Exam 21: Tissue Integrity

A client recovering from abdominal surgery tells the nurse that "something popped" in his abdominal incision.Upon inspection,the nurse finds that evisceration has occurred.What actions by the nurse are appropriate? Select all that apply.

A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area.Which response by the nurse is appropriate?

Hemostasis and phagocytosis are characteristic of which stage of the wound healing process?

A client is evaluated after suffering severe burns to the torso and upper extremities.The nurse notes edema at the burned areas.Which of the following best describes the underlying cause of this manifestation?

A client requests a small inflated doughnut-style device to sit on to relieve pressure.Which response by the nurse is most appropriate?

A nurse is conducting a skin assessment of a patient.Upon palpating skin temperature,the nurse notes the skin is warm and red.This is an abnormal sign that may be indicative of

A client has a pressure injury on the medial malleolus.The client's skin is intact with purple discoloration and a blood-filled blister.When documenting this finding,which terminology is appropriate for the nurse to use?

A nurse educator is teaching a group of student nurses about newborn skin and factors that relate to this concept.Which statement will the educator include in the teaching session?

Which of the following medications may be discontinued in a client who is experiencing delayed wound healing?

The nurse is planning care for a client with a surgical wound.Which goal related to the surgical wound is most appropriate for this client?

How should the nurse position a client who is returned to the burn unit following a graft procedure to the leg?

The nurse is evaluating the adequacy of the burn-injured client's nutritional intake.Which laboratory value is the best indicator of nutritional status?

An older adult client is admitted to the medical-surgical unit for a hip fracture.During postoperative recovery,the nurse notices a stage 1 pressure injury forming on the client's sacrum.Which action by the nurse is appropriate to reduce the progression of this injury?

A client who sustained burns to both lower extremities reports feeling frustrated by not being able to provide self-care.Which nursing diagnosis would be appropriate for the client at this time?

The nurse observes flakes of greasy white dandruff in a client's hair.The nurse should correctly identify this as which type of secondary lesion?

An older adult client diagnosed with chronic obstructive pulmonary disease (COPD)is scheduled for a total knee replacement.What should the nurse include in this client's plan of care to address the risk of an alteration in tissue integrity?

A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate.Three days after the debridement,the client's surgical wound was closed with staples that are aiding in healing.Given this information,which of the following terms should the nurse use when documenting this client's care?

Which of the following findings suggests that a wound is infected with pyogenic bacteria?

A nurse is caring for a client with a stage 2 pressure injury on the coccyx who is at risk for additional pressure injuries.Which nursing intervention is appropriate when caring for this client?

The nurse is providing care to a pediatric client who was admitted to the pediatric intensive care unit (PICU)with a partial-thickness thermal burn.When planning care for this client,which should the nurse consider regarding this type of burn?