NUR 111 Tissue Integrity/Pressure Ulcers Pearson Study Plan

The nurse is assessing diffuse bullae and vesicles on a​ client's hands and arms. Which question should the nurse ask the​ client? A. "Have you been in contact with poison ivy?" B. "Have you been scratching your skin?" C. "Do you have a history of chronic dermatitis?" D. "Do you have a history of psoriasis?"

A ​Rationale: Bullae and vesicles are found on a client who has been in contact with poison ivy. Scales is a finding associated with psoriasis. Excoriation is a result of scratching the surface of the skin. Findings associated with chronic dermatitis include lichenification.

A client who has been sedated and on mechanical ventilation for several days is on a​ low-air-loss bed;​ however, the client has a localized purple area of discoloration over the coccyx that does not blanch. Which pressure injury should the nurse suspect for this​ client? A. Suspected deep tissue injury B. Bruising C. Stage 1 pressure injury D. Stage 3 pressure injury

A ​Rationale: Deep tissue injury is suspected when intact skin has a localized purple discoloration and does not blanch when pressed. A thin blister or eschar can develop very quickly. The assessment does not describe bruising. A stage 1 pressure injury has intact skin with localized redness that does not blanch when pressed. A stage 2 pressure injury has a shallow open wound or blister without sloughing.

The nurse is caring for an adolescent female client who has begun menstruating. Which preexisting disorder should the nurse expect to be exacerbated by the hormonal changes that​ occur? A. Eczema B. Contact dermatitis C. Warts D. Fungal tinea

A ​Rationale: Eczema is exacerbated by the hormonal changes that accompany menstruation. The incidence of warts and fungal tinea infections increase due to the involvement with sports and use of public showers. Contact dermatitis is not associated with hormonal changes that occur during menstruation.

The nurse is reviewing the chart of a client diagnosed with paronychia. Which assessment finding should the nurse​ anticipate? A. Infection around the fingernail B. Superficial skin infection in children C. Fungal oral mucosal infection D. Infection of the hair follicles

A ​Rationale: Paronychia is a soft tissue infection around the fingernail. Folliculitis is an infection of the hair follicles. A fungal oral mucosal infection is known as candidiasis. Impetigo is a superficial skin infection in children.

The nurse performing a home visit for an older adult client determines the client would benefit from teaching about the promotion of skin integrity. Which assessment finding indicates the need for further​ teaching? A. The client uses a body spray perfume. B. The client showers four times a week. C. The client applies a moisturizer after bathing. D. The client washes the hands with soap and running water before eating.

A ​Rationale: The client using a body spray perfume is at risk of impaired skin integrity. Perfumes contain​ alcohol, which dries the skin. Showering four times a​ week, applying a moisturizer after​ bathing, or washing hands with soap and running water prior to eating do not place the client at risk for impaired skin integrity.

A client with a deep tissue injury and white exudate develops a fever. Which test should the nurse anticipate being prescribed by the healthcare​ provider? A. Culture and sensitivity of the wound bed B. Urine culture and sensitivity C. Serum protein D. ESR

A ​Rationale: The wound bed can be cultured to determine the organism causing the infection. ESR can determine the presence of osteomyelitis. Serum protein helps establish nutritional status. Urine culture and sensitivity will determine presence of a urinary tract infection​ (UTI).

A client is suspected of having a deep tissue injury. Which intervention should the nurse include in the plan of​ care? (Select all that​ apply.) A. Application of a moisturizing barrier cream B. Consideration of appropriate support surfaces and other measures to remove all pressure C. Application of a nonadhesive protective dressing D. Debridement of wound bed and edges E. Wet-to-damp dressing changes twice daily

A, B, C ​Rationale: To treat a client with a suspected deep tissue​ injury, the nurse should apply a moisturizing barrier​ cream, a nonadhesive protective​ dressing, and consider support surfaces that will remove all pressure from the area. Debridement of wound bed and edges and​ wet-to-damp dressing changes are not appropriate for deep tissue injuries.

The nurse is discussing factors that are attributed to allergic contact dermatitis with a client. Which factor should the nurse include in the​ discussion? (Select all that​ apply.) A. Exposure to plants B. Exposure to soap C. Dry environment D. Exposure to perfumes E. Infrequent hand washing

A, B, D ​Rationale: Factors that are attributed to allergic contact dermatitis include​ soap, plants, and perfumes. Dry environments and infrequent hand washing are not associated with allergic contact dermatitis.

The nurse is preparing to perform an assessment on a client. Which factor should the nurse include in the integumentary​ assessment? (Select all that​ apply.) A. Texture B. Turgor C. Sensation D. Nails E. Temperature

A, B, D, E ​Rationale: An integumentary assessment includes the​ nails, skin​ turgor, texture, and temperature. Sensation is included in a neurological examination.

A client with poor nutritional intake is at high risk for developing pressure injuries. Which device should the nurse identify as appropriate for this​ client? (Select all that​ apply.) A. Foam wedges and pillows B. Static low-air-loss bed C. Rolled blankets to protect heels D. Memory foam chair pad while client is in chair E. Gel flotation pads

A, B, D, E ​Rationale: Gel flotation pads can be used to protect bony prominences and are filled with a substance similar to fat. A static​ low-air-loss bed is made up of many​ air-filled cushions that can be reduced under bony prominences and inflated to provide support in other areas. Foam wedges and blocks can be used to prevent​ bone-on-bone contact and support positioning. Memory foam chair pads distribute weight more evenly over the surface of the seat and can mold to the body. Foam​ blocks, not rolled​ blankets, are used to protect heels from shearing and limit pressure.

While applying lotion to the skin of an older adult​ client, the client asks why it is more important to take better care of the skin now than at a younger age. Which aspect of integumentary changes in older adult clients should the nurse include in the​ response? (Select all that​ apply.) A. Greater sensitization to allergens B. Increased efficiency of blood circulation to skin C. Decreased turnover of the outer skin layer D. Impaired skin barrier E. Faster wound healing

A, C, D ​Rationale: The integumentary changes that occur in older adult clients include impaired skin​ barrier, greater sensitization to​ allergens, and a decreased turnover of the outer skin layer. Wound healing is slowed and circulation to the skin decreases.

The nurse is caring for a client admitted with a pressure injury. Which data should the nurse document when assessing the pressure​ injury? (Select all that​ apply.) A. Color of the wound bed B. Home management of the pressure injury C. Integrity of the surrounding tissue D. Signs of infection E. Stage of the ulcer

A, C, D, E ​Rationale: Documenting the stage of the pressure​ injury, color of the wound​ bed, integrity of the surrounding​ tissue, and signs of infection are of utmost importance. Assessment of home management does not need to be documented.

The nurse is reviewing a​ client's chart who presents to the clinic with report of a​ "skin rash." Which descriptive characteristic indicates a specific skin disorder that the nurse may​ consider? (Select all that​ apply.) A. Wheal B. Pruritus C. Exudate D. Vesicle E. Macule

A, D, E ​Rationale: Characteristics of skin disorders include​ macules, wheals, and vesicles. Exudate is fluid drainage from a wound. Pruritus is itching of the skin.

A client has a​ follow-up appointment for treatment of a pressure injury. Which client outcome should indicate to the nurse that treatment goals have been​ met? (Select all that​ apply.) A. The client has enrolled in a smoking cessation program. B. There is a greenish exudate on the dressing. C. The client's BMI is 16, and the weight is down by 4 pounds. D. The client and family demonstrate an understanding of preventive care measures. E. The wound has decreased in size.

A, D, E ​Rationale: The client and family demonstrate an understanding of wound​ care, the wound has decreased in​ size, and the client has enrolled in a smoking cessation program indicate that nursing interventions and education have been effective. Greenish exudate indicates a possible infection. The​ client's decrease in weight indicates that nutrition may not be adequate for optimal wound healing and maintenance of proper weight.

A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. Which stage should the nurse document this ulcer to​ be? A. Stage 2 B. Stage 4 C. Stage 1 D. Stage 3

B ​Rationale: A stage 4 pressure injury may be covered with eschar. Eschar is not present in stage 1 or stage 2. Stage 3 pressure injuries may have eschar​ present, but tissue damage is limited to the subcutaneous tissue.

The nurse is reviewing documentation on a client at risk for developing a pressure injury. Which note in the documentation should indicate to the nurse that the plan of care has been followed​ correctly? A. "Client comfort and pain level assessment daily." B. "Client refusing meals. Nutritional consult prescribed." C. "Client turned every 4 hours." D. "Client ate all of lunch. Given a nutritional supplement."

B ​Rationale: Nutritional consults should be prescribed for clients with inadequate nutritional intake. Clients should be turned every 2 hours. Client comfort and pain should be assessed more often than daily. Nutritional supplements should be given to clients who eat​ 50% or less of their meals.

The nurse is caring for a client with acne. Which condition describes the​ nurse's understanding of the classification of​ acne? A. Dermatitis B. Inflammatory C. Infectious D. Neoplastic

B ​Rationale: The nurse caring for the client with acne understands that the classification of acne is inflammatory. Acne is not classified as infectious or neoplastic. Dermatitis is another inflammatory disorder of the skin.

While assessing the skin of a client who has undergone​ surgery, the nurse observes erythema to the left scapulae. Which action should the nurse take before reassessing the skin to determine if the erythema is a pressure​ injury? A. Massage the scapulae with lotion. B. Reposition the client. C. Apply a warm blanket. D. Cover the area with a dressing.

B ​Rationale: The nurse should reposition the client to remove pressure from the scapulae and then reassess for redness in​ one-half or​ three-fourths the time it took to create the reddened area. If the reddened area does not​ clear, the client has a stage 1 pressure injury. Massaging the scapulae with​ lotion, applying a warm​ blanket, or covering the area with a dressing are not the most appropriate actions to take before reassessing the client.

The charge nurse receives report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure​ injuries? (Select all that​ apply.) A. Client admitted to an acute care unit B. Client who is 92-years-old C. Client with a history of anorexia nervosa D. Client with type 1 diabetes mellitus E. Client on bedrest

B, C, D, E ​Rationale: A client on bedrest is​ immobile, which increases the risk for developing pressure injuries. An older adult client is at risk because of the loss of lean body​ mass, epidermal​ thinning, decreased skin​ elasticity, and increased skin dryness. A client with type 1 diabetes mellitus is at risk because of compromised oxygen delivery to the tissues. A client with a history of anorexia nervosa is at risk because of inadequate​ nutrition, which leads to weight​ loss, muscle​ atrophy, and loss of subcutaneous tissue. A client admitted to an acute care unit is not usually at risk for developing a pressure injury.

The nurse is preparing a client scheduled for a skin biopsy. The client asks how this will be done. Which procedure should the nurse​ include? (Select all that​ apply.) A. Culture B. Excision C. Incision D. Shaving E. Punch

B, C, D, E ​Rationale: A skin biopsy can be obtained by a​ punch, incision,​ excision, or shaving. Cultures are used to identify infections obtained from tissue​ samples, wounds,​ drainage, lesions, or serum.

The nurse is caring for a client with incontinence of urine and sudden onset of watery diarrhea. Which action should be included in the plan of care to maintain skin​ integrity? (Select all that​ apply.) A. Massage bony prominences at least twice daily to promote circulation. B. Clean skin immediately at the time of soiling and routinely. C. Apply a moisturizing barrier cream to the skin at greatest risk of breakdown. D. Increase humidity in the room and limit exposure to cold. E. Assess skin systematically at least once a day.

B, C, D, E ​Rationale: To maintain skin integrity of a client with incontinence of urine and​ stool, the nurse should assess skin systematically at least once a​ day, clean skin immediately upon soiling and​ routinely, increase the humidity in the room and limit exposure to​ cold, and apply a barrier cream to the skin at the greatest risk of breakdown. Bony prominences should not be massaged.

The nurse identifies that a client is at risk for impaired skin integrity. Which intervention should the nurse add to this​ client's plan of​ care? (Select all that​ apply.) A. Place the client in the side-lying position only. B. Use positioning devices. C. Keep the head of the bed elevated more than 30 degrees. D. Avoid massaging bony prominences. E. Inspect the skin every day.

B, D, E ​Rationale: Using positioning devices such as pillows or foam wedges to protect bony​ prominences, not massaging bony​ prominences, and inspecting the skin daily help prevent skin breakdown. A​ side-lying position or keeping the head of bed elevated more than 30 degrees can put pressure on specific body areas.

The nurse is reviewing the chart of a client who is pregnant and reports​ "red patches of skin that​ itch." Which assessment finding should the nurse​ anticipate? A. Lacy exanthema on the cheeks B. Seborrheic dermatitis C. Eczematous skin changes around the neck D. Scaly rash on the chest

C ​Rationale: Atopic eruption of pregnancy is a common​ pregnancy-specific skin disorder that is characterized by eczematous skin​ changes, most often around the neck and flexor surfaces of the body. A scaly rash on the​ chest, lacy​ exanthema, and seborrheic dermatitis are not associated with pregnancy.

The nurse assessing a client notes the client is at risk for candidiasis. Which client behavior observed by the nurse would support this​ conclusion? A. The client applies a moisturizer immediately after washing the hands. B. The client washes the hands four times in an hour. C. The client is on an antibiotic. D. The client used a child's brush to fix the hair.

C ​Rationale: The client taking the antibiotic is at risk for candidiasis. The antibiotic alters the normal flora in the​ body, resulting in the potential for opportunistic​ infections, such as​ candidiasis, to occur. A client using a​ child's brush is at risk for parasite transmission. The client who washes the hands four times in an hour is at risk of impaired skin integrity. The client who applies moisturizer immediately after washing the hands is not at risk for​ candidiasis, and this demonstrates good skin care.

The nurse is caring for an older adult client who is significantly underweight. Which intervention should the nurse include in the plan of care for the client to maintain skin​ integrity? A. Recommend daily exercise followed by thorough bathing. B. Instruct the client to avoid the use of topical skin lotions. C. Review safety strategies to prevent injuries and falls. D. Explain the need to receive adequate exposure to sunlight.

C ​Rationale: The intervention the nurse will include in the plan of care to help maintain the skin integrity of the older adult client who is significantly underweight is reviewing the safety strategies to prevent injuries and falls. Avoiding topical skin lotions is applicable if they contain alcohol due to the drying effect alcohol has on the skin. Daily bathing may contribute to dry skin. Adequate exposure to sunlight does not contribute to the maintenance of skin integrity.

The nurse is reviewing the chart of a client who has developed keloids as a result of multiple surgeries. Which assessment finding should the nurse​ anticipate? A. Wearing away of the superficial epidermis B. Rough, thickened, hardened area of epidermis C. Elevated, irregular, darkened area D. Flat, irregular area of connective tissue

C ​Rationale: The nurse can expect to find an​ irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. A scar is a​ flat, irregular area of connective tissue left after a lesion or wound has healed. A wearing away of the superficial epidermis causes a​ moist, shallow depression known as erosion. Lichenification is characterized by a​ rough, thickened, hardened area of epidermis.

The nurse is reviewing the chart of a client diagnosed with neurofibromatosis. Which change in skin pigmentation should the nurse anticipate finding based on the​ client's diagnosis? A. Hemangioma B. Acanthosis nigricans C. Cafe au lait spots D. Actinic keratosis

C ​Rationale: The nurse can expect to find​ café au lait spots on the skin of the client who is diagnosed with neurofibromatosis.​ Café au lait spots are hyperpigmented​ freckle-like macules that can vary in color from light brown to dark​ brown, with borders that may be smooth or irregular. A hemangioma is the most common tumor of infancy. Lesions may be superficial or deeper and vary in color. Actinic keratosis is precancerous changes in skin cells that occur from many years of sun exposure. Hyperglycemia is a common cause of acanthosis​ nigricans, which is characterized by​ dark, thickened, velvety discoloration in body folds and​ creases, usually around the​ neck, axilla, and groin.

The nurse is planning teaching for a client with infected contact dermatitis. Which information should the nurse include in the​ teaching? A. Cover the infected site with a sterile dressing. B. Stop antibiotics when redness disappears. C. Keep nails trimmed short. D. Use cold water and a mild soap to cleanse skin.

C ​Rationale: The nurse will instruct the client to keep nails trimmed short to avoid scratching the infected dermatitis. It is not necessary to cover the infected site with a sterile dressing or cleanse the skin with cold water. The skin can be cleansed with tepid water. Antibiotics should be taken until all of the medication is completed as ordered.

The nurse is caring for a client with an open pressure injury with minimal necrotic tissue. Which dressing should the nurse identify as most appropriate for the​ client? A. Hydrocolloid dressing B. Skin prep Granulex C. Wet-to-dry gauze dressing with sterile normal saline D. Transparent dressing

C ​Rationale: Wet-to-dry gauze dressing with sterile normal saline will soften the necrotic tissue so it will adhere to the gauze and be debrided with the dressing change. Granulex is appropriate for intact skin. Transparent and hydrocolloid dressings help to prevent skin breakdown.

The nurse reviews alginate dressings with a new nurse. For which type of pressure injury should the nurse identify this dressing is​ used? (Select all that​ apply.) A. Stage 1 B. Stage 4 with eschar C. Stage 4 without eschar D. Stage 2 E. Stage 3

C, D, E ​Rationale: Alginate dressing should be used for stage​ 2, 3, and 4 without eschar pressure​ injuries, but not for stage 4 with eschar pressure injuries. An alginate dressing is not used for stage 1 pressure injuries.

The nurse is caring for a client at risk for a pressure injury. Which action should the nurse use to maintain the skin​ integrity? (Select all that​ apply.) A. Avoiding exposure to high humidity B. Scrubbing the skin to clean it thoroughly when bathing C. Cleaning the skin immediately if exposed to urine or feces D. Assessing the skin upon admission and then daily using the same screening tool E. Treating dry skin with moisturizing lotions directly applied to moisten skin after bathing

C, D, E ​Rationale: To maintain skin integrity for clients at risk for pressure​ injuries, assess the skin upon admission and then​ daily, using the same screening​ tool; treat dry skin with moisturizing lotions directly applied to moist skin after​ bathing; and immediately clean the skin if exposed to urine or feces. Do not scrub the​ client's skin when​ bathing; instead, minimize the force and friction applied to the skin to prevent injury. Avoid exposing the client to cold and low humidity.

A client is in the​ high- Fowler position to facilitate breathing. Which body pressure area should the nurse be most concerned​ about? A. Ilium B. Zygomatic bone C. Knee D. Heels

D ​Rationale: A client in Fowler position has pressure on the​ heels, pelvis,​ sacrum, and vertebrae. A client in the lateral position has pressure on the knee and ilium. A client in the prone position has pressure on the zygomatic bone.

The nurse is assisting nursing assistive personnel​ (NAP) reposition a client who is immobile and has been lying on the left side. For which action by the NAP should the nurse​ intervene? A. Places of foam wedge under the client's left hip B. Looks at the skin over bony prominences on the left side C. Places pillows under the client's legs to keep heels off the bed D. Ask for help pulling the client back up to the head of the bed

D ​Rationale: Clients should not be pulled up in​ bed, as shearing forces and friction can break down skin tissue. Clients should be lifted instead of being pulled. It is appropriate for the foam wedge to be placed under the​ client's left side. The skin over bony prominences on the left side should be inspected when the client is turned. It is appropriate to use pillows to keep the​ client's heels off the bed.

The nurse reviewing a​ newborn's chart notes Mongolian spots found on a prior assessment. Which describes the​ nurse's understanding of the​ etiology? A. Minor trauma B. Dilated blood vessels C. Immune-mediated D. Congenital

D ​Rationale: Mongolian spots are​ congenital, non-blanching, hyperpigmented patches most commonly seen over the lumbosacral area. Mongolian spots do not result from minor​ trauma, are not​ immune-mediated, and do not occur due to dilated blood vessels.

A client asks what effect nutrition has on skin integrity. Which response should the nurse make that explains the relationship of nutrition to pressure injury​ development? A. "Increased dietary intake of carbohydrates and minerals can cause pressure injuries." B. "Poor dietary intake of carbohydrates and minerals can increase the risk of pressure injuries." C. "Increased dietary intake of protein can cause pressure injuries." D. "Poor dietary intake of kilocalories, protein, and iron can increase the risk of pressure injuries."

D ​Rationale: Poor dietary intake of​ kilocalories, protein, and iron has been associated with the development of pressure injuries. An association between minerals and risk of pressure injury development is unknown. Increased intake of protein will not cause pressure injuries to develop.

The nurse notes that a client appears to have an integumentary infection. Which diagnostic test should the nurse anticipate will be​ prescribed? A. Punch biopsy B. Skin shaving C. Patch test D. Wood lamp

D ​Rationale: The nurse anticipates a Wood lamp test to be prescribed to identify an integumentary infection. A patch test is used to identify an allergy. Punch biopsy and skin shaving are procedures used to obtain a skin biopsy.

The nurse manager observes a new nurse talk with a client with a stroke and decreased mobility about ways to prevent pressure injures. For which statement should the nurse manager​ intervene? A. "You can help by using your right side to make small adjustments to your left side every 30 minutes or so." B. "We will keep your skin clean, dry, and moisturized to prevent tissue damage." C. "We will ensure your diet contains adequate calories, protein, vitamins, and iron." D. "Due to decreased mental status, you will need to be turned every 2 hours."

D ​Rationale: There is no indication the client has decreased mental status. The client should be turned and repositioned every 2 hours. Keeping the skin​ clean, dry, and moisturized will help prevent tissue damage. A diet with adequate​ calories, protein,​ vitamins, and iron will help to prevent skin breakdown. The client can be encouraged to participate by helping to move the left side every​ 15-30 minutes. Even small adjustments of​ 10-20 degrees can prevent tissue injury.

A client with deep tissue damage develops eschar. Which procedure should the nurse anticipate being​ prescribed? A. Application of a moisture-retaining protective dressing B. Application of a barrier cream C. Application of a petroleum ointment D. Surgical debridement

D ​Rationale: When eschar has​ formed, surgical debridement and removal of necrotic material is necessary. Application of a barrier cream is appropriate for intact skin. Use of petroleum ointment is not appropriate. Application of a​ moisture-retaining protective dressing is appropriate for a pressure injury without eschar or after the eschar has been surgically removed.

The nurse is caring for a client with impaired mobility. Which concern regarding tissue integrity should the nurse​ address? (Select all that​ apply.) A. Increased susceptibility to microorganisms B. Allergic response C. Production of exudate D. Pressure ulcer formation E. Skin breakdown

D, E ​Rationale: The effects that impaired mobility have on tissue integrity include skin breakdown and pressure ulcer formation. The immune system mediates an allergic response. Exudate is a response to infection. Increased susceptibility to microorganisms may result from a compromised immune system.

The nurse notes circular lesions on a​ client's upper back. Which condition should the nurse consider prior to​ examination? (Select all that​ apply.) A. Tinea versicolor B. Ringworm C. Herpes zoster D. Poison ivy E. Contact dermititis

​Rationale: The circular lesions may be attributed to either ringworm or tinea versicolor. Circular lesions are not characteristic of poison​ ivy, herpes​ zoster, or contact dermatitis.