Pressure Injury Prevention and Assessment Quiz

1. Question 1
   • Localized damage to skin or underlying soft tissue, usually over a bony prominence, caused by intense and prolonged pressure combined with shear
   • A superficial skin infection caused by exposure to environmental microorganisms
   • A generalized inflammatory response affecting skin equally across the body
   • A traumatic wound caused only by a sharp object penetrating the skin
2. Question 2
   • Thighs, forearms, calves, and upper arms
   • Sacrum, heels, ischia, and coccyx
   • Abdomen, sternum, lips, and eyebrows
   • Forehead, palms, fingertips, and earlobes
3. Question 3
   • It prevents all movement within the deeper tissues
   • It traps skin and soft tissue between the surface and an underlying bone
   • It causes blood vessels to dilate throughout the entire body
   • It causes only chemical irritation of the epidermis
4. Question 4
   • Rubbing that produces heat and removes the top layer of skin
   • Opposing movement of tissue layers that stretches and tears subcutaneous blood vessels
   • Uniform compression of the skin without movement between layers
   • Discoloration caused by temporary increased blood flow
5. Question 5
   • Shear
   • Blanching
   • Undermining
   • Friction alone
6. Question 6
   • Compressing muscle between two internal bones
   • Rubbing the skin against a hard object
   • Stretching capillaries beneath the skin because tissue layers oppose one another
   • Creating a passageway beneath the wound surface
7. Question 7
   • It stretches and tears capillaries, reducing blood flow
   • It causes the wound surface to become dry and leathery
   • It makes all skin discoloration disappear temporarily
   • It increases the thickness of the epidermis
8. Question 8
   • Persistent maroon discoloration at the bone-muscle interface
   • Visible bone beneath a full-thickness wound
   • A pocket forming beneath the wound edge
   • Removal of the top layer of skin after rubbing against a hard object
9. Question 9
   • Brief pressure with blanching
   • Moisture with superficial redness only
   • Intense and prolonged pressure with shear
   • Friction with tunneling only
10. Question 10
    • Friction affects capillaries directly, whereas shear affects only the epidermis
    • Friction is surface rubbing, whereas shear is opposing movement of tissue layers
    • Friction is a staging category, whereas shear is a wound color
    • Friction occurs only over bone, whereas shear occurs only on the limbs
11. Question 11
    • Superficial blistering, increased blood flow, pressure relief, then capillary repair
    • Surface drying, increased oxygenation, capillary enlargement, then tissue recovery
    • Opposing tissue movement, capillary damage, reduced blood flow and oxygenation, then tissue injury
    • Tissue cooling, epidermal thickening, increased perfusion, then bone exposure
12. Question 12
    • A superficial scratch on the fingertip
    • Localized tissue damage over the sacrum
    • Generalized dryness of the scalp
    • Diffuse discoloration across the forearm
13. Question 13
    • Diligent assessment, frequent repositioning, and good skin care
    • Relying on discoloration alone in every skin tone
    • Assessing only the center of a wound and not surrounding tissue
    • Ignoring intact skin until an open ulcer develops
14. Question 14
    • Full-thickness loss with visible adipose tissue
    • Full-thickness loss with exposed bone
    • Partial-thickness loss with exposed dermis
    • Intact skin with localized nonblanchable erythema
15. Question 15
    • Pale skin that becomes darker when pressed
    • A wound covered by dry, black tissue
    • Reddened skin that does not turn white when pressed
    • A blister that contains visible adipose tissue
16. Question 16
    • It indicates underlying tissue damage and may worsen if pressure is not relieved
    • It proves that no tissue damage has occurred
    • It confirms that the wound has reached muscle
    • It means the finding is only temporary and cannot progress
17. Question 17
    • Classify every dark area as eschar
    • Use visible redness as the only assessment criterion
    • Assess only after the skin becomes open
    • Compare pain, firmness, softness, temperature, and color with surrounding areas
18. Question 18
    • Intact skin with nonblanchable erythema
    • Full-thickness loss with visible adipose tissue and no exposed deeper structures
    • Full-thickness loss with exposed muscle or bone
    • Partial-thickness skin loss with exposed dermis and a viable, shallow wound bed
19. Question 19
    • Stage 2
    • Stage 1
    • Stage 3
    • Stage 4
20. Question 20
    • A viable shallow wound bed
    • An intact epidermis
    • Nonblanchable erythema only
    • Visible adipose tissue
21. Question 21
    • Exposed dermis in a shallow wound
    • Full-thickness tissue loss with visible fat
    • Persistent redness with intact skin
    • An intact or ruptured blister
22. Question 22
    • Tendon
    • Adipose tissue
    • Bone
    • Muscle
23. Question 23
    • Intact skin with nonblanchable erythema
    • Exposure of cartilage, tendon, ligament, muscle, or bone
    • A shallow viable wound bed
    • Visible adipose tissue without deeper exposure
24. Question 24
    • Stage 3
    • Stage 4
    • Stage 1
    • Stage 2
25. Question 25
    • Only the epidermis is removed by surface rubbing
    • The depth varies by anatomical location, but deeper structures are not exposed
    • The skin is intact and redness is nonblanchable
    • The injury is always obscured by eschar
26. Question 26
    • Stage 3, Stage 1, Stage 2, Stage 4
    • Stage 4, Stage 3, Stage 2, Stage 1
    • Stage 2, Stage 1, Stage 4, Stage 3
    • Stage 1, Stage 2, Stage 3, Stage 4
27. Question 27
    • Swelling or discoloration around the wound
    • Visible adipose tissue
    • Pain in the wound area
    • An intact or ruptured blister
28. Question 28
    • Exposed muscle
    • A shallow viable bed
    • Visible adipose tissue
    • Intact skin
29. Question 29
    • Eschar
    • Undermining
    • Slough
    • Adipose tissue
30. Question 30
    • Dark brown or black, dry, thick, leathery dead tissue
    • Light yellow, soft, moist inflammatory exudate
    • A shallow wound with exposed dermis
    • A passageway extending beneath the skin

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