Wound Classification

Every question here, with the answer

1. A patient returns from a procedure with a planned surgical cut made under aseptic conditions. The wound edges are approximated, bleeding is controlled, and the incision was closed immediately after the procedure. How should the nurse classify this wound?

   1. Intentional wound
   2. Unintentional wound
   3. Friction injury
   4. Chronic wound

   Answer: Intentional wound

   This wound was planned as part of treatment, performed under aseptic conditions, and closed immediately, which matches an intentional wound. Unintentional wounds result from unexpected trauma; chronic wounds have delayed healing; a friction injury occurs when two surfaces rub together.

2. An incontinent patient is at risk for pressure injury development related to moisture exposure. Which nursing actions are appropriate? Select all that apply.

   1. Cleanse the patient as quickly as possible after each soiling.
   2. Monitor the patient for skin breakdown.
   3. Use skin barriers to protect intact skin.
   4. Apply excessive moisture to the skin to keep tissues softened.
   5. Leave urine or feces on the skin until the next scheduled bath to avoid over-washing.

   Answer: Cleanse the patient as quickly as possible after each soiling., Monitor the patient for skin breakdown., Use skin barriers to protect intact skin.

   The section identifies incontinence-related moisture as a cause of maceration, irritation, skin breakdown, and infection risk. Monitoring, prompt cleansing after soiling, and skin barriers for intact skin are appropriate; leaving excretions on the skin or overmoistening the skin increases risk.

3. A patient repeatedly slides down in bed when the head of the bed is elevated. The nurse is concerned that one tissue layer is sliding over another, stretching and tearing blood vessels. Which injury mechanism is the nurse identifying?

   1. Shear
   2. Incision
   3. Friction
   4. Contusion

   Answer: Shear

   Shear occurs when one tissue layer slides over another and can happen when a patient’s torso slides down in bed with the head of the bed elevated. Friction involves two surfaces rubbing together; contusion and incision are different wound types.

4. The nurse is planning care for an older adult with thin skin and reduced sensation of pressure and pain. Which interventions help reduce the risk of friction and shear injuries? Select all that apply.

   1. Check the skin frequently for breakdown or tears.
   2. Pull the patient up in bed by the draw sheet to prevent delay in repositioning.
   3. Keep bedding and linens dry and wrinkle free.
   4. Pad bony prominences.
   5. Use proper lifting technique when moving or transferring the patient.

   Answer: Check the skin frequently for breakdown or tears., Keep bedding and linens dry and wrinkle free., Pad bony prominences., Use proper lifting technique when moving or transferring the patient.

   Older adults are more susceptible to friction and shear injuries, so frequent skin checks, dry wrinkle-free linens, padding bony prominences, and proper lifting technique are appropriate. Pulling patients up in bed by a draw sheet is listed as a situation that can contribute to friction injury.

5. A patient’s Braden scale score is 16 on admission. What is the nurse’s priority action based on this score?

   1. Reassess the patient regularly according to the facility and healthcare setting schedule.
   2. Document that the patient is not at risk because the score is above the risk range.
   3. Stage the patient as having a stage I pressure injury.
   4. Wait to reassess until the patient has a condition-related change.

   Answer: Reassess the patient regularly according to the facility and healthcare setting schedule.

   A Braden score of 18 or below requires regular reassessment based on the facility and healthcare setting schedule. Reassessment only with condition-related changes applies to scores above 18, and the Braden scale identifies risk rather than stages an existing injury.

6. The nurse is assessing intact skin over a bony prominence after the patient has been lying in one position for a prolonged time. Which findings are consistent with a stage I pressure injury? Select all that apply.

   1. Partial-thickness skin loss involving the epidermis or dermis.
   2. An open sore caused by poor blood flow.
   3. Localized nonblanchable erythema of intact skin.
   4. In darker pigmented skin, the area is a different color than the adjacent skin.
   5. Purple or maroon skin discoloration.

   Answer: Localized nonblanchable erythema of intact skin., In darker pigmented skin, the area is a different color than the adjacent skin.

   Stage I pressure injury is identified by localized nonblanchable erythema with intact skin; in darker skin, the color may differ from adjacent skin. Purple or maroon discoloration suggests deep-tissue pressure injury, partial-thickness skin loss describes stage II, and an open sore caused by poor blood flow is an ulcer.