PEAT Integumentary Conditions and Wound Care 1 — Questions and Answers
Question 1: Which pressure injury stage is characterized by full-thickness skin loss with visible subcutaneous fat but no exposed bone, tendon, or muscle?
- Stage I
- Stage II
- Stage III (Correct answer)
- Stage IV
Correct answer: Stage III
Stage III pressure injuries involve full-thickness skin loss where subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
Question 2: Which characteristic best describes a Stage IV pressure injury?
- Non-blanchable erythema of intact skin
- Partial-thickness skin loss with a shallow open crater
- Full-thickness tissue loss with exposed bone, tendon, or muscle (Correct answer)
- Unstageable due to slough or eschar obscuring the base
Correct answer: Full-thickness tissue loss with exposed bone, tendon, or muscle
Stage IV pressure injuries involve full-thickness tissue loss with exposure of bone, tendon, or muscle, often with undermining and tunneling.
Question 3: A patient's wound bed appears red/pink, moist, and bleeds easily when touched. This finding indicates:
- Necrotic tissue requiring debridement
- Fibrin slough needing removal
- Healthy granulation tissue (Correct answer)
- Wound eschar formation
Correct answer: Healthy granulation tissue
Healthy granulation tissue appears red/pink, moist, and bleeds easily when touched, indicating active wound healing and adequate perfusion.
Question 4: Which primary intervention is MOST effective for preventing pressure injuries in a non-ambulatory patient?
- Applying moisture barrier cream to bony prominences
- Repositioning every 2 hours (Correct answer)
- Placing a foam mattress overlay
- Providing a high-protein diet
Correct answer: Repositioning every 2 hours
Regular repositioning every 2 hours is the cornerstone of pressure injury prevention by relieving sustained pressure over bony prominences.
Question 5: Venous insufficiency ulcers are most commonly located on the:
- Plantar surface of the foot
- Lateral malleolus
- Medial lower leg (gaiter area) (Correct answer)
- Heel
Correct answer: Medial lower leg (gaiter area)
Venous insufficiency ulcers typically occur on the medial lower leg due to venous hypertension and pooling in that region from incompetent valves.
Question 6: Which burn classification presents with erythema only, no blistering, and involves only the epidermis?
- Superficial (first-degree) burn (Correct answer)
- Superficial partial-thickness (second-degree) burn
- Deep partial-thickness burn
- Full-thickness (third-degree) burn
Correct answer: Superficial (first-degree) burn
First-degree (superficial) burns affect only the epidermis, presenting as erythema without blistering, similar to a mild sunburn.
Question 7: The primary goal of maintaining a moist wound healing environment is to:
- Prevent bacterial colonization in the wound bed
- Promote cell migration and granulation tissue formation (Correct answer)
- Reduce wound odor and patient discomfort
- Decrease the volume of wound drainage
Correct answer: Promote cell migration and granulation tissue formation
Moist wound healing promotes cell migration, angiogenesis, and granulation tissue formation, leading to faster healing compared to dry wound environments.
PEAT Integumentary Conditions and Wound Care 1
Which pressure injury stage is characterized by full-thickness skin loss with visible subcutaneous fat but no exposed bone, tendon, or muscle?