Potter-Perry Chapter 48 Skin Integrity and Wound Care, funds exam 3, Potter and Perry Chapter 39

What should the nurse teach a diabetic patient about exercise? 1) "Exercise leads to improved glucose control." 2) "You can perform medium- to high-intensity exercise." 3) "The effect of exercise on blood glucose levels often lasts for 10 hours." 4) "You can start an exercise routine on your own without any physical examination."

1 The nurse should teach a diabetic patient that exercise leads to improved glucose control. Diabetic patients should perform low- to-medium intensity exercise. The effect of exercise on blood glucose lasts for 24 hours, not 10 hours. The nurse should instruct the patient to undergo a complete physical examination before starting any physical exercise routine.

The nurse is attending to an older adult patient who has sustained a fall and has broken a femur. The nurse explains to the patient that as the body ages, the bones become weak due to osteoporosis and become more prone to fracture. Which statements are true about osteoporosis? Select all that apply. 1) The cause may be hormonal imbalances or insufficient intake of nutrients. 2) There is a structural curvature of the spine associated with vertebral rotation. 3) Osteoporosis is a disorder of aging and results in the reduction of bone density or mass. 4) There is inadequate and delayed mineralization, resulting in compact and spongy bone. 5) The bone remains biochemically normal but has difficulty maintaining integrity and support.

1, 2, 5 In osteoporosis, the bones remain biochemically normal but have a reduction in density or mass. The cause of osteoporosis is uncertain, and theories vary from hormonal imbalances to insufficient intake of nutrients. Osteoporosis is common in aging adults. Osteomalacia, not osteoporosis, is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bones. Scoliosis is a structural curvature of the spine associated with vertebral rotation.

Which actions should the nurse perform during the assessment phase when caring for a patient diagnosed with impaired physical mobility? Select all that apply. 1) Inspect the patient's body alignment, posture, and mobility 2) Reassess the patient for signs of improved activity and exercise tolerance 3) Observe the response of the patient's body systems to activity and exercise 4) Consult and collaborate with members of the health care team to increase activity 5) Ask for the patient's perception of activity and exercise status after interventions

1, 3 Inspecting the patient's body alignment, posture, and mobility and observing how the patient's body systems respond to activity and exercise are parts of the assessment phase of a patient diagnosed with impaired physical mobility. Reassessing the patient for signs of improved activity and exercise tolerance is part of the evaluation phase. Consulting and collaborating with members of the health care team to increase activity form a part of the planning phase. Asking for the patient's perception of activity and exercise status after the intervention forms a part of the evaluation phase

A patient is admitted to the hospital with osteoporosis and lower back pain. The patient loses balance when trying to stand and walk. The patient has a nursing diagnosis of body imbalance. What instructions does the nurse give the patient? Select all that apply. 1) Instruct the patient to widen the base of support by separating the feet. 2) Instruct the patient to bring the knees closer together to maintain a broad base. 3) Instruct the patient to lower the center of gravity closer to the base of support. 4) Instruct the patient to keep the center of gravity away from the base of support. 5) Instruct the patient to maintain a vertical line from the center of gravity through the base of support.

1, 3, 5 To maintain body balance, the patient must attain a posture that requires the least muscular work and places the least strain on muscles, ligaments, and bones. To do this, the patient must first separate the feet to a comfortable distance to widen the base of support. Then the patient must try to increase balance by bringing the center of gravity closer to the base of support. The body posture is adjusted such that the vertical line from the center of gravity falls through the base of support to attain body balance. The knees should not be kept closer, because this could decrease the width of the base of support and impair balance. Increasing the distance between the center of gravity and the base of support would also impair the balance of the patient. Knees should be kept wide. Keeping the center of gravity away from the base of support will result in a loss of balance while standing or walking.

A patient with a body mass index (BMI) of 36 has a sedentary job. The patient states that she has never exercised. The patient has been advised to reduce weight. What actions should the nurse advise the patient to do to promote reduction of weight? Select all that apply. 1) Advise her to discuss her diet with a dietitian. 2) Advise her to undergo gastric banding. 3) Advise her to undergo an intensive exercise training program. 4) Advise her to have realistic goals such as losing 4 pounds over 2 weeks. 5) Advise her to resign from her job immediately because it is the cause of her obesity.

1, 4 A dietitian can help the patient plan a diet for weight reduction. The patient should be advised to set realistic goals for weight reduction. A reduction of 4 pounds over 2 weeks is acceptable. Gastric banding is the surgical procedure used for morbidly obese patients, if dietary measures and medications do not help them. Exercise is a healthy way to lose weight, but it should be gradual. A patient who has never exercised should not start with high-intensity exercises. The patient should start with a mild intensity exercise and gradually increase the intensity. Although her job is one of the reasons for her sedentary lifestyle and weight gain, it is not the only reason. Resigning from the job will not help the patient.

stages of wound healing

1.inflammatory, 2.proliferative, 3. remodeling

What nursing intervention should the nurse provide to a patient who has impaired gas exchange related to decreased cardiac output? 1) Teach the patient how to restrict fluid intake 2) Administer oxygen at 2 L/min via the nasal cannula 3) Record activity of the patient in an exercise log daily along with the response 4) Ask the patient to perform a 2-to 3-mile brisk walk and isometric exercises three to four times a week

2 A patient should be administered oxygen at a rate of 2 L/min via the nasal cannula if the patient has impaired gas exchange related to decreased cardiac output. A patient who is diagnosed with decreased cardiac output related to decreased myocardial contractility should be taught how to restrict the intake of fluids. The nurse should record the activity of the patient in exercise log daily along with the response in case of activity intolerance related to physical deconditioning. The nurse should guide a patient who is diagnosed with activity intolerance related to physical deconditioning to take brisk walks and perform isometric exercise three to four times a week.

Which environmental issue is a hindrance to activity and exercise? 1) Hormonal changes and increased osteoclastic activity with increasing age 2) Work sites reluctant in motivating employees for physical fitness regimens 3) A patient's decisions to change his or her behavior to include a daily exercise routine 4) A patient's knowledge, values, and beliefs about exercise in relation to health

2 Activity and exercise promotion (or lack thereof) at work sites is an environmental factor that affects a patient's ability to exercise. Hormonal changes and increased osteoclastic activity with increasing age are developmental factors that affects activity and exercise. A patient's decision to change his or her behavior to include a daily exercise routine and the patient's knowledge, values, and beliefs about exercise in relation to health are behavioral factors that influence activity and exercise.

Which measure should the nurse adopt to reposition a patient in bed? 1) When pulling a patient up in bed, the bed should be in anti-Trendelenburg's position. 2) For patients with stage III or IV pressure ulcers, care should be taken to avoid shearing force. 3) If the patient weighs less than 200 lb (91 kg), friction-reducing devices should be avoided. 4) If the caregiver needs to lift about 55 lb (25 kg) of a patient's weight, the patient is considered fully dependent.

2 For patients with stage III or IV pressure ulcers, care should be taken to avoid shearing forces. When pulling a patient up in bed, the bed should be flat or in a Trendelenburg's position. If the patient weighs less than 200 lb (91 kg), friction reducing devices and two to three caregivers are needed. If the caregiver needs to lift more than 35 lb (16 kg) of a patient's weight, then the patient is considered fully dependent and assistive devices should be used.

Which statement if made by a nurse is correct? 1) "Permanent cartilage is ossified." 2) "Ligaments connect bones to cartilage." 3) "Cartilage is a vascular supporting connective tissue." 4) "The Achilles tendon is the thinnest tendon in the body."

2 Ligaments connect bones to cartilage. Permanent cartilage is unossified, except in adults with advanced age and diseases such as osteoarthritis. Cartilage is a nonvascular supporting connective tissue. The Achilles tendon is the thickest tendon in the body.

Which is a congenital defect? 1) Arthritis 2) Scoliosis 3) Osteoporosis 4) Osteomalacia

2 Scoliosis is a structural curvature of the spine associated with vertebral rotation; it is a congenital defect. Arthritis is an inflammatory joint disease that causes systemic signs of inflammation and destruction of the synovial membrane and articular cartilage. Osteoporosis is an aging disorder that results in the reduction of bone density or mass. Osteomalacia is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bones.

Which group of patients is most at risk for severe injuries related to falls? 1) Adolescents 2) Older adults 3) Toddlers 4) Young children

2 Some older adults walk more slowly and are less coordinated. They also take smaller steps, keeping their feet closer together, which decreases the base of support. Thus, body balance is unstable, and they are at greater risk for falls and injuries.

What group of muscles contract to accomplish the same movement? 1) Skeletal muscles 2) Synergistic muscles 3) Antigravity muscles 4) Antagonistic muscles

2 Synergistic muscles contract to accomplish the same movement. Skeletal muscles are attached to the skeleton by tendons. Antigravity muscles continuously oppose the effect of gravity on the body and permit a person to maintain an upright posture. Antagonistic muscles relax when active mover muscles contract.

A patient is admitted to the hospital with injury to the knee joint following a fall. The nurse notices an increased mobility of the joint while assessing the range of motion (ROM). What could be the reason for the increased mobility of the knee joint? 1) Arthritis of the joint 2) Ligament tears in the joint 3) Contractures of the joint 4) Fluid collection in the joint

2 While assessing the ROM of the patient, if increased mobility is noticed, it indicates that there is a possibility of ligament tears. Arthritis is an inflammation of the joint resulting in decreased mobility and stiffness. Contractures and fluid collection in the joint may decrease joint mobility and cause stiffness.

While assessing a patient with a head injury, the nurse suspects damage to the central nervous system (CNS). Why should the nurse assess the patient's voluntary movements? Select all that apply. 1) Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes fractures. 2) Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes impaired mobility. 3) Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes joint degeneration. 4) Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes articular disruption. 5) Damage to any part of the central nervous system (CNS) that regulates voluntary movement causes impaired body alignment.

2, 5 Central nervous system (CNS) damage may cause impaired body alignment and immobility because the CNS regulates voluntary and involuntary activities. Fractures, joint degeneration, and articular disruption are caused by musculoskeletal trauma.

What is the minimum patient weight that requires the use of friction reducing devices and at least three caregivers to handle and position the patient? Record your answer in pounds using a whole number.___________________________ lb

200 If the patient weighs more than 200 lb, then friction reducing devices and at least three caregivers are needed to handle and position the patient.

Which statement is true about the different forms of exercise? 1) Isotonic exercises promote osteoclastic activity. 2) Push-ups and hip lifting are examples of isotonic exercises. 3) A patient who is immobilized can perform isometric exercises. 4) Resistive isometric exercises involve tensing muscles without moving body parts.

3 A patient who is immobilized in bed can perform isometric exercises. Isotonic exercises promote osteoblastic activity rather than osteoclastic activity. Push-ups and hip lifting are examples of resistive isometric exercises. Isometric exercises involve tensing muscles without moving body parts.

Which term is used to explain the relationship of one body part to another along a horizontal or vertical line? 1) Friction 2) Body balance 3) Body alignment 4) Coordinated body movement

3 Body alignment refers to the relationship of one body part to another along a horizontal or vertical line. Friction is a force that opposes movement. Body balance is a technique in which a relatively low center of gravity is balanced over a wide, stable base of support and a vertical line falls from the center of gravity through the base of support. Coordinated body movement is a result of weight, center of gravity, and balance.

When caring for a patient who can assist with positioning, what should the nurse keep in mind? 1) If the center of gravity is higher, the nurse can have more stability. 2) If the base of support is narrower, the nurse can have more stability. 3) If the balancing activity is divided between the arms and legs, there is a reduced risk of back injury. 4) If the nurse's face is towards the direction opposite to movement, this positioning prevents abnormal twisting of the spine.

3 Dividing the balancing activity between the arms and legs reduces the risk of back injury. The lower the center of gravity, the greater the stability of the nurse. The wider the base of support, the greater the stability of the nurse. Facing the direction of movement prevents abnormal twisting of the spine.

A toddler has awkward posture because of a slight swayback and protruding abdomen. The legs and feet are far apart, and the feet are slightly averted. By what age does the child becomes slimmer, taller, and better balanced? Record your answer using a whole number. _ years

3 Toddlers usually have a protruding abdomen and a slight swayback. They usually walk with their legs and feet far apart, and the feet are slightly averted. The posture changes by the third year, and the child's gait becomes more balanced.

What height of the bed is used to transfer and handle the patient safely? 1) Knee level 2) Hand level 3) Elbow level 4) Shoulder level

3 While transferring and handling a patient, the height of the bed should be at elbow level for the purpose of safety.

The nurse is assessing joint movements in a patient. What happens during the process of flexion at the elbow joint? 1) Triceps brachii acts as an antagonistic muscle and contracts. 2) Biceps brachii acts as a synergistic muscle and relaxes. 3) Triceps brachii acts as a synergistic muscle and contracts. 4) Biceps brachii acts as a synergistic muscle and contracts.

4 During flexion of the elbow joint, the biceps brachii acts as a synergistic muscle and contracts. Contraction of the biceps brings the arm and forearm closer to each other and causes flexion. At the same time, the triceps brachii acts as an antagonistic muscle and relaxes. The biceps brachii relaxes and the triceps brachii contracts during extension of the joint.

Which statement is true regarding exercise and activity? 1) There are four categories of exercise. 2) Isotonic exercises cause muscle relaxation. 3) Examples of resistive isometric exercise are walking and swimming. 4) Isometric exercises involve tensing muscles without moving body parts.

4 Isometric exercises involve tightening or tensing muscles without moving body parts. There are three categories of exercise: isotonic, isometric, and resistive isometric. Isotonic exercises cause muscle contraction and changes in muscle length. Examples of resistive isometric exercises are push-ups and hip lifting.

How is the isotonic form of exercise different from the isometric form? 1) Isotonic exercises promote osteoblastic activity. 2) Isotonic exercises enhance circulatory functioning. 3) Isotonic exercises increase muscle mass, tone, and strength. 4) Isotonic exercises cause muscle contraction and changes in muscle length.

4 Isotonic exercises cause muscle contraction and changes in muscle length, whereas isometric exercise involves tightening or tensing muscles without moving the body parts. Both isotonic and isometric forms of exercise promote osteoblastic activity. Both forms of exercise enhance circulatory functioning. Both forms of exercise increase muscle mass, tone, and strength.

What is the normal state of balanced muscle tension? 1) Muscle tension 2) Isotonic contraction 3) Isometric contraction 4) Muscle tone/tonus

4 Muscle tone, or tonus, is the normal state of balanced muscle tension. Muscle tension can be in various states. Muscle tone helps maintain functional positions such as sitting or standing, without excess muscle fatigue; this tone is maintained through the continual use of muscles. Isotonic (dynamic) contraction is a combination of concentric and eccentric muscle actions for active movement. Isometric (static) contraction causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle.

A patient with a body mass index (BMI) of 36 has a sedentary job. She has been advised to reduce her weight through exercise. To begin an exercise program, she needs to go through five steps. Arrange the steps in the appropriate order. 1. Assemble equipment. 2. Get started. 3. Design the fitness program. 4. Monitor progress. 5. Assess fitness level.

5, 3, 1, 2, 4 A health care provider assesses the patient's fitness level, which is used as a basis for the fitness program; then the fitness program needs to be designed. The exercise equipment should be assembled accordingly. Next, the patient should begin the program. Progress is monitored regularly to determine the effect of the exercise. Fitness is assessed at 6 weeks and then every 3 to 6 months.

14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? a. Complaint by patient that something has given way b. Protrusion of visceral organs through a wound opening c. Chronic drainage of fluid through the incision site d. Drainage that is odorous and purulent

A

15. A patient has developed a decubitus ulcer. What laboratory data would be important to gather? a. Serum albumin b. Creatine kinase c. Vitamin E d. Potassium

A

17. The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. b. Notify the charge nurse about the change in status and the potential for infection. c. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). d. Notify the wound care nurse about the change in status and the potential for infection.

A

2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is a. Pressure. b. Resistance. c. Stress. d. Weight.

A

20. A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to a. Inspect the wound for bleeding. b. Inspect the wound for foreign bodies. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection.

A

26. The nurse is completing an assessment of the skin's integrity, which includes a. Pressure points. b. All pulses. c. Breath sounds. d. Bowel sounds.

A

30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a. Ineffective tissue perfusion b. Risk for infection c. Imbalanced nutrition: less than body requirements d. Acute pain

A

36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? a. Gentle cleaners and thorough drying of the skin b. Absorbent pads and garments c. Positioning with use of pillows d. Therapeutic beds and mattresses

A

39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage a. I. b. II. c. III. d. IV.

A

8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). a. 4 b. 2 c. 1 d. 7

A

1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel e. Chaplain f. Pharmacist

A, B, C, D

3. The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. "Can you easily change your position?" b. "Do you have sensitivity to heat or cold?" c. "How often do you need to use the toilet?" d. "Is movement painful?" e. "What medications do you take?" f. "Have you ever fallen?"

A, B, C, D

5. The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.) a. Inspecting the skin for abrasions and edema b. Covering exposed wounds c. Assessing condition of current dressings d. Assessing the skin at underlying areas for circulatory impairment e. Marking the sites of all abrasions f. Cleansing the area with hydrogen peroxide

A, B, C, D

2. The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) a. Nutrition b. Evisceration c. Tissue perfusion d. Infection e. Hemorrhage f. Age

A, C, D, F

1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include a. A diet low in calories and fat. b. Alteration in level of consciousness. c. Shortness of breath. d. Muscular pain.

B

11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.

B

21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a. Don sterile gloves. b. Provide analgesic medications as ordered. c. Avoid accidentally removing the drain. d. Gather supplies.

B

22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step? a. Remove the drain; a drain is no longer needed. b. Call the physician; a blockage is present in the tubing. c. Call the charge nurse to look at the drain. d. As long as the evacuator is compressed, do nothing.

B

23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? a. Standard mattress b. Nonpowered redistribution air mattress c. Low-air-loss therapy unit d. Lateral rotation

B

28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? a. Encourage the patient to sit up in the chair. b. Provide analgesic medication as ordered. c. Explain the risks of immobility to the patient. d. Turn the patient every 3 hours while in bed.

B

3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? a. The patient ate two thirds of breakfast. b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.

B

32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a a. Respiratory therapist. b. Registered dietitian. c. Chaplain. d. Case manager.

B

35. The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care? a. Sterile technique b. Clean dressings and no touch technique c. Double bagging of contaminated dressings d. Ability of the caregiver

B

40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? a. Tell the patient to close his eyes. b. Explain the procedure. c. Turn on the television. d. Ask the family to leave the room.

B

42. The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder? a. The binder creates pressure over the abdomen. b. The binder supports the abdomen. c. The binder reduces edema at the surgical site. d. The binder secures the dressing in place.

B

5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage a. I. b. II. c. III. d. IV.

B

4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.) a. Mobility b. Hyperemia c. Induration d. Blanching e. Temperature of skin f. Nutritional status

B, C, D, E

6. The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.) a. Ask whether patient's expectations are being met. b. Prevent injury to the skin and tissues. c. Obtain the patient's perception of interventions. d. Reduce injury to the skin. e. Reduce injury to the underlying tissues. f. Restore skin integrity.

B, D, E, F

16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing? a. Muscular strength assessment b. Sleep assessment c. Pulse oximetry assessment d. Sensation assessment

C

18. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E.

C

19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? a. "I think I will be ready to go home early next week." b. "I am so weak and tired, I want to feel better." c. "I am ready for my bath and linen change as soon as possible." d. "I am hoping there will be something good for dinner tonight."

C

24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes a. Monitoring of the wound. b. Irrigation of the wound. c. Débridement of the wound. d. Management of drainage.

C

25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? a. Use a low-air-loss therapy unit. b. Consult a dietitian. c. Irrigate with hydrogen peroxide. d. Utilize hydrogel dressing.

C

27. The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient's Braden scale total score? a. 15 b. 17 c. 20 d. 23

C

29. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain

C

31. The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? a. Teach the family how to manage the odor associated with the wound. b. Discuss with the family how to prepare for care of the patient in the home. c. Encourage thorough handwashing of all individuals caring for the patient. d. Encourage increased quantities of carbohydrates and fats.

C

33. The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient? a. The patient's family will demonstrate specific care of the wound site. b. The patient will state what to look for with regard to an infection. c. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. d. The patient's family members will wash their hands when visiting the patient.

C

34. The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for a. Infection. b. Impaired skin integrity. c. Trauma. d. Imbalanced nutrition.

C

37. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a. At least 3 hours b. Not longer than 30 minutes c. Less than 2 hours d. As long as the patient remains comfortable

C

4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? a. Stage I pressure ulcer b. Healing stage II pressure ulcer c. Healing stage III pressure ulcer d. Stage III pressure ulcer

C

41. The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? a. Allowing the solution to flow from the most contaminated to the least contaminated b. Scrubbing vigorously when applying solutions to the skin c. Cleansing in a direction from the least contaminated area d. Utilizing clean gauge and clean gloves to cleanse a site

C

43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement? a. Monitor vital signs every 15 minutes. b. Apply brace to right knee. c. Elevate right knee and apply ice. d. Check pulses in right foot.

C

7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of a. Primary intention. b. Partial-thickness wound repair. c. Full-thickness wound repair. d. Tertiary intention.

C

9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? a. Eschar b. Slough c. Granulation d. Purulent drainage

C

10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.

D

12. Which nursing observation would indicate that a wound healed by secondary intention? a. Minimal scar tissue b. Minimal loss of tissue function c. Permanent dark redness at site d. Scarring can be severe.

D

13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? a. The incision site has started to itch. b. The incision site is approximated. c. The patient has pain at the incision site. d. The incision has a mass, bluish in color.

D

44. The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? a. 12 b. 13 c. 20 d. 23

D

6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? a. Cotton-tipped applicator b. Disposable measuring tape c. Sterile gloves d. Halogen light

D

pressure ulcer

a localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure, shear, to friction

tertiary intention

a wound being left open for several days and closed at a later time.

which scale uses 5 risk factors with a total score of 5-20 to calculate skin integrity. a lower score indicates a higher risk for pressure ulcer development? a) norton b) braden c) gosnell

a) Norton

the nursing assistant asks you the difference between a wound that heals primary or secondary intention. you will reply that a wound heals by primary intention when the skin edges: a) are approximated b) migrate across the incision c) appear slightly pink d) slightly overlap with each other

a) are approximated

eschar

black or brown necrotic tissue

which scale uses six risk factors to determine skin integrity. total range from 6-23, where a lower score indicate high risk for pressure ulcer? a) norton b) braden c) gosnell

braden

38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? a) Obtain assistance and use the drawsheet to place the patient into the new position. b) Place the patient in a 30-degree supine position. c) Utilize a transfer sliding board and assistance to slide the patient into the new position. d) Elevate the head of the bed 45 degrees.

c) Utilize a transfer sliding board and assistance to slide the patient into the new position.

secondary intention

edges are not approximated makes it hard to measure. the granulate tissue closes the wound from the inside out

Risk factors of pressure ulcers

impaired sensory perception, alterations in LOC, impaired mobility, shear, friction, moisture

nursing diagnostics with impaired skin and wounds

impaired skin integrity, risk for impaired skin integrity, risk for infection, acute ir chronic pain, impaired mobility, impaired peripheral tissue perfusion

Primary intention healing

includes the use of suture and staples

a postoperative patient arrives at an ambulatory care center and sates, "I am not feeling good.: Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: a) it has no odor b) a culture is negative c) the edges reveal the presence of fluid d) it shows purulent drainage coming from the incision site

it shows purulent drainage coming from the incision site

hydrogel dressing

maintains a moist surface to support healing

a surgical wound requires a hydrogel dressing. the primary advantage of this type of dressing is that it provides: a) an absorbent surface to collect wound drainage b) decreased incidence of skin maceration c) protection from the external environment d) moisture needed for wound healing

moisture needed for wound healing

what are some factors influencing ulcer formation and wound healing?

nutrition, tissue perfusion, infection, age, psychosocial impact if wound

Hydrocolloid dressing

protects the wound from surface contamination

nursing implementation for skin integrity and wound care

purpose of dressing, type of dressing, changing dressing, packing a wound, securing dressing

debridement

removal of necrotic nonviable tissue

What stage pressure ulcer is this? intact skin with nonblanchable redness a) stage 1 b) stage 2 c) stage 3 d) stage 4

stage 1

what stage pressure ulcer is this? partial thickened skin loss involving epidermis, dermis, or both a) stage 1 b) stage 2 c) stage 3 d) stage 4

stage 2

what stage pressure ulcer is this? full thickness tissue loss with visible fat. may include undermining and tunneling a) stage 1 b) stage 2 c) stage 3 d) stage 4

stage 3

What stage pressure ulcer is this? full thickness tissue loss with exposed bone, muscle or tendon. often include undermining and tunneling. slough or eschar may be present/ a) stage 1 b) stage 2 c) stage 3 d) stage 4

stage 4

tunneling refers to an infection underneath tissue that produces holes on the surface of the pressure ulcer a) true b) false

true

undermining is a term used to describe tissue that expands underneath a pressure ulcer a) true b) false

true

wound V.A.C therapy

uses negative pressure to support healing