PrepU Tissue Integrity

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client? a. Use an electric razor when assisting client with shaving. b. Elevate the client's head of the bed. c. Where a mask when entering the client's room. d. Apply supplemental oxygen to maintain the client's oxygenation.

a; Petechia are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving. Elevating the head of the bed and applying supplemental oxygen would be appropriate for a client with decreased oxygenation. Wearing a mask when entering the client's room would be appropriate for a client with neutropenia, not thrombocytopenia.

The nurse is caring for a client who will be having artificial implants for breast reconstruction. The client is arriving at the physician's office for which procedure to be completed before the surgery can be done? a. Incisional alignment b. Tissue expansion c. Fluid drainage d. Pain control

b; Before an implant for breast reconstruction can produce an optimum cosmetic appearance, the skin and tissue on the chest wall are expanded to provide a large enough space to fill and approximate the size of the remaining breast. The other options are not correct.

A client is evaluated for a diagnosis of Paget's disease. Which laboratory value would the nurse find to confirm the diagnosis? a. Calcium of 9.2 mg/dL (2.3 mmol/L.) b. Urinary creatinine of 0.95 mg/dL (83.98 mol/L) c. Alkaline phosphate of 165 IU/L (2750 mol/L) d. Magnesium level of 2 mg/dL (0.82 mol/L)

c; The normal range for alkaline phosphate level is 20 to 140 |U/L. An elevated serum concentration of alkaline phosphate reflects increased osteoblastic activity and is seen in clients with Paget's disease. A calcium level of 9.2 (2.3 mol/L) is normal. A urinary creatinine level of 0.95 mg/dL (83.98 mmol/L) is normal. A magnesium level of 2 mg/dL (0.82 mol/L) is normal.

A patient had hand surgery to correct a Dupuytren's contracture. What nursing intervention is a priority postoperatively? a. Changing the dressing b. Applying a cock-up splint and immobilization c. Having the patient exercise the fingers to avoid future contractures d. Performing hourly neurovascular assessments for the first 24 hours

d; Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion.

The initial sign of skin pressure is erythema, which normally resolves in less than? a. 15 minutes b. 30 minutes c. 45 minutes d. 1 hour

d; The initial sign of pressure is erythema caused by reactive hyperemia, which normally resolves in less than 1 hour. All of the other time frames are incorrect.

A nurse is creating plan of care to maintain skin integrity who experiences frequent diarrhea due to ulcerative colitis which intervention should nurse include? a. wiping the perineal area with warm water and apply barrier cream. b. only applying barrier cream c. wiping with cold water and patting dry d. no intervention needs to be taken

a

Which type of fracture is one in which the skin or mucous membrane wound extends to the fractured bone? a. Compound b. Complete c. Incomplete d. Simple

a; A compound fracture is one in which the skin or mucous membrane wound extends to the fractured bone. A complete fracture involves a break across the entire cross section of the bone and is frequently displaced. An incomplete fracture involves a break through only part of the cross section of the bone. A simple fracture is one that does not cause a break in the skin.

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client? a. allograft b. xenograft c. autograft d. slit graft

a; Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

When performing a skin assessment, the nurse notes a localized skin infection of a single hair follicle. The nurse documents the presence of: a. a furuncle b. a carbuncle c. chelitis d. a comedone

a; Furuncles are localized skin infections of a single hair follicle. They can occur anywhere on the body but are most prevalent in areas subjected to irritation, pressure, friction, and excessive perspiration, such as the back of the neck, the axillae, or the buttocks. A carbuncle is a localized skin infection involving several hair follicles. Cheilitis refers to dry cracking at the corners of the mouth. Comedones are the primary lesions of acne, caused by sebum blockage in the hair follicle.

A nursing student is preparing a teaching plan about peptic ulcer disease. The student knows to include teaching about the percentage of clients with peptic ulcers who experience bleeding. The percentage is? a. Less than 5% b. 15% c. 25% d. Greater than 50%

b; Fifteen percent of clients with peptic ulcer experience bleeding.

A nurse should expect a client with hypothyroidism to report: a. increased appetite and weight loss. b. puffiness of the face and hands. c. nervousness and tremors. d. thyroid gland swelling.

b; Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

Which type of cardiomyopathy are characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch. a. Hypertrophic cardiomyopathy (HCM) b. Restrictive cardiomyopathy (RCM) c. Dilated cardiomyopathy (DCM) d. Arrhythmogenic right ventricular cardiomyopathy (ARVC)

b; RCM may be associated with amyloidosis (amyloid, a protein substance, is deposited within cells) and other such infiltrative diseases. However, the cause is idiopathic in most cases. Hypertrophic cardiomyopathy occurs when the heart muscle asymmetrically increases in size and mass, especially along the septum. Dilated cardiomyopathy is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. Arrhythmogenic right ventricular cardiomyopathy occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? a. Hemoconcentration b. Hemodilution c. Metabolic acidosis d. Lack of erythropoietin factor

b; Reduced hematocrit is caused by hemodilution 48 hours after a burn, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbuminemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced hematocrit level in this situation. Erythropoietin factor is reduced if kidney failure occurs; however, lack of erythropoietin factor doesn't affect hematocrit level.

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have? a. Vitiligo b. Psoriasis c. Melanoma d. Petechia

b; Scales are flakes of desquamated, dead epithelium that may adhere to the skin surface. They may be of various colors (silvery, white) and textures (thick, fine). Examples include dandruff, psoriasis, dry skin, pityriasis, and rosea.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? a. Anemia b. Gastric ulcers c. Hyperthyroidism d. Cardiac arrest

b; The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? (Select all that apply). a. Constipation b. Sensory overload c. Edema d. Anemia e. Diaphoresis

c, d, e; Risk factors for pressure ulcer development include prolonged pressure on the tissue, sensory deficit or loss, edema, urinary or fecal incontinence, malnutrition, anemia, hypoproteinemia, and excessively moist skin.

The nurse is conducting a community education program on basal cell carcinoma (BCC). Which statement should the nurse make? a. It is more invasive than squamous cell carcinoma (SCO. b. It metastasizes through blood or the lymphatic system. c. It begins as a small, waxy nodule with rolled translucent, pearly borders. d. It is a malignant proliferation arising from the epidermis.

c; BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders. It is less invasive than SCC. It does not metastasize through the blood or lymphatic system. SCC is a malignant proliferation arising from the epidermis.

A client with infective endocarditis is assessed by the nurse for the presence of Janeway lesions. On inspection, the nurse recognizes these lesions by identifying which characteristic sign? a. Patterns of petechiae on the chest b. Erythematosus modules on the pads of the fingers c. Red or purple macules found on the palms of the hands d. Splinter hemorrhages seen under the fingernails

c; Janeway lesions are painless, red or purple macules found on the palms and soles.

A young adult visits a health clinic for treatment of a severe case of eczema on his left leg. Which of the following is the preferred method for delivering medication in this scenario? a. Therapeutic bath b. Cream c. Ointment d. Topical anesthetic

c; Ointments retard water loss and lubricate and protect the skin. They are the preferred vehicle for delivering medication to chronic or localized dry skin conditions, such as eczema or psoriasis.

A nurse in a healthcare provider's office teaches a client how to apply plastic film as an occlusive dressing to cover a medicated ointment applied to the arm. What important teaching point would be included by the nurse? a. Place heat on top of the dressing to increase skin temperature. b. Immobilize the arm when it is wrapped. c. Limit use of the dressing to 12 hours. d. Cover the dressing with an elastic wrap to facilitate daily activities during treatment.

c; Plastic film is thin and readily adapts to all sizes, body shapes, and skin surfaces. In general, plastic wrap should be used no more than 12 hours each day. Immobilization is not necessary. Applying heat or covering the dressing in an elastic wrap would be contraindicated.

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects; a. squamous cell carcinoma. b. actinic keratoses. c. melanoma. d. basal cell carcinoma.

c; The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma. Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration. Actinic keratosis is a premalignant skin lesion. Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated.