Deck 26: Skin Integrity and Wound Healing

Question 1

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

A) Bowel obstruction
B) Pressure injury
C) Depression
D) Urinary incontinence

Answer 1

Pressure injury

Question 2

The thin, outermost layer of the skin is continuously shed in a process called:

A) dermabrasion.
B) dermatitis.
C) exfoliation.
D) desquamation.

Answer 2

desquamation.

Question 3

The cells in the epidermis that provide protection from microorganisms are:

A) macrophages and mast cells.
B) melanin and sebum.
C) Langerhans and keratinocytes.
D) granulocytes and agranulocytes.

Answer 3

Langerhans and keratinocytes.

Question 4

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

A) milia.
B) prickly heat.
C) acne vulgaris.
D) lanugo.

Question 5

A mother is asking the nurse about care of her toddler's skin. The nurse should instruct the mother:

A) to only use cloth diapers, since disposable ones can cause eczema.
B) to apply sunscreen when exposed to ultraviolet rays.
C) that lanugo is hair of a different color that is permanent.
D) to never trim the baby's nails due to susceptibility to infection.

Question 6

The nurse is instructing mothers of toddlers on the care of skin and the prevention of injury. The nurse should include which educational intervention?

A) Protect from burns by covering electric outlets, and have a safe zone.
B) Be sure that the child receives three servings of dairy products daily.
C) Read to the child daily to enhance intellectual development.
D) Provide time for interaction with other children to assist with socialization.

Question 7

A nursing student visits a nursing instructor's office and the instructor states, "Gina, are you tanning in a tanning booth?" The nursing student says yes. The nursing instructor's best response would be to instruct her on:

A) the rate of cancer from exposure to sun and tanning beds.
B) the need to apply sunscreen after tanning sessions.
C) the application of skin lotions to protect from skin ulcers.
D) the need to consume milk products to enhance bone development.

Question 8

In the older adult client, wrinkling is related to:

A) loss of protein.
B) loss of elasticity.
C) loss of fat.
D) loss of circulation.

Question 9

Which nutrient will prevent abnormal pigmentation?

A) Copper
B) Vitamin D
C) Vitamin E
D) Fat

Question 10

A nurse is providing a complete bed bath to a 60-year-old client with diabetes. The nurse is conducting an assessment during the bath and observes a red, raised rash under the client's breasts. This manifestation is most consistent with:

A) an allergic reaction to medications.
B) an allergic reaction to detergent.
C) a rash related to a yeast infection.
D) a rash related to immobility.

Question 11

A child is brought to the clinic by his mother. The mother states he has been at Boy Scout camp. The child has a rash on his face, arms, and legs. The child states it itches severely. The child has probably come in contact with:

A) latex gloves.
B) a food to which he is allergic.
C) chlorine in the pool.
D) poison ivy.

Question 12

A skin infection caused by beta-hemolytic streptococci common in children is:

A) acne vulgaris.
B) impetigo.
C) scabies.
D) herpes.

Question 13

A full-thickness burn develops a leathery covering called a(an):

A) eschar.
B) static.
C) abrasion.
D) erythema.

Question 14

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

A) Support the client from sliding in bed.
B) Lubricate the area with skin oil.
C) Improve the client's hydration.
D) Pull client up under the arms.

Question 15

A client has a fissure on her finger due to chafing. The client asks "How long will it be painful?" The nurse explains that the inflammation phase will last:

A) 3 days.
B) 5 days.
C) 7 days.
D) 2 weeks.

Question 16

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for:

A) infection.
B) herniation.
C) dehiscence.
D) evisceration.

Question 17

A woman fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. The client has a(an):

A) infection.
B) dehiscence.
C) evisceration.
D) fistula.

Question 18

A client has developed blisters around the tape that secures the dressing. The nurse should:

A) apply tape to the side of the blisters.
B) use Montgomery straps.
C) apply the dressing with a binder.
D) apply skin barrier to protect skin.

Question 19

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?

A) Cleanse labia with scented soap.
B) Soak in a warm bath for drainage.
C) Apply an ice pack to relieve pain.
D) Expose the area to a heat lamp.

Question 20

The nurse is caring for a client who has recently noted abnormal pigmentation in the skin. What is most likely deficient in the client's diet?

A) Vitamin A
B) Vitamin B₁₂
C) Zinc
D) Magnesium

Question 21

The nurse is performing an admission assessment on a client being admitted to a long-term care facility. The nurse notes the client has a history of psoriasis. Which locations on the body is the nurse most likely to find manifestations consistent with the condition? Select all that apply.

A) Trunk
B) Elbows
C) Knees
D) Soles of the feet
E) Neck

Question 22

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate?

A) "The condition is hard to cure."
B) "You will likely experience periods of increased skin outbreaks and periods of remissions."
C) "You will have this disease for life."
D) "Your personal health habits will dictate how well you handle this condition."

Question 23

The nurse is discussing home remedies for insect bites with a group of college students. The nurse correctly includes which remedy in the presentation?

A) Chamomile
B) Lavender
C) Aloe vera
D) Tree tea oil

Question 24

The nurse is discussing traditional cultural beliefs relating to skin care and healing with a group of nursing students. Which remark by a participant indicates the need for further instruction?

A) Canadians traditionally are concerned about the cost of medical treatment.
B) Native Americans often believe in the use of herbal or spiritual therapy.
C) Body image is of little importance to the traditional French cultural beliefs.
D) Asian culture often embraces the use of acupuncture.

Question 25

A nurse is teaching a client who has a history of pressure injury about nutrition and its role in promoting wound healing. The nurse determines that the client has understood the information when the client identifies the importance of including foods containing which vitamin in the client's diet? Select all that apply.

A) Vitamin D
B) Vitamin A
C) Vitamin C
D) Vitamin B₇ (biotin)
E) Vitamin B₉ (folic acid)

Question 26

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:

A) first degree.
B) second degree.
C) third degree.
D) fourth degree.

Question 27

A client has been admitted to the acute care unit after surgery to debride an infected skin ulceration. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?

A) Primary intention
B) Secondary intention
C) Tertiary intention
D) Granulation

Question 28

An client on the unit who is obese has demonstrated difficulty healing a large pressure ulcer. The nurse correctly recognizes that this is most likely because of which factor?

A) The client's size limits his or her activity level.
B) Adipose tissue is poorly vascularized.
C) Obesity is linked to impaired white blood cell function.
D) The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.