| 1 The stage 1 of the pressure ulcer is characterized by intact skin, with hyperemia in a localized area, which shows no visible blanching or whose color differs from the surrounding area. (T) |
72 |
75.8 |
|
92 |
96.8 |
| 2 The risk factors for the development of pressure ulcer are: impaired mobility, incontinence, inadequate nutrition and change in the level of consciousness. (T) |
90 |
94.7 |
|
92 |
96.8 |
| 3 All patients at risk for pressure ulcer should have a systematic skin inspection at least once a week. (F) |
81 |
85.3 |
|
83 |
87.4 |
| 4 The use of hot water and soap may dry the skin and increase the risk for pressure ulcers. (T) |
59 |
62.1 |
|
87 |
91.6 |
| 5 Massage of bony prominences is important in case of hyperemia in such areas. (F) |
47 |
49.5 |
|
91 |
95.8 |
| 6 A Stage 3 pressure ulcer is a partial thickness skin loss, involving the epidermis. (F) |
68 |
71.6 |
|
71 |
74.7 |
| 7 All individuals should be assessed on admission to a hospital for risk of pressure ulcer development. (T) |
91 |
95.8 |
|
92 |
96.8 |
| 8 The creams, transparent dressings and extra fine hydrocolloid dressings help in protecting the skin against the effects of friction. (T) |
77 |
81.1 |
|
82 |
86.3 |
| 9 Stage 4 pressure ulcers show a full thickness skin loss with extensive destruction and tissue necrosis, or damage to muscle, bone, or supporting structure. (T) |
92 |
96.8 |
|
93 |
97.9 |
| 10 An adequate dietary intake of proteins and calories should be maintained during illness/hospitalization. (T) |
91 |
95.8 |
|
95 |
100 |
| 11 Patients confined to bed should be repositioned every 3 hours. (F) |
75 |
78.9 |
|
84 |
88.4 |
| 12 1 A turning schedule should be used for each patient at risk for or with pressure ulcer. (T) |
91 |
95.8 |
|
90 |
94.7 |
| 13 Water-filled/air-filled gloves relieve pressure on calcanei. (F) |
22 |
23.1 |
|
85 |
89.5 |
| 14 Air or water donut cushions help to prevent pressure ulcers. (F) |
10 |
10.5 |
|
71 |
74.7 |
| 15 In a side lying position, a patient with or at risk for pressure ulcer should be at a 30 degree angle with the bed. (T) |
39 |
41.1 |
|
69 |
72.6 |
| 16 In a patient with or at risk for pressure ulcer, the head of the bed should be maintained at an angle no higher than 30 degrees, if there is no medical contraindication. (T) |
30 |
31.6 |
|
67 |
70.5 |
| 17 A patient who cannot move him or herself should be repositioned every 2 hours while sitting in a chair. (F) |
32 |
33.7 |
|
47 |
49.5 |
| 18 A patient with impaired mobility who can move him/herself without aid should be taught to shift his/her weight every 15 minutes for relief of pressure, while sitting in a chair. (T) |
52 |
54.7 |
|
82 |
86.3 |
| 19 The patient with impaired mobility who can remain in the chair should be fitted for a cushion for protection of the areas of bony prominences. (T) |
79 |
83.2 |
|
80 |
84.2 |
| 20 Stage 2 pressure ulcers present full thickness skin loss. (F) |
61 |
64.2 |
|
64 |
67.4 |
| 21 The skin of a patient at risk for pressure ulcer should remain clean and dry. (T) |
91 |
95.8 |
|
95 |
100 |
| 22 Preventive measures against new injuries do not need to be adopted continuously when the patient already has pressure ulcer. (F) |
89 |
93.7 |
|
92 |
96.8 |
| 23 Sliding sheets or underpads should be used to transfer or move patients who cannot move themselves without aid. (T) |
83 |
87.4 |
|
87 |
91.6 |
| 24 Mobilization and transfer of patients who do not move themselves without aid should always be performed by two or more people. (T) |
94 |
98.9 |
|
94 |
98.9 |
| 25 For the patient with chronic condition who does not move himself/herself without aid, rehabilitation must be initiated and include orientations on the prevention and treatment of pressure ulcer. (T) |
95 |
100 |
|
95 |
100 |
| 26 Every patient who does not walk must be submitted to risk assessment concerning the development of pressure ulcer. (T) |
92 |
96.8 |
|
94 |
98.9 |
| 27 Patients and family members should be oriented regarding the causes and risk factors for the development of pressure ulcer. (T) |
95 |
100 |
|
95 |
100 |
| 28 Bony prominences should not have direct contact with one another. (F) |
92 |
96.8 |
|
95 |
100 |
| 29 Every person assessed to be at risk for developing pressure ulcers should be placed on a pressure-redistribution bed surface. (T) |
81 |
85.3 |
|
64 |
67.4 |
| 30 Skin macerated from moisture tears more easily. (T) |
95 |
100 |
|
94 |
98.9 |
| 31 Pressure ulcers are sterile wounds. (F) |
75 |
78.9 |
|
71 |
74.7 |
| 32 A pressure ulcer scar will break down faster than unwounded skin. (T) |
71 |
74.7 |
|
83 |
87.4 |
| 33 A blister on the heel is nothing to worry about. (F) |
92 |
96.8 |
|
95 |
100 |
| 34 A good way to decrease pressure on the heels is to elevate them off the bed. (T) |
71 |
74.7 |
|
86 |
90.5 |
| 35 All care given to prevent or treat pressure ulcers do not need to be documented. (F) |
94 |
98.9 |
|
95 |
100 |
| 36 Shear is the force that occurs when the skin sticks to a surface and the body slides. (T) |
81 |
85.3 |
|
85 |
89.5 |
| 37 Friction may occur when moving a person up in bed. (T) |
91 |
95.8 |
|
90 |
94.7 |
| 38 Stage 2 pressure ulcers may be extremely painful due to exposure of nerve endings. (T) |
45 |
47.4 |
|
50 |
52.6 |
| 39 For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals. (T) |
92 |
96.8 |
|
93 |
97.9 |
| 40 Developing educational programs in the institution may reduce the incidence of pressure ulcers. (T) |
95 |
100 |
|
95 |
100 |
| 41 Hospitalized patients need to be evaluated as to the risk for pressure ulcer at least once during their hospitalization. (F) |
95 |
100 |
|
94 |
98.9 |
