Final Exam Module 8: NUR 2356 /
NUR2356 (Latest Update 2025 / 2026) Multidimensional Care I / MDC 1 | Questions & Answers | 100% Correct | Grade A - Rasmussen
Question:
Friction vs Shearing
Answer:
Shearing forces pulling skin layers away from deeper tissue. The skin is "bunched up" against the back of the mattress while the rest of the bone and muscle in the area presses downward on the lower part of the mattress. Blood vessels become kinked, obstructing circulation and leading to tissue death.
Question:
JCAHO National Patient Safety Goals
Answer:
•All patients are to be assessed with a risk assessment tool to identify clients at high risk for pressure ulcer development
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Question:
What is Braden Scale?
Answer:
•Commonly used.
•The scale evaluates the client for the following:
•Sensory perception; Moisture; Activity; Mobility; Nutrition; Friction and Shear.
Question:
What is Norton Scale?
Answer:
•The scale evaluates the client for the following:
•Physical Condition; Mental Condition; Activity; Mobility; Incontinence.
Question:
Analysis/Diagnosis of Pressure Wounds
Answer:
•Dx: Risk for impaired tissue integrity related to prolonged bed rest
•Dx: Impaired tissue integrity related to vascular insufficiency and trauma
•These patients also have a potential for wound deterioration and/or infection due to insufficient wound management
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Question:
Positioning to prevent Pressure Injuries
Answer:
•Pad hard surfaces with pressure redistribution properties
•Do not elevate head of bed greater than 30 degrees to prevent shearing
•Suspend heels-off the bed surface
Question:
Nutrition Education to Pressure Injuries
Answer:
•Encourage protein and calorie intake at each meal •Serve protein shakes between meals
Question:
Skin Care for Pressure Injuries
Answer:
•Complete a daily skin inspection •Moisturize dry skin with lotion •Do not massage bony prominences
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