ATI Tissue Integrity Quizz

A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan?

The nurse should change the client's position every 2 hours to stimulate circulation and prevent pressure ulcers.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should document this as which of the following types of wounds? Abrasion Contusion Laceration Puncture

-Laceration Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged and irregular. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound.

A nurse is planning care for an older adult who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

-Use a transfer device to lift the client up in bed. Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse in a provider's office is caring for a client who reports pruritus and reddened, oozing lesions on her lower leg. The nurse should suspect which of the following disorders? Alopecia Contact dermatitis Pediculosis Tinea pedis

Contact dermatitis These findings are consistent with contact dermatitis, which is skin inflammation that results from direct skin contact with chemicals or causative agents.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serous Purulent Sanguineous Serosanguineous

serosanguineous Watery red drainage should be documented as serosanguineous.

A nurse in a community health clinic is caring for a client who has a new diagnosis of plantar warts. The nurse should include which of the following in the teaching plan for this client?

Plantar warts are painful with ambulation.

A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which if the following statements by the parents indicates an understanding of the teaching? -"All recently used clothing, bedding, and towels must be washed in hot water." -"My child must be free from nits before returning to school." -"I will treat all the family members to be on the safe side." -"Toys that can't be dry cleaned or washed must be thrown out."

"All recently used clothing, bedding, and towels must be washed in hot water." Pediculosis capitis is commonly referred to as head lice. All recently used clothing, bed sheets, and towels need to be washed in hot water. Anything that cannot be washed should be sealed in a plastic bag for 10 to 14 days. Unwashable items can include jackets, sweaters, hats, pillows, bicycle helmets, and stuffed animals. Furniture, carpets, and car seats can be sprayed with a variety of over-the-counter products.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Reposition the client every 3 hr. Massage bony prominences to promote circulation. Provide the client with a diet high in protein. Apply cornstarch to keep the skin dry.

-Provide the client with a diet high in protein. Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.i

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

-apply a moisture barrier ointment Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (select all that apply) Vitamin A Vitamin B12 Vitamin C Vitamin D Vitamin E

-vitamin A -vitamin C -vitamin E Vitamin A is important for tissue synthesis, wound healing, and immune function. Vitamin C is important for capillary formation, tissue synthesis, and wound healing. Vitamin E functions as an antioxidant to protect from cell damage, and enhances Vitamin A utilization.

A nurse is caring for a child who has tinea pedis. The child's parents ask the nurse what this infection is commonly called. The nurse should respond with which of the following common names? Shingles Athlete's foot Fever blister Valley fever

Athlete's foot Athlete's foot is the common name for tinea pedis.

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic subcutaneous tissue.

A school nurse is assessing a school-aged child and notices white flakes that don't brush off the hair and a rash on the back of the child's neck. The nurse should suspect which of the following disorders? Pediculosis capitis Impetigo contagiosa Folliculitis Tinea capitis

Pediculosis capitis Pediculosis capitis is head lice, and its nits (eggs) are cemented to the hair shaft. The nits are silvery to white in color, similar to dandruff. They are typically seen on hair on the back of the head near the nape of the neck. A papular rash might be present at the nape of the neck secondary to scratching.

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an unexpected finding? -Report of exposure to a skin irritant -Denial of pruritus -Systemic symptoms including elevated temperature -Report of generalized joint discomfort

Report of exposure to a skin irritant The most common cause of contact dermatitis is exposure to a topical irritant therefore identifying this irritant is a component of treatment.

A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client? Use friction when washing the affected area. Use an oil-based soap to wash affected areas daily. Express the larger comedones periodically. Use a new cosmetic pad with each limited application of makeup.

-Use a new cosmetic pad with each limited application of makeup. Use of a new cosmetic pad with each makeup application decreases the risk of reinfection. Makeup should be applied on a limited basis, as many are oil-based products, clog pores, and exacerbate acne.