Segment 1 – Pressure Injuries and ... - Care Training Online



Pressure Injuries and Pressure CareMultiple choice Questions – (with answers)Contents TOC \o "1-3" \h \z \u Segment 1 – Pressure Injuries and Pressure Care PAGEREF _Toc484352054 \h 2Segment 2 – Anatomy of the Skin PAGEREF _Toc484352055 \h 4Segment 3 – How pressure injuries occur PAGEREF _Toc484352056 \h 6Segment 4 – Index Risk PAGEREF _Toc484352057 \h 8Segment 5 – Assessment PAGEREF _Toc484352058 \h 10Segment 6 – Prevention PAGEREF _Toc484352059 \h 12Segment 7 – Your role PAGEREF _Toc484352060 \h 14Segment 8 – Pressure area Development PAGEREF _Toc484352061 \h 16Segment 9 – Potential Pressure Injury Areas PAGEREF _Toc484352062 \h 19Segment 1 – Pressure Injuries and Pressure CareWhere is a Pressure injury usually located?You will find them at the site of jointsYou will find them at fatty sitesThey are only ever found on the buttocksOver bony prominence areasOn a persons’ weaker sideHow is a pressure injury described?As a localised injury to the skin and / or underlying tissueAn injury that needs pressure placed over it to healAn infection that spreads throughout the skin originating from a pressure pointSkin erosion caused by pressureBruising or damage to the skin from pressure impact such as walking into a wallWhich ones of these is NOT a cause of pressure injury?Damage from unrelieved pressurePoor blood flowDamage from walking into objectsChaffing and rubbing of the skinThese are all forms of pressure injuriesA pressure injury will not do what?GrowBlanchHealGet infectedCause painA pressure injury will generally be what colours?White or RedBlack or Blue / PurpleRed or Blue / PurpleYellow or whiteBlack or RedWhat may be happening under the skin of a pressure area?A cavity could be formingInfectionSkin becoming thickBecome a storage site for fatty tissuePressure injuries only effect the top layers of the skinWhat can prevent pressure injuries?Nothing can prevent pressure injuriesWrapping padding around the clientKeeping the client moving oftenGood nursing carePlenty of calcium in the dietWhat can pressure injuries be a sign of?The client is not getting up and moving like they were told toThe client is not consuming enough calciumThe client is a smokerThe client is not consuming enough waterThe client may be getting neglected or abusedWhich of the following is another term used for pressure injuries?Bed soresPressure soresPressure ulcersPressure areasAll of the aboveHow long can pressure injuries take to develop?Sudden impactA matter of minutesA matter of hoursHalf a dayA day or 2How often do you need to ensure a person is turned or moved?Every hourEvery 2 hoursEvery 3 hoursEvery 4 hoursEvery 5 hoursWhat is the first indication of a pressure injury?A change of colour to the areaWarmth in the areaCoolness in the areaBlotching in the areaSkin breakdown over the areaSegment 2 – Anatomy of the SkinWhich of the following is the role of skin?Protects internal organsHeat regulationSensation Making Vitamin DAll of the aboveHow many main layers are there to skin?12345The outermost layer of the skin is called what?DermisEpidermisPeridermisSubcutaneousShellSkin gets its toughness from a protein called what?KeratinElastinCollagenAmyloidFibronectinHow many layers are there to the epidermis?12345How long does it take for the new cells to reach the surface of the skin?24 hours48 hours1 week2 weeks1 monthThe dermis layer contains what?Collagen and ElastinCollagen and KeratinElastin and AmyloidElastin and KeratinKeratin and AmyloidThe epidermis and dermis combined are called what?SubcutaneousCutaneousSkin barrier1st layer of skinDual layerThe subcutaneous layer stores what?The ends of the pain receptorsRed blood cellsWhite blood cellsMost of the bodies fatKeratinWhy is skin thinner over joints?It is not thinner over the jointsBecause of the wear and tear to the inside of the skinBecause it would be difficult to bend if there was thick skin at jointsBecause there are no organs needing protectionBecause the insertion points of muscle to bone make it difficult for skin to develop thereSegment 3 – How Pressure Injuries OccurPressure injuries can be grouped into how many main “themes”?23456What type of injury is caused by the body squashing the skin and blocking blood flow to the tissue?Prolonged unrelieved pressure ShearingFrictionTourniquetImpact What is the term used when the skin moves one way but the bone moves the other way?This is impossible to happenFrictionSliding pressureDistortionShearingWhen do friction injuries happen?When a person is left in the same position for a whileWhen you drag a person up the bed without a slid sheetWhen two surfaces rub together like moving up and down the bedWhen a person has something around their body too tight cutting of circulationWhen something has scratched their body like a finger nailWhen is skin more susceptible to damage?If skin is too moistIf skin is too dryIf skin has no haira and ba and cWhat will happen if blood cannot flow through an area due to pressure applied?Cell death can occurA build-up of blood near the area will occurPeople stop feeling pain in that area as the nerve cells dieThe person will experience ‘pins and needles’ sensationThe area will get cold causing discomfort to the personHow can you prevent pressure injuries from occurring?Keeping a person sitting up not lying downMoving or turning a person regularlyGetting a person to get up and walk around regularlyKeeping a person warmThere is nothing you can do to prevent pressure injuries from occurringWhat is the term used to describe skin that has become soft and separated or to waste away?CyanosedSloughShearingDistortionMacerateSegment 4 – Index RiskWho is at risk of developing a pressure injury?Elderly peopleFrail peoplePeople with limited mobilityAll of the aboveAnyone can develop a pressure injury if seated for more than 2 hoursWho will do a risk assessment to determine how likelihood a client could develop a pressure injury?The client will tell youThe assigned health care workerA registered nurseAn occupational therapistA physical therapistWhich of the following is NOT a type of scale used to determine how likely a pressure injury could occur?Braden scaleGlasgow scaleNorton scaleWaterlow scaleGlamorgan scaleHow many categories are assessed using the Braden scale?34567Which of the following is NOT a category assessed in the Braden scale?Sensory perceptionMoistureActivityMobilityTemperatureWhich scale system scores risk from 1-4 to ascertain likelihood of pressure injuries?Norton scaleBraden scaleWaterlow scaleGlasgow scaleGlamorgan scaleWhich scale system is used for children?Norton scaleBraden scaleWaterlow scaleGlasgow scaleGlamorgan scaleWhy does a health care worker need to know what assessments are done for pressure injury risk?Because a health care worker will be required to complete the assessmentsSo the health care worker sound knowledgeable when talking to medical staffIt will help the care worker know what information to pass on to the registered nurse when doing caresThe healthcare worker does not need to know about the assessments scales other than they existSo the health care worker can further explain the assessment to the clientSegment 5 – AssessmentWhat is vital for the care and prevention of pressure injuries?A sound assessmentAdequate trainingA compliant patientThe right equipmentSupervision of a registered nurseWhen doing an assessment where is the first place to start?The headThe feetWith a clinical historyWhatever order is comfortable for youChecking medicationsWhat information would you require when obtaining a clinical history?Current illnessesPast health issuesAny illness that could impact current healthMedicationsAll of the aboveWhich of the following is NOT part of a skin assessment?ColourviscosityIntegrityTemperatureDrynessWhat is a key indicator that a person is at risk for pressure injuries?WeightMedicationsDiabetesMobilityAgeName two other assessments that are key to determining risk of pressure injuries:Nutritional and continenceCardiac and continenceMental health and nutritionalCardiac and nutritionalCardiac and mental healthWhich of the following in NOT an example of an external factor influencing the likelihood of pressure injuries?The person spends a lot of time in bedThe person spends all their time in bedThe person is uncoordinated when walking The person is reliant on people to move themThe person spends a lot of time in a wheelchairWhat other factor is important to consider when assessing the level of risk for pressure injuries?Illness such as stroke or COPDPoor blood flowSkin sensationFrailAll of the aboveIf the person has had a pressure injury in the past, this would indicate what?That they do not look after themselves very wellThey are more likely to get another pressure injuryThat they are less likely to get another pressure injuryThat they need a softer bedThat people have failed to adequately care for themHow does weight impact a person’s risk of pressure injuries?They are more likely to get pressure injuries if they are over weightThey are more likely to get pressure injuries if they are under weightThey are less likely to get pressure injuries if they are overweightThey are less likely to get pressure injuries if they are underweightIf they are over or underweight it increases the likelihood of pressure injuriesHow can equipment cause pressure injuries?They cannot cause pressure injuriesIt is only when they are not used properly that injuries can occurOnly heavy / metal equipment can cause pressure injuries while things like oxygen tubes are fineAnytime equipment is against the skin for a period of time pressure injuries can happenEquipment is unsafe to use with anybody who is at risk of pressure injuriesSegment 6 – PreventionAfter a client has been assessed by a registered nurse, what is the next thing that should happen if there is a risk of pressure injury?The client should be prescribed creams that work to protect skinThe client should be prescribed medication that works to protect skinA care plan should be developedThe bed should be positioned correctly to reduce pressureThey should have a “high pressure risk” notice made for their room Which of the following would you expect to see in a care plan?Timeframes for moving a personSchedule for completing skin checksEquipment list to useNursing interventionsAll of the aboveWhat is the common timeframe for moving a patient?Every hourEvery 2 hoursEvery 4 hoursEvery 6 hoursEvery 8 hoursIf you notice redness over an area when turning a patient, how soon should you report it?ImmediatelyCheck it at the next turn to see if it has changed, then reportNo need to report, but it needs to be written in notesMonitor it for changes over the course of your shift then report at the end of shiftRedness happens all the time, you only need to report it if the skin is breaking downWhat can be used as a heel protection device for people that are bed bound?Specially designed heal padsSlippersA pillowA foot spaHeals are not much of a concern as the skin is thickWhich of the following is NOT a reactive surface product?Device that periodically redistributes pressureGelMemory foam squareAir inflated deviceSheepskin heal padWhen does a person no longer need to be turned?When the gel is applied When using a memory foam bedding is being usedWhen any active surface products are being usedWhen any reactive surface products are being usedA person always needs to be turned regardless of productsHow should you move a person up the bed?Two people put their hands under their arms and drag them upTwo people lift and shuffle them upGet the person to help you move them up the bedUse a sliding sheet to move a person up the bedAny of the above options are appropriateSegment 7 – Your roleWho develops the care plan?The health care assistantThe Registered NurseThe family of the clientThe GP A gerontologistWhat is the key aspect of your role?To design a care planTo assess the effectiveness of the care planTo critique the care planTo follow the care planTo do what you think should be doneWhat do you need to document?What you think should be doneWhat you are planning to doWhat you have doneWhat you thought you did wellWhat the client thought you did wellWhat do you need to observe when doing cares?Red areas on the skinMoisture of the skinDryness of the skinIf a person is showing signs of dehydrationAll of the aboveHow does moisture on the skin cause pressure injuries?It does not cause pressure injuries; the skin needs to be moistIt does not cause pressure injuries but it does make it more susceptible due to softening and macerating the skinMoisture acts as a suction pulling the skin to objects increasing the risk of pressure injuriesMoisture erodes the skin away Moisture bloats the skin causing more pressure between the bone the objectWhat type of soap should be used on older adults’ skin?Soap free productsA soap that contains antisepticStrong smelling soapSoap with moisturiserWhatever is most cost effectiveWhat is the most effective measure for preventing pressure injuries?A good barrier creamKeep them lying or sitting still A good quality pillow and mattressTurning or moving the person regularlyA healthy dietHow often should a person be moved or turned?Every ? hourEvery hourEvery 2 hoursEvery 3 hoursEvery 6 hoursBesides the turning chart, what two other charts are useful tools to use in the prevention of pressure injuries?Fluid balance and Food intakeFluid balance and MedicationMedication and Food intakeFood Intake and CleaningMedication and CleaningWhich is the most common place for a pressure injury?Shoulder, Elbow, SacralShoulder, hip, StomachElbow, Stomach SacralSacral, Shoulder, StomachHips, Stomach, SacralHow can you protect a persons’ knees from rubbing together?Knees are not a problematic area so this is not a concernAs long as they have been moisturised it is fineThe person should be positioned on their back with their legs apartA wedge that keeps their legs apart can be usedA pillow between their legs can be usedSegment 8 – Pressure Area DevelopmentHow many stages of development are there with pressure injuries?34567A pressure injury is the result of what?Clothing being too tightBanging against objectsOld age skin deteriorationRubbing an area too roughlyIntense pressure on an areaIf you see redness that does not blanch when you touch it, what stage of pressure area development is present?12345If you can see yellow fatty tissue and a layer of the skin is missing what stage of pressure area injury is apparent?23456If the ulcer has rolled edges and there is beginning to be dead tissue what stage of pressure injury is a person in?12345If the skin is blistering, what stage of pressure area injury is a person in?12345When the wound extends down to the muscle, bones and fascia, what stage of pressure injury is present?23456What does blanching mean?The skin ‘bounces back’ after being pressed within 2 secondsA red area will go dark when touchedA red area will go white when touchedThere will be no touch sensation felt when touchedWhen you lightly pinch the skin it will go back down within 2 secondsDuring stage one, what may you see happen with the skin?RednessChange in sensationChange in temperatureFirmnessAll of the aboveWhat is mean if there is tunnelling?You are in stage 4 of pressure injuryYou can see underlayers of fat or muscleYou can see to the boneIt is difficult to ascertain how deep the ulcer isAll of the aboveWhat would there likely be a lot of in stage 3 and 4 of pressure injury?FluidgranulationblisteringblanchingScabbingA pressure injury will not heal while there is the presence of what?GranulationBlanchingScabbingPussBlisteringHow does healing take place?From the bottom upFrom the top downHealing will not take place after stage 3By packing the woundHealing will take place naturally when there is no longer pressure on the areaWho should do wound dressings?Any health care assistantAny trained health care assistantAnyone including familyA district health nurseA registered nurseSegment 9 – Potential Pressure Injury AreasAny skin that is dry or cracking is what?Has already begun to become a pressure injuryIn imminent danger of a pressure injuryIs at risk of a pressure injuryIs a low risk of being a pressure injuryWill not turn into a pressure injuryWhat type of skin is likely to macerate?Dry skinCracking skinSkin with a low pHMoist skinThin skinWhat should you avoid doing when moving a person?Rubbing themLifting themTaking pressure off the area too quicklyUsing a slide sheetUsing pillows to adjust themWhat is the most important thing to look out for when moving a person?PainRednessWarmth in the areaHardnessAll of the aboveWhat should you do if you suspect a pressure injury may be at risk of forming?Monitor it for the duration of your shiftLet the Registered nurse knowDocument ita and cb and c ................
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