Deck 17: Care of Aging Skin and Mucous Membranes

Question 1

What is the purpose of the hydrocolloid dressing applied to a clean stage II pressure ulcer? (Select all that apply.)

A) Débride the ulcer
B) Prevent shear force trauma
C) Absorb the exudate
D) Harden eschar
E) Make an air-occlusive seal

Answer 1

Débride the ulcer
Prevent shear force trauma
Absorb the exudate
Make an air-occlusive seal

Question 2

What would be the most effective intervention to prevent pressure ulcers in the bedridden patient?

A) Perform skin assessment every day.
B) Use a draw sheet to move the patient.
C) Change the patient's position every 2 hours.
D) Remove wet bed linens promptly.

Answer 2

Change the patient's position every 2 hours.

Question 3

The older man complains of a hard white patch that has developed on the side of his tongue. What would be the most appropriate action of the nurse?

A) Request a dental consult to evaluate his dentures for adequate fit.
B) Examine his teeth to assess for a lost filling, which has left sharp edges on his teeth.
C) Request a medical consult for evaluation of a precancerous lesion.
D) Provide frequent, warm, salt water rinses for his mouth.

Answer 3

Request a medical consult for evaluation of a precancerous lesion.

Question 4

On the admission assessment of an 80-year-old to a long-term care facility, the nurse notes that the resident's toenails are dark, thick, and brittle; extremely misshapen; and growing at an angle from the toe. What does the nurse suspect has caused the changes in the nails?

A) Fungal infection of the nails
B) Ram's horn nails
C) Ingrown nails
D) Expected age-related changes in the nails

Question 5

The nurse assesses an area of skin on the patient's upper thigh that is different in appearance than the surrounding skin. What documentation would be the most informative?

A) Red area on upper right thigh. Patient denies discomfort
B) Erythematous scaly patch 2 ´ 2 cm on lateral aspect of right thigh. Patient denies pain
C) Painless red patch on right thigh 2 ´ 2 cm
D) Medium-size red scaly patch on right thigh. 0 drainage. 0 pain

Question 6

The male patient who has been on long-term antibiotic therapy inquires what may have caused his thrush. What is the most informative response of the nurse?

A) A vitamin A deficiency
B) Long-term antibiotic therapy has destroyed the normal flora of his mouth
C) An allergy to the antibiotic
D) Oral hygiene has been inadequate

Question 7

An 80-year-old woman complains of pruritus from dry skin. What would be an appropriate bathing schedule for the patient?

A) A hot shower every night before going to bed.
B) A cool shower every morning using a detergent soap.
C) A soak in a warm sudsy bath, leaving a film of soap on the skin.
D) One shower a week, with sponge baths in between.

Question 8

When the patient complains of dry mouth, what should the nurse assess for?

A) Difficulty in chewing and swallowing
B) Mouth ulcerations
C) Adequate intake of vitamin B
D) Inflammation of the tongue

Question 9

The admitting nurse gives the new long-term care facility resident a score of 20 on both the Norton Risk Assessment Scale and the Braden Scale for Predicting Pressure Sore Risk. These scores indicate that the resident has

A) a high probability of developing a pressure ulcer.
B) a moderate risk of developing a pressure ulcer.
C) a low risk of developing a pressure ulcer.
D) at least one pressure ulcer at the time of admission.

Question 10

The long-term care facility resident who has not worn his dentures for several months complains that the dentures no longer fit. Why do the dentures no longer fit?

A) The gums have hypertrophied.
B) The gums have receded.
C) The jaw shape has altered.
D) The dentures have warped from disuse.

Question 11

A patient's toenails are brittle and thick. What other assessment should the nurse be sure to include?

A) Respiratory sounds
B) Pedal pulses
C) History of gout
D) Intake of dietary calcium

Question 12

The 80-year-old woman newly admitted to a long-term care facility complains of intense itching in her axillae and antecubital fossa. There are small red lesions in linear patterns. What condition does the nurse suspect?

A) Rosacea
B) Keratosis
C) Pruritus
D) Scabies

Question 13

What is the cause of progressively graying hair?

A) Decreased production of melanin
B) Altered blood circulation to the scalp
C) Decreased density of hair
D) Environmental factors

Question 14

The older adult complains of multiple bruises on his extremities. What are the marks the result of?

A) Arteriosclerotic changes in the vessels
B) Prolonged clotting time
C) Fragility of capillary walls
D) Reduction of subcutaneous fat

Question 15

When performing a skin assessment for pressure ulcers on an older man who is bedridden and prefers to lie on his right side, the nurse will pay special attention to the __________. (Select all that apply.)

A) right ear
B) lateral edge of the right foot
C) sacrum
D) medial edge of the left foot
E) right scapula

Question 16

What preventative action can be taken to prevent skin trauma from shearing force?

A) Slide the patient across the bed linens to change position.
B) Apply generous amounts of lotion to the patient's skin.
C) Lift the patient on draw sheets when pulling up in bed.
D) Give the patient frequent tub baths to soften the skin.

Question 17

What position would be most appropriate to reduce pressure ulcers in a bedridden patient?

A) Directly on his side, with the trochanter bearing the weight
B) Supine, with the sacrum and iliac crest bearing the weight
C) In a semi-Fowler position, with the sacrum and ischium bearing the weight
D) In a lateral position, with body rotated 30 degrees with gluteus bearing the weight

Question 18

What factors make the older adult more susceptible to pressure ulcers? (Select all that apply.)

A) The epidermal layer has thickened
B) Subcutaneous fat has diminished
C) Bruising is prevalent
D) Skin receptor cells have reduced in sensitivity
E) The skin is dry and scaly

Question 19

What are causes of pruritus in the older adult? (Select all that apply.)

A) A reduction of sebaceous gland function
B) A reduction in the amount of perspiration
C) Excessive bathing
D) Use of emollients
E) Environmental conditions

Question 20

The long-term care facility nurse requests a dental consult to treat gingivitis in a resident. If left untreated, what can gingivitis ultimately cause?

A) Receding gums
B) Tooth loss
C) Bleeding
D) Halitosis

Question 21

Which of the following are signs of Vincent angina? (Select all that apply.)

A) An advanced state of malnutrition
B) Enlargement of the cervical lymph nodes
C) Epistaxis
D) Dysphagia
E) A discolored tongue

Question 22

On the admission assessment of a resident to a long-term care facility, the nurse notes a painless area on the patient's coccyx that has partial skin loss. The nurse would record this as a stage _____ pressure ulcer.

Question 23

The nurse instructs a group of older adults on how to maintain intact skin. What would be included in the teaching plan? (Select all that apply.)

A) Altering their body position every 30 minutes while sitting in the chair
B) Changing incontinent products when they become soiled
C) Using a pressure-relieving device like the "donut" to sit on
D) Routinely checking their feet for redness and indentations
E) Patting the skin dry after a shower or bath

Question 24

What are causes of xerostomia in the older adult? (Select all that apply.)

A) Reduction in saliva
B) Allergy
C) Eating highly seasoned foods
D) Inadequate fluid intake
E) Use of diuretic medications

Question 25

A dark-complexioned African American has a suspected skin breakdown over the trochanter. What would be appropriate measures for the nurse to implement during the assessment? (Select all that apply.)

A) Use a halogen light to examine the area.
B) Palpate for local edema in the area.
C) Touch the area to feel for changes in tissue temperature.
D) Assess for localized pain.
E) Press the area to test for blanching.

Question 26

What interventions by the nurse will aid in maintaining skin integrity in the long-term care facility residents? (Select all that apply.)

A) Changing the briefs and bed linens when damp
B) Maintaining the temperature in the room at 80 degrees
C) Rinsing excess soap off the skin during a shower
D) Administering frequent pericare on the continent resident
E) Laying residents down after lunch

Question 27

Which long-term care residents would benefit from a referral to a podiatrist? (Select all that apply.)

A) 90-year-old poststroke patient with right hemiparesis
B) 85-year-old diabetic patient who is 100 lb overweight
C) 80-year-old resident with phlebitis and a stasis ulcer on the left ankle
D) 75-year-old resident with congestive heart failure (CHF)
E) 70-year-old resident with chronic obstructive pulmonary disease (COPD)