone, tendon, muscle, etc. Marked edema, insensate

Answer 25

4th degree

Question 26

Pressure ulcer scale:

intact skin, non blanchable redness

Answer 26

Stage 1

Question 27

Pressure ulcer scale:

shallow open ulcer, partial thickness loss of dermis

Answer 27

Stage 2

Question 28

Pressure ulcer scale:

full thickness, subcutaneous tissue visible

Answer 28

Stage 3

Question 29

Pressure ulcer scale:

full thickness, bone tendon, muscle exposed

Answer 29

Stage 4

Question 30

Pressure ulcer scale:

subcutaneous tissue is exposed but not bone and tendon

Answer 30

Stage 3

Question 31

Pressure ulcer scale:

localized purple/maroon area of intact skin

Answer 31

Suspected Deep tissue injury

Question 32

Wagner Scale:

Intact skin

Answer 32

Stage 0

Question 33

Wagner Scale:

Superficial Ulcer with no subcutaneous involvement

Answer 33

Stage 1

Question 34

Wagner Scale:

Deep ulcer with involvement of ligament, tendon, or joint capsule

Answer 34

Stage 2

Question 35

Wagner Scale:

Deep ulcer with bone involvement. abscess/osteomyelitis

Answer 35

Stage 3

Question 36

Wagner Scale:

Forefoot gangrene

Answer 36

Stage 4

Question 37

Wagner Scale:

Full foot gangrene

Answer 37

Stage 5

Question 38

Pressure Ulcer Scale:

Wound bed covered with slough and eschar

Answer 38

Unstageable

Question 39

Big difference between stage 1 and 2 on Wagner

Answer 39

Stage 1 has no subcutaneous involvement, stage 2 does

Question 40

Big difference between stage 0 and 1 on Wagner

Answer 40

Stage 0 is when the skin is intact, stage 1 the skin is not intact

Question 41

Big difference between stage 2 and 3 on Wagner

Answer 41

Stage 2 there is no osteomyelitis, stage 3 there is.