Exam 21: Tissue Integrity

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?

The nurse is planning care for a client with a large area of erythema,swelling,and pruritic lesions on the hands and arms.Which nursing diagnosis should the nurse use to guide this client's care?

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

The nurse has established as an expected outcome that a client will "demonstrate healing of a stage II pressure ulcer over the coccyx." Which finding indicates that the client failed to achieve this outcome?

A nurse is caring for a client who is scheduled to undergo diagnostic testing to determine the cause of dermatitis.When educating the client about diagnostic testing,which statement by the nurse is appropriate?

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

The nurse is providing care to a client who is experiencing skin inflammation and pruritus.Which medication prescriptions does the nurse anticipate for this client? Select all that apply.

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

The nurse is assessing a client with a surgical wound.Which observation indicates that care has been effective for this client?

A client is admitted with a gunshot wound to the leg.Which nursing diagnosis would be important to include in this client's plan of care?

The nurse is concerned that a client is at risk for pressure ulcers.Which assessment data supports the nurse's concern? Select all that apply.

A middle-age adult client states to the nurse "I do want to have liver spots like my parents did as they got older".Which instruction by the nurse is appropriate?

A client has a documented stage III pressure ulcer on the right hip.Which nursing diagnosis is most appropriate for this client?

The nurse is providing care to a client who has a vitamin D deficiency and is at risk for an alteration in skin integrity.The client states,"how can this be? I drink 3 glasses of milk each day." Which response by the nurse is appropriate?

A client tells the nurse that flakes of skin come loose with every shampoo.Based on this data,which secondary skin lesion does the nurse suspect the client is experiencing?

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?

An older adult client with poor nutritional intake is demonstrating signs of poor wound healing.Which actions by the nurse are appropriate? Select all that apply.

When planning care for a client at risk for developing pressure ulcers,which intervention should be included? Select all that apply.

A nurse is working in a skilled nursing facility and is performing an assessment on an older adult client.The nurse notes that the client has hypopigmentation of the skin on both hands.Based on this data,which condition does the nurse suspect?

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?