Tissue Integrity

Question 1

The outer most layer of the skin, made of squamous epithelial cells, which provides a barrier against the external environment.

Answer 1

Epidermis

Question 2

Cells formed in the basal layer of the skin that function to protect the skin from the external environment.

Answer 2

Keratinocytes

Question 3

A pigment that determines he color of the hair, skin, and eyes.

Answer 3

Melanin

Question 4

Receptor cells in the epidermis that are specialized for detection of light touch.

Answer 4

Merkel cells

Question 5

Cells found in the epidermis that play a role in cutaneous immune system reactions.

Answer 5

Langerhans cells

Question 6

The layer under the epidermis that is composed mainly of connective tissue and provides strength and flexibility of the skin.

Answer 6

Dermis

Question 7

An irritation of the epidermis caused by moisture.

Answer 7

Maceration

Question 8

A red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates.

Answer 8

Dermatitis

Question 9

Loss of the top skin layer caused by mechanical forces. The severity of a skin tear is defined by the depth of the skin layer loss.

Answer 9

Skin tears

Question 10

At-risk vulnerable skin

Answer 10

Skin frailty

Question 11

Localized damage to the skin and/or the soft underlying tissue, which can be caused by prolong contact with a firm surface that interferes with circulation to the area.

Answer 11

Pressure injuries

Question 12

An infection of the superficial layers of skin.

Answer 12

Cellulitis

Question 13

redness of the skin due ot dilation of blood vessels.

Answer 13

Erythema

Question 14

An area of a reddened skin that temporarily turns white or pale when light pressure is applied. The skin then reddens when pressure is relieved.

Answer 14

Blanchable eryhema

Question 15

Redness of the skin that does not go away when pressure is applied and indicates structural damage has occurred in the small vessels supplying blood to the underlying skin and tissues.

Answer 15

Nonblanchable erythema

Question 16

Any tearing of the skin, usually caused by blunt or sharp objects

Answer 16

Lacerations

Question 17

Fluid secreted by the body during the inflammatory stage of healing and is made of plasma.

Answer 17

Exudate

Question 18

Moisture-associated skin damage

Answer 18

A form of dermatitis; a skin irritation that forms when the skin is exposed to irritants like feces, urine, stoma content, and wound exudates.

Question 19

Thin, watery wound drainage.

Answer 19

Serous

Question 20

Thin watery wound drainage mixed with blood.

Answer 20

Serosanguineous

Question 21

Bloody drainage.

Answer 21

Sanguineous

Question 22

Blood/yellow wound drainage.

Answer 22

Purulent

Question 23

A narrow channel or passage way extending it in any direction from the base of the wound.

Answer 23

Tunneling.

Question 24

A force parallel to the surface of the skin.

Answer 24

Shearing

Question 25

Imbalance in a client' s intake, which can include deficiencies or excesses in nutrients, vitamins, or calories.

Answer 25

Malnutrition

Question 26

Inadequate supply of blood circulation, which results in low oxygen levels in tissues.

Answer 26

Hypoperfusion

Question 27

An open area extending under skin along the edge of the wound.

Answer 27

Undermining.

Question 28

Comparing results and outcomes to other sources of similarly retrieved data

Answer 28

Benchmarking

Question 29

Obscured full-thickness skin and tissue loss injury.

Answer 29

Unstageable pressure injury

Question 30

New skin tissue that forms on the surface of the wound

Answer 30

Granulation tissue

Question 31

Obscured full-thickness skin and tissue loss injury.

Answer 31

Unstageable pressure injury

Question 32

Yellow, stingy nonviable tissue found in the base of the wound.

Answer 32

Slough

Question 33

Hard nonviable black/brown tissue found in the wound bed.

Answer 33

Eschar

Question 34

Persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color.

Answer 34

Deep tissue pressure injury.

Question 35

Injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device.

Answer 35

Mucosal membrane pressure injury

Question 36

The process of surgically removing dead tissue and other debris that can cause infection.

Answer 36

Debridement

Question 37

Accumulation of blood in the body

Answer 37

Hematoma

Question 38

Accumulation of serous fluid

Answer 38

Seroma

Question 39

Death of body tissue as a result of diminished blood flow.

Answer 39

Necrosis

Question 40

Below the expected level of oxygen in body tissue.

Answer 40

Hypoxia

Question 41

Vasoconstriction

Answer 41

The narrowing of the blood vessels due to acute blood loss, pain, and/or low body temperature.

Question 42

What are the universal skin prevention measures utilized in skin care plans? (Enter your response and submit to compare to an expert’s response.)​​​​​​​

Answer 42

Hydration, nutrition, hygiene, circulation. The universal plan for skin care includes plans for adequate hydration, nutrition, hygiene, and circulation. Structured prevention plans for hygiene will help with proper maintenance of the skin. The nurse should monitor for signs of dehydration by assessing for skin turgor, weight, urine output, elevated serum sodium levels, and serum osmolality. Good nutrition is a major part of the prevention strategy for maintaining skin integrity. A nutritional assessment is a part of the risk assessment, and the client’s nutrition should be closely monitored to maintain tissue integrity and optimize healing.

Question 43

What is the correct order of steps in obtaining a wound culture?

Answer 43

Label culture tube. Remove old dressing. Rinse wound with 0.9% sodium chloride. Remove swab from culture tube. Place sterile swab into the wound bed. Rotate the swab stick in an area of drainage. Activate the culture medium. Note if client has received any recent antibacterial or antifungal therapy

Question 44

The complete or partial searation of the suture line and underlying tissues that occurs when a wound fails to heal properly.

Answer 44

Dehiscence

Question 45

What are the risk factors for a Stage 1 Pressure injury?

Answer 45

immobility or limited mobility, older age, poor nutrition, incontinence, decreased sensation, fragile skin, medical conditions affecting blood flow like diabetes or peripheral artery disease, spinal cord injury, obesity, dehydration, and decreased mental awareness

Question 46

What are the nursing interventions for a stage 1 pressure injury?

Answer 46

Implement effective pressure relief and redistribution strategies. Optimize wound care and promote healing. Manage pain and discomfort associated with pressure injuries. Prevent infection through proper wound hygiene and antimicrobial treatments. Provide education on self-care and prevention measures. Address underlying factors contributing to pressure injuries, such as immobility or poor nutrition.

Question 47

highly absorbent dressing that is used for wounds with moderate to heavy exudate, maintaining a moist environment to promote healing and autolytic debridement

Answer 47

Alginate Dressings

Question 48

_________ can be used to manage dry wounds for debridement of necrotized tissue and eschar. They work differently than other dressings because they contain water, to provide moisture to or draw moisture away from the wound depending on the needs of the wound.

Answer 48

Hydrogel

Question 49

How long do staple wounds take to heal?

Answer 49

7-14 days.

Question 50

Non-blanchable Erythema is a ________ pressure injury

Answer 50

Stage one

Question 51

Partial-Thickness Skin Loss is a ________ Pressure injury

Answer 51

Stage Two

Question 52

Full-Thickness Skin Loss with visual adipose tissue is a _________ pressure injury

Answer 52

Stage Three

Question 53

Full-Thickness Skin and Tissue Loss is a __________ pressure injury

Answer 53

Stage four