Module 21 - Tissue Integrity

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% thinner than an adult's skin at birth." B) "The newborn's skin contains less water than an adult's and has tightly 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."

A) "The newborn's skin is about 40% to 60% thinner than an adult's skin at birth."

A patient with an allergy to latex develops contact dermatitis following an examination during which the nurse wore latex gloves. Which best describes the associated pathophysiology? A) An immune response that leads to issues with tissue integrity B) Impaired tissue integrity that leads to an immune response C) Impaired tissue integrity that leads to an infection D) Decreased perfusion that leads to issues with tissue integrity

A) An immune response that leads to issues with tissue integrity

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. The nurse should recognize that this condition is related to which age-related skin change? A) Hyperplasia of melanocytes B) Decreased perfusion of the dermis C) Increased permeability of the epidermal layer D) Hyperplasia of capillaries

A) Hyperplasia of melanocytes

Hemostasis and phagocytosis are characteristic of which stage of the wound healing process? A) Inflammatory phase B) Proliferative phase C) Granulation phase D) Maturation phase

A) Inflammatory phase

When planning care for a client at risk for developing pressure injuries, which intervention(s) should be included? Select all that apply. A) Initiate a frequent toileting schedule. B) Raise the client's heels off 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.

A) Initiate a frequent toileting schedule. B) Raise the client's heels off the bed.

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) Maintain the head of the bed at a 30-degree angle, with the 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 injury. D) Maintain the head of the bed at a 45-degree angle.

A) Maintain the head of the bed at a 30-degree angle, with the client positioned on the right or left side.

A client recovering from abdominal surgery tells the nurse that "something popped" in his 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 client's wound with nonadherent gauze. C) Turn the client onto his abdomen. D) Position the client in bed with his knees bent. E) Cover the incision with a large, saline-soaked dressing.

A) Notify the client's surgeon. D) Position the client in bed with his knees bent. E) Cover the incision with a large, saline-soaked dressing.

The nurse is planning care for a client in the acute stage of a burn injury. Which aspects of care should the nurse identify as a priority? Select all that apply. A) Nutrition B) Psychosocial support C) Pain management D) Fluid resuscitation E) Wound care

A) Nutrition C) Pain management D) Fluid resuscitation E) Wound care

Which of the following medications may be discontinued in a client who is experiencing delayed wound healing? A) Oral prednisone B) Topical antibiotics C) Topical growth factors D) Oral antibiotics

A) Oral prednisone

A client has a wound on the left lateral aspect of the thigh. Which action by the nurse would best promote wound healing for this client? A) Positioning the client to keep weight off the wound B) Positioning the client with weight directly on the wound C) Restricting fluids D) Enforcing strict bedrest

A) Positioning the client to keep weight off the wound

Softening of the skin as a result of prolonged wetting or soaking is also referred to as A) maceration. B) debridement. C) excoriation. D) shearing.

A) maceration.

An adult burn patient is receiving fluid resuscitation of warm, lactated Ringer's solution during the first 24 hours following injury. The client's hourly urine output is being monitored to determine whether the resuscitation is adequate. The most recent reading is 1.10 mL/kg/hr. The nurse understands that this amount of urine output is A) slightly higher than the normal range. B) slightly lower than the normal range. C) within the normal range. D) extremely low.

A) slightly higher than the normal range.

The nurse is caring for an older adult. Which age-related changes should the nurse identify as increasing the risk of dry skin? Select all that apply. A) Reduction in elastin B) Depleted moisture in epidermal cells C) Decreased size of sebaceous glands D) Thinner subcutaneous skin layer E) Poor nutrition

B) Depleted moisture in epidermal cells C) Decreased size of sebaceous glands E) Poor nutrition

Which statement about wound care across the lifespan is correct? A) "When applying transparent dressings on older adult clients, do not hold the skin taut, because doing so can cause damage." B) "In young children, staph bacteria and fungi are the most common causes of infection in minor wounds." C) "Pressure injuries and contact irritation are rare among newborns and infants in NICUs." D) "As compared to younger clients, older adults have a heightened inflammatory response, which can contribute to delayed wound healing."

B) "In young children, staph bacteria and fungi are the most common causes of infection in minor wounds."

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, then use the doughnut at home." D) "I will obtain the device for you."

B) "Using the doughnut can cause skin breakdown."

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.

B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis.

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

B) Assess postoperative wound healing.

A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered? A) Skin biopsy B) Culture C) Wood's lamp D) Patch test

B) Culture

What impact might corticosteroids have on tissue integrity? A) It may increase sensitivity to sunlight, leading to sunburns. B) It may cause thinning of the skin, making skin more easily injured. C) It may make skin appear shiny and lose its hair distribution. D) It may cause the skin to become overly dry.

B) It may cause thinning of the skin, making skin more easily injured.

A client who sustained burns to both lower extremities reports 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

B) Powerlessness

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

B) Proliferative phase

A client is admitted to the hospital with a gunshot wound to the leg. Which nursing diagnosis is a priority? A) Situational Low Self-Esteem B) Risk for Infection C) Anxiety D) Ineffective Coping

B) Risk for Infection

What stage of pressure injury presents as a shallow open ulcer with a viable, moist wound bed that is red or pink? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

B) Stage 2

) 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? A) The 38-year-old pregnant mother is more likely to require an allograft than the other members of the family. B) The 82-year-old grandmother is more likely to have burns to a greater percentage of her total body surface area (TBSA) than younger family members. C) The 14-year-old son is less likely to experience edema associated with his injuries than older members of the family. D) The 6-year-old daughter is more likely to go into burn shock than the other members of the family.

B) The 82-year-old grandmother is more likely to have burns to a greater percentage of her total body surface area (TBSA) than younger family members.

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 of the following 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.

B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase.

The nurse is assessing a client with a surgical wound. Which finding 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.

B) The client performs wound care independently.

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? 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 used. D) Nurses did not document disinfection of the wound with alcohol at each dressing change.

C) A right side-back-left side-back turning schedule was used.

Which data supports the nurse's concern that a client is at a high risk for a burn injury? Select all that apply. A) Part-time employment at a convenience store B) Diagnosis of hypertension C) Age 71 years D) Uses public transportation for grocery shopping E) Currently smokes one pack of cigarettes per day

C) Age 71 years E) Currently smokes one pack of cigarettes per day

What does the nurse anticipate finding in a client with impetigo? A) An infection in the hair follicles B) Loss of skin color in blotches or sections C) An itchy rash with clusters of fluid-filled vesicles D) A fungal infection in the skinfolds

C) An itchy rash with clusters of fluid-filled vesicles

A client has a documented stage 3 pressure injury 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

C) Impaired 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. 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

C) Irrigation of the burn wounds D) Application of wet-to-dry gauze dressings E) Hydrotherapy

A burn patient is currently in the acute stage. When did this stage begin, and when will it end? A) It began with the onset of the burn injury and will end with fluid resuscitation. B) It began with wound closure and will end when the patient's health is fully restored. C) It began with the start of diuresis and will end with the closure of the burn wound. D) It began with the onset of the burn injury and will end with the closure of the burn wound.

C) It began with the start of diuresis and will end with the closure of the burn wound.

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

C) Low serum albumin level E) Prescribed bedrest

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

C) Major

The nurse presses a finger into swollen skin tissue on a client's feet and ankles and notes that it creates an indentation. The nurse should correctly document a finding of which alteration in skin integrity? A) Poor turgor B) Ascites C) Peripheral edema D) Hypothermia

C) Peripheral edema

An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which intervention best addresses the client's nutritional needs? A) Assist with deep-breathing exercises. B) Medicate for pain prior to dressing changes. C) Request a dietary consult. D) Encourage ambulation.

C) Request a dietary consult.

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) Nodule B) Macule C) Scales D) Crusts

C) Scales

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) Partial-thickness loss of dermis B) Nonblanchable erythema C) Suspected deep tissue injury D) Full-thickness tissue loss

C) Suspected deep tissue injury

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

C) Tertiary intention healing

A nurse is conducting a skin assessment of a patient. Upon palpating skin temperature, the nurse notes the skin is warm and red. This is an abnormal sign that may be indicative of A) decreased hydration. B) decreased blood flow to the skin. C) inflammation and elevated body temperature. D) hypothyroidism.

C) inflammation and elevated body temperature.

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? A) "As people age, their epidermis becomes more elastic. This increased elasticity makes older adults' skin more susceptible to damage." B) "As compared to younger clients, older adults have higher average body temperatures, and excess body heat is a risk factor for pressure injuries." C) "Due to increased oil production, the skin of older adults tends to be moister than that of younger clients. Increased moistness increases the risk for impaired skin integrity." D) "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity."

D) "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity."

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) "Massage may actually cause more harm to a potentially compromised area of skin."

D) "Massage may actually cause more harm to a potentially compromised area of skin."

Which of the following clients would be the most appropriate candidate for autolytic debridement? A) A 47-year-old client with a stage 2 pressure injury B) A 68-year-old client with a suspected deep tissue injury C) A 71-year-old client with a stage 1 pressure injury D) A 59-year-old client with a stage 3 pressure injury

D) A 59-year-old client with a stage 3 pressure injury

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) Blood urea nitrogen (BUN) levels C) Hemoglobin D) Albumin level

D) Albumin level

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

D) Avoid placing the client in the side-lying position.

A middle-age adult client states to the nurse, "I do not want to have brown spots on my skin 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.

D) Avoid the sun or use a sunscreen to reduce skin damage.

The nurse is providing care to a client who is experiencing skin inflammation and pruritus. Which of the following medications does the nurse anticipate will be prescribed for this client? Select all that apply. A) Erythromycin B) Bacitracin C) Gentamycin D) Desoximetasone E) Desonide

D) Desoximetasone E) Desonide

How should the nurse position a client who is returned to the burn unit following a graft procedure to the leg? A) Place the client flat with the affected extremity abducted. B) Elevate the head of bed 30 degrees C) Maintain the head of bed flat D) Elevate the affected extremity

D) Elevate the affected extremity

A client is evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause of this manifestation? A) Decreased osmotic pressure in the burned tissue B) Reduced microvascular permeability at the site of the burned area C) Increased potassium in the intracellular compartment D) Inability of the damaged capillaries to maintain fluids in the cell walls

D) Inability of the damaged capillaries to maintain fluids in the cell walls

An 84-year-old client with poor skin turgor has slipped down in the hospital 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 bed B) Placing the bed in reverse Trendelenburg position C) Using the client's arms to pull the client up in bed D) Lifting the client, using the client's legs and arms for assistance

D) Lifting the client, using the client's legs and arms for assistance

A client has a laceration that was closed with tissue adhesive. By what process will this wound heal? A) Tertiary intention B) Secondary intention C) Delayed primary intention D) Primary intention

D) Primary intention

Which of the following findings suggests that a wound is infected with pyogenic bacteria? A) Sanguineous exudate B) Serous exudate C) Serosanguineous exudate D) Purulent exudate

D) Purulent exudate

The nurse is planning care for a client with a surgical wound. Which goal related to the surgical wound is most appropriate for this client? A) The client will discharge to home as soon as possible. B) The client will resume independent activities of daily living (ADLs). C) The client will increase ambulation. D) The client will regain intact skin.

D) The client will regain intact skin.

An adult burn patient is brought in to the intensive care unit (ICU) for treatment. Prior to sustaining the injury, the client was considered underweight for her height. The nurse understands that this may have important implications for the client because A) she will have lower fluid resuscitation calculations than patients of normal weight. B) she will be at greater risk for developing cardiac or renal insufficiencies. C) she will require more supportive care than patients who are normal weight. D) she will lose as much as 20% of her preburn weight during rehabilitation.

D) she will lose as much as 20% of her preburn weight during rehabilitation.