Deck 21: Tissue Integrity

Question 1

While assessing the feet and ankles of an older adult client,the nurse presses a finger into the client's skin in order to create an indentation.For what is the nurse assessing?

A) Periorbital edema
B) Ascites
C) Pitting edema
D) Sacral edema

Answer 1

Pitting edema

Question 2

A client has superficial burns on the hand from boiling water.What can the nurse suggest that the client use to help with the healing of these burns?

A) Chamomile
B) Vitamin C
C) Evening primrose oil
D) Aloe vera gel

Answer 2

Aloe vera gel

Question 3

An older adult client complains of having dry skin.Which items would support this client's complaint? Select all that apply.

A) Reduction in elastin
B) Depleted moisture in epidermal cells
C) Reduced fluid intake
D) Thinner subcutaneous skin layer
E) Poor nutrition

Answer 3

Depleted moisture in epidermal cells
Reduced fluid intake
Poor nutrition

Question 4

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?

A) Minor
B) Moderate
C) Major
D) Significant

Question 5

After a skin graft procedure to the leg,a client is returned to the burn care unit.Based on this data,which action by the nurse is appropriate?

A) Placing the client flat with the affected extremity abducted.
B) Elevating the head of bed 30°
C) Maintaining the head of the bed flat
D) Elevating the affected extremity

Question 6

A client with a burn injury is prescribed mechanical debridement of the wounds.Based on this data,which should the nurse include in the client's plan of care? Select all that apply.

A) Homograft
B) Application of a topical agent to dissolve necrotic tissue
C) Irrigation of the burn wounds
D) Application of wet-to-dry gauze dressings
E) Hydrotherapy

Question 7

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.

A) Erythromycin
B) Bacitracin
C) Gentamycin
D) Desoximetasone
E) Desonide

Question 8

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) "In patch testing, an adhesive patch with common allergens is placed on your back."
B) "The patch from the patch test is usually removed after 2 weeks."
C) "Skin prick and skin injection tests are used to test for delayed reactions."
D) "You may shower or exercise while the patch from the patch test is in place."

Question 9

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

A) Ineffective Coping
B) Powerlessness
C) Anxiety
D) Situational Low Self-Esteem

Question 10

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

A) Decreased osmotic pressure in the burned tissue
B) Reduced vascular permeability at the site of the burned area
C) Increased fluids in the extracellular compartment
D) Inability of the damaged capillaries to maintain fluids in the cell walls

Question 11

An older adult client with severe burns over more than half of the body has an indwelling catheter.When evaluating the client's intake and output,which should be taken into consideration?

A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.
B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase.
C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins.
D) The amount of urine output will be greatest in the first 24 hours after the burn injury.

Question 12

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

A) Creatine phosphokinase (CPK)
B) BUN levels
C) Hemoglobin
D) Albumin level

Question 13

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) Spend at least 15 minutes each day in the sun.
B) Increase the intake of calcium.
C) Increase the intake of dietary fat.
D) Avoid the sun or use a sunscreen to reduce skin damage.

Question 14

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) Hyperplasia of melanocytes
B) Decreased perfusion of the dermis
C) Increased permeability of the epidermal layer
D) Hyperplasia of capillaries

Question 15

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) "A loss of melanin causes a decrease in vitamin D."
B) "The skin synthesizes vitamin D from sunlight."
C) "Insufficient protein intake causes a vitamin D deficiency."
D) "Not all milk contains vitamin D."

Question 16

A client has an excoriated skin area with drainage.Which diagnostic test does the nurse anticipate to diagnose the skin lesion?

A) Skin biopsy
B) Culture
C) Wood's lamp
D) Patch test

Question 17

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

A) Part-time employment at a convenience store
B) Diagnosis of hypertension
C) Age 71 years
D) Utilizes public transportation for grocery shopping
E) Currently smokes 1 pack per day of cigarettes

Question 18

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?

A) "The newborn's skin is about 40% to 60% thicker than an adult's skin at birth."
B) "The newborn's skin contains more water than an adult's and has loosely attached cells."
C) "The newborn's thicker skin decreases absorption of harmful chemical substances and topical medications."
D) "The newborn's skin has a greater percentage of underlying subcutaneous fat compared to adults."

Question 19

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?

A) Nodule
B) Macule
C) Scale
D) Crust

Question 20

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?

A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only.
B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis.
C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation.
D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn.

Question 21

The nurse is evaluating care provided to a client with contact dermatitis.Which observation indicates that treatment has been effective?

A) The client is fatigued from inadequate sleep due to pruritus.
B) The client is observed walking in the hallway.
C) The client has areas of excoriation on the arms and anterior legs from scratching during sleep.
D) The client has reduced areas of contact dermatitis with evidence of skin healing.

Question 22

The nurse is creating a teaching plan for a client with allergic contact dermatitis.Which instructions are appropriate for the nurse to include for this client? Select all that apply.

A) Use the topical steroid for 2 to 3 weeks even when the skin is healing.
B) Apply a thin film of steroid cream to damp skin area for 2 to 3 weeks.
C) Apply topical steroid once a day before sleep.
D) Soak hand in Burow's solution.
E) Apply a thick layer of steroid cream to dry skin area twice a day for 1 month.

Question 23

The nurse is planning care for a client with contact dermatitis.Which interventions should be included in this plan of care? Select all that apply.

A) Provide instruction in washing clothes in bleach and hot water.
B) Instruct to avoid perfumes and lotions containing alcohol.
C) Provide instruction in the use of hot water and soap to bathe the body.
D) Teach the client the need to keep the skin dry.
E) Stress the importance of utilizing prescribed medication for the entire course.

Question 24

A client has a laceration that was closed with tissue adhesive.Which is the process by which this wound will heal?

A) Open approximation
B) Secondary healing
C) Delayed closure
D) Primary intention

Question 25

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) The rubber doughnut pressure relief device was not delivered by central supply.
B) The client's serum albumin increased over the last month.
C) A right side-back-left side-back turning schedule was utilized.
D) Nurses did not document disinfection of the wound with alcohol with each dressing change.

Question 26

An older adult client with friable skin and poor skin turgor has slipped down in the bed.Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown?

A) Using the bed sheet to slide the client up in the bed
B) Placing the bed in reverse Trendelenburg
C) Using the client's arms to pull the client up in the bed
D) Lifting the client, using the client's legs and arms for assistance

Question 27

A nurse is planning care for a client with a contact dermatitis.When conducting discharge teaching,which statement by the nurse is appropriate?

A) "Bathe or shower twice daily to reduce allergen contact."
B) "Avoid the use of all lotions."
C) "When using steroid ointments, use a thick layer on dry skin for maximum absorption."
D) "Use steroid ointments for 2 to 3 weeks for best results."

Question 28

A client has a pressure ulcer 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) Partial-thickness loss of dermis
B) Non-blanchable erythema
C) Suspected deep tissue injury
D) Full-thickness tissue loss

Question 29

A client is diagnosed with acute allergic contact dermatitis over 25% of the body.Which prescription does the nurse anticipate for the client?

A) Calamine lotion to affected skin area as needed
B) Topical steroids applied twice a day for 2 to 3 weeks
C) Cool compresses with Burow's solution twice a day
D) Oral steroids for 7 to 10 days

Question 30

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?

A) "I will need to obtain an order from the healthcare provider to perform a massage."
B) "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care."
C) "I will record these findings in the medical record."
D) "Massaging the area may actually cause more harm to a potentially compromised area of skin."

Question 31

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

A) Impaired Skin Integrity
B) Risk for Injury
C) Impaired Tissue Integrity
D) Ineffective Peripheral Tissue Perfusion

Question 32

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

A) Initiate a frequent toileting schedule.
B) Raise the heels off of the bed.
C) Turn the client every 4 hours.
D) Use inflatable doughnut-style devices to reduce pressure on the sacrum.
E) Massage pressure areas with lotion every 4 hours.

Question 33

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

A) "I will need to get an order from the physician."
B) "Using the doughnut can cause skin breakdown."
C) "You will need to wait until discharge and use this at home."
D) "I will obtain the device for you."

Question 34

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) Impaired Social Interaction
B) Anxiety
C) Impaired Skin Integrity
D) Situational Low Self-Esteem

Question 35

A client shows the nurse an area of erythema,swelling,and lesions under a wedding ring.Based on this data,which condition does the nurse suspect?

A) Psoriasis
B) Allergic contact dermatitis
C) Eczema
D) Irritant contact dermatitis

Question 36

The nurse identifies a client at risk for contact dermatitis.Which assessment findings support the nurse's assumption? Select all that apply.

A) Blood pressure of 120/72 mmHg
B) Frequent hand washing
C) Heart rate of 76 and regular
D) Cares for plants in a garden
E) Employment as a computer operator

Question 37

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?

A) Maintain the head of the bed at 30° angle, with client positioned on the right or left side.
B) Apply a heat lamp to the area to increase circulation.
C) Apply a dry dressing to the pressure ulcer.
D) Maintain the head of the bed at 45° angle.

Question 38

A nurse is caring for a client with a Stage II pressure ulcer on the coccyx who is at risk for additional pressure ulcers.Which nursing intervention is appropriate while caring for this client?

A) Clean the pressure ulcer as needed.
B) Use hydrogen peroxide as chemical debridement of wound bed as needed.
C) Maintain the head of the client's bed at 30°.
D) Avoid placing the client in the side-lying position.

Question 39

A client with contact dermatitis tells the nurse about scratching the skin raw at night from the itching.Which response by the nurse is appropriate?

A) "You should wear cotton gloves during sleep."
B) "You should restrict fluids during the day."
C) "You should bathe every day."
D) "You should apply a lotion containing alcohol to the affected area."

Question 40

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) Age 54
B) Body temperature within normal limits
C) Low serum albumin level
D) Continence of urine and stool
E) Prescribed bedrest

Question 41

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

A) The client's temperature is 100°F.
B) The client performs wound care independently.
C) There is only a scant amount of purulent drainage on the dressing.
D) A small area of erythema and edema is present.

Question 42

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.

A) Ensure an adequate fluid intake.
B) Assist with deep-breathing exercises.
C) Medicate for pain prior to dressing changes.
D) Request a dietary consult for nutritional support.
E) Encourage ambulation.

Question 43

A client has a wound of the left lateral aspect of the thigh.Which action by the nurse promotes wound healing for this client?

A) Positioning to keep weight off of the wound
B) Positioning with weight directly on the wound
C) Restricting fluids
D) Enforcing strict bedrest

Question 44

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?

A) Situational Low Self-Esteem
B) Risk for Infection
C) Anxiety
D) Ineffective Coping

Question 45

A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate.The client's surgical wound has staples that are aiding in the wound healing.When documenting this client's care,which terminology best describes this client's care?

A) Primary intention healing
B) Secondary intention healing
C) Tertiary intention healing
D) Quaternary intention healing

Question 46

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

A) Discharge to home as soon as possible.
B) Resume independent activities of daily living.
C) Increase ambulation.
D) Regain intact skin.

Question 47

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 a "healing ridge" noted.Which healing phase best describes the incision?

A) Inflammatory phase
B) Proliferative phase
C) Maturation phase
D) Synthesis phase

Question 48

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.

A) Notify the client's surgeon.
B) Pack the wound with nonadherent gauze.
C) Turn the client onto the abdomen.
D) Position the client in bed with knees bent.
E) Cover the area with a large, saline-soaked dressing.

Question 49

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?

A) Monitor urine output.
B) Assess postoperative wound healing.
C) Restrict protein intake.
D) Expect purulent drainage.