SMS Pressure Injury Prevention and Skin Integrity 1 — Questions and Answers
Question 1: According to the National Pressure Injury Advisory Panel (NPIAP), a Stage 2 pressure injury is characterized by:
- Intact skin with non-blanchable erythema
- Partial-thickness skin loss with exposed dermis (Correct answer)
- Full-thickness skin loss with visible fat
- Full-thickness tissue loss with exposed bone, tendon, or muscle
Correct answer: Partial-thickness skin loss with exposed dermis
Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis; the wound bed is pink or red and moist.
Question 2: Which seated position places the highest pressure on the ischial tuberosities?
- Semi-reclined with tilt
- Upright 90-degree hip flexion without cushion (Correct answer)
- Fully reclined at 135 degrees
- Anterior pelvic tilt on a contoured cushion
Correct answer: Upright 90-degree hip flexion without cushion
An upright 90-degree seated position without a pressure-relieving cushion concentrates the highest interface pressures directly on the ischial tuberosities.
Question 3: Shear forces in seating contribute to pressure injury development primarily by:
- Increasing blood flow to the skin surface
- Causing tissue deformation and disrupting microcirculation in deeper tissues (Correct answer)
- Reducing moisture on the skin surface
- Stretching the skin surface without affecting underlying tissue
Correct answer: Causing tissue deformation and disrupting microcirculation in deeper tissues
Shear forces cause mechanical deformation of deeper tissues, disrupting microcirculation and accelerating ischemia even at lower interface pressures.
Question 4: A pressure mapping system in seating evaluation is used to:
- Measure the client's blood pressure during sitting
- Visualize and quantify interface pressure distribution between the client and the seating surface (Correct answer)
- Assess joint range of motion in sitting
- Test cushion durability over time
Correct answer: Visualize and quantify interface pressure distribution between the client and the seating surface
Pressure mapping provides a visual map of interface pressure distribution to help identify high-pressure areas and evaluate the effectiveness of different cushion options.
Question 5: Which client population is at HIGHEST risk for seated pressure injuries?
- Ambulatory clients who use a wheelchair occasionally
- Clients with full sensation and normal cognition
- Clients with spinal cord injury, insensate skin, and limited mobility (Correct answer)
- Elderly clients with mild osteoarthritis
Correct answer: Clients with spinal cord injury, insensate skin, and limited mobility
Clients with spinal cord injury have insensate skin, limited mobility to shift weight, and often circulatory impairment, placing them at the highest risk for seated pressure injuries.
Question 6: How often should a client with full sensation be instructed to perform seated pressure reliefs?
- Every 2 hours
- Every 15–30 minutes (Correct answer)
- Once daily
- Only when experiencing discomfort
Correct answer: Every 15–30 minutes
Clients with sensation should perform pressure reliefs every 15–30 minutes while seated to prevent ischemic damage.
SMS Pressure Injury Prevention and Skin Integrity 1
According to the National Pressure Injury Advisory Panel (NPIAP), a Stage 2 pressure injury is characterized by: