Exam 21: Tissue Integrity

The nurse is planning to provide care to extended family members spanning three generations who are being treated for burn injuries after a fire. Based on an understanding of lifespan factors, the nurse should anticipate that which of the following is true?

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?

A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified?

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?

The nurse is caring for a client who is to receive mechanical debridement of burn wounds. Which methods should the nurse anticipate using to complete this treatment? Select all that apply.

Softening of the skin as a result of prolonged wetting or soaking is also referred to as

A nurse working in the intensive care unit (ICU)is caring for a client who is 10 days postoperative after open abdominal surgery. The client has a well-approximated midline surgical incision that has numerous staples, and the nurse notes a "healing ridge" is present. Based on this information, the incision is currently in which phase of the healing process?

A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered?

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

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 caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor?

An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which intervention best addresses the client's nutritional needs?

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

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

Which data supports the nurse's concern that a client is at a high risk for a burn injury? Select all that apply.

A nurse is conducting a training session with new staff members at a nursing home. One of the staff members asks why the facility's older adult clients are at elevated risk for pressure injuries. Which response is best?

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

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 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?