NU 272: Tissue Integrity
In which stage is a pressure ulcer considered a partial-thickness wound? Stage I Stage II Stage III Stage IV
Stage II A stage I pressure ulcer is an area of erythema that does not blanch with pressure. A stage II pressure ulcer is considered a partial-thickness wound. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends to the underlying muscle and bone.
The mother of a 11-month-old has come to the clinic with concerns. She reports to the nurse that her baby's "soft spot in the front" is now gone. The nurse assesses the infant and notes the fontanel has closed. What response by the nurse is most appropriate? "The soft spot or fontanel has closed." "This closure of the fontanel is very premature and warrants some further testing." "This may signal your baby's calcium levels are elevated." "We will need to do additional neurological testing to make certain your infant is developing normally."
"The soft spot or fontanel has closed." The anterior fontanel traditionally closes between 12 and 18 months. In some infants this may close sooner. This does not indicate there is any abnormality in the development of the infant.
A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? Tissue tearing away from supporting structures Incision of the skin with well-defined edges, usually long rather than deep Skin tear with irregular edges and vein bridging Denuded skin
Tissue tearing away from supporting structures An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually long rather than deep.
The nurse is caring for a child, weighing 100 lb (45.5 kg), on the burn unit who has partial-thickness or second-degree burns over 30% of the body. During the beginning shift assessment, which assessment finding is of most concern to the nurse? Pain at a 7 on a 0 to 10 scale Urine output of 15 mL per hour over the last 4 hours Refused dinner due to nausea Weight gain of 0.9 kg over the last 2 days
Urine output of 15 mL per hour over the last 4 hours Fluid and electrolyte imbalance is a primary concern when caring for the client with burns. The urine output should be a minimum of 1 mL/kg/hour. The client weighs 45.5 kg, so output should equal approximately 45 mL/hour. Pain is a major concern, but the higher priority at this time is the decreased output. Refusal of one meal is not a high priority. Weight gain of 0.9 kg over 2 days is not a concern at this time.
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? Assessing WBC count, temperature, and wound appearance Obtaining dietary consultation for improved wound healing Educating the client on safe bed-to-chair transfer procedures Administering pain medications within 1 hour of the client's request
Assessing WBC count, temperature, and wound appearance The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."
After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? Epidermis Dermis Papillary layer Stratum corneum
Dermis The dermis is often referred to as the true skin. The epidermis is the outermost layer of the skin, with the stratum corneum as the outermost layer of the epidermis. The papillary layer is the outermost layer of the dermis that lieds directly beneath the epidermis.
The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition? Heroin withdrawal Hypoglycemia Hypoxia Hemolytic disease
Hemolytic disease Any infant admitted to the newborn nursery should be examined for jaundice during the first 36 hours or more. Early development of jaundice (within the first 24 to 48 hours) is a probable indication of hemolytic disease. Heroin withdrawal symptoms commonly include tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea, disturbed sleep patterns, and a shrill high-pitched cry. The hypoglycemic newborn's blood glucose would be low, and a newborn with hypoxia would show signs of respiratory distress.
Which of the following is the effect of protein catabolism in a client with severe burns? It compromises wound healing and immunocompetence. It compromises dexterity and mobility. It maximizes the risk of sodium retention and hypotension. It maximizes the risk of impaired ventilation.
It compromises wound healing and immunocompetence. Protein catabolism in a client with severe burns compromises wound healing and immunocompetence. Burns of the face, neck, or chest have the potential to impair ventilation, while burns involving the hands or major joints may affect dexterity and mobility. Release of aldosterone, not protein catabolism, causes sodium retention.
