skin integrity

Shearing injury

deep tissue shifts, but skin tissue remains stationary

Tissue load

function of the distribution of pressure, friction, and shear on tissue

Which condition is an example of a bacterial infection? 1 Impetigo 2 Candidiasis 3 Plantar warts 4 Verucca vulgaris

1 impetigo is the bacterial infection of skin caused by group A β-hemolytic streptococci or Staphylococcus aureus. Candidiasis is the fungal infection caused by Candida albicans. Plantar warts and verucca vulgaris are fungal infections caused by the human papilloma virus.

Which disorder of the foot is caused by continual pressure over bony prominences? 1 Corn 2 Plantar wart 3 Hammer toe 4 Hallux rigidus

1 A corn is a foot disorder caused by continual pressure over bony prominences. A plantar wart is a foot disorder caused by a virus. Hammer toe is a foot disorder caused by flexion and deformity in the joints. Hallux rigidus is caused by osteoarthritis.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? 1 Incontinence and inability to move independently 2 Periodic diaphoresis and occasional sliding down in bed 3 Reaction to just painful stimuli and receiving tube feedings

1 Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers. Although periodic exposure to moisture and occasional friction are risk factors for pressure ulcers, they do not place a client at highest risk. Although immobility places a client at risk for pressure ulcers, tube feedings should meet the client's nutritional needs and promote tissue integrity. Although being chair-bound increases a client's risk for pressure ulcers, adequate nutritional intake supports tissue integrity. If the client has upper body strength, weight can be shifted periodically to relieve pressure.

Which organ-specific autoimmune disorder is associated with a client's kidney?

1 Graves' disease 2 Addison's disease Correct3 Goodpasture syndrome 4 Guillain-Barré syndrome Goodpasture syndrome is an autoimmune disorder associated with the client's kidney. Graves' disease and Addison's disease are autoimmune disorders associated with the endocrine system. Guillain-Barré syndrome is an autoimmune disorder associated with the central nervous system.

A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia (CREST syndrome). Which clinical indicators should the nurse expect to identify upon assessment? Select all that apply.

1 Joint pain 2 Masklike facies Correct3 Esophageal dysmotility Correct4 Spiderlike hemangiomas Correct5 Episodic blanching of the fingers Esophageal dysmotility is associated with CREST syndrome; it results in dysphagia and esophageal reflux. Spiderlike hemangiomas (telangiectasia) is associated with CREST syndrome. Episodic blanching of the fingers (Raynaud phenomenon), caused by vasospasms of the arterioles, is a sign associated with CREST syndrome. Joint pain, caused by inflammation, is a symptom associated with scleroderma, not CREST syndrome. Masklike facies is a sign associated with scleroderma, not CREST syndrome; it is caused by fibrotic tissue changes.

The nurse is providing postoperative care to a client who had surgery in which a hip prosthesis was inserted. An abductor splint is in place. When should the nurse remove the splint?

1When the client gets up to sit in a chair 2 If the client needs a change of position 3 Once the client's edema and pain have ceased Correct4 During the client's skin care and physical therapy Until the prescription is written to discontinue the abduction splint, it is only removed for mobility such as physical therapy and hygiene; adduction to or beyond the midline is not permitted until allowed by the primary healthcare provider. When the client gets up to sit in a chair, the splint is needed unless the client can be trusted to maintain abduction; flexing the hip with a prosthesis cannot be beyond 60 degrees for up to 10 days; from then on it cannot be beyond 90 degrees until permitted by the primary healthcare provider. If the client needs a change of position, a splint helps to maintain position and keep the hip prosthesis in the hip socket. It is inappropriate to remove the splint once the client's edema and pain have ceased; there are no criteria for discontinuing abduction of the affected extremity.

After reviewing the client's laboratory reports, the physician concludes that the client has primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed in that client? 1 Edema at extremities 2 Uneven patches of pigment loss 3 Reddish-purple stretch marks on the abdomen 4 "Buffalo hump" between shoulders on the bac

2 Vitiligo [1] [2] is manifested by the presence of large patchy areas of pigment loss. This is mainly caused by primary hypofunction of the adrenal gland. Presence of edema at extremities indicates fluid and electrolyte imbalances mainly observed in a client with thyroid problems. Presence of reddish-purple stretch marks on the abdomen and "buffalo hump" between shoulders on the back of the neck often indicates excessive adrenocortical secretions.

9.Which drug is prescribed for the client to treat severe nodulocystic acne? 1 Imiquimod 2 Isotretinoin 3 Clindamycin 4 Corticosteroids

2 Isotretinoin is used for nodulocystic acne and may provide lasting remission. Imiquimod is a topical immunomodulator used to treat plantar warts. Clindamycin is a topical antibiotic used to treat acne vulgaris to suppress new lesions and minimize scarring. Corticosteroids are contraindicated because use of corticosteroids may cause flare-ups in clients with acne.

Which skin color in a client indicates an increased urochrome level? 1 Red 2 Blue 3 Reddish blue 4 Yellow-orange

4 A yellow-orange skin color indicates an increased urochrome level. A red-colored face, cheeks, nose, and upper chest indicate increased blood flow to the skin. A bluish color of the nail beds indicates an increase in deoxygenated blood in the body. A reddish-blue color of the distal extremities indicates decreased peripheral circulation.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A client is admitted with extensive bone and soft-tissue injuries to the leg. Sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. Which action should the nurse take to loosen the dressing? 1 Apply diluted hydrogen peroxide. 2 Pull with gentle but steady traction. 3 Soak the area in a solution of Betadine. 4 Moisten the dressing with sterile saline

4 Sterile saline will soften the dried exudates adhered to the dressing, limiting tissue damage when the dressing is removed. The use of hydrogen peroxide can be irritating to the tissues. Pulling off the dressing with steady traction may be painful and cause unnecessary tissue damage. The use of Betadine to remove a dressing is not recommended.

Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? 1 Tenting 2 Angioma 3 Varicosity 4 Telangiectasi

4 Telangiectasia is a permanent condition characterized by cutaneous blood vessels that are superficial and visibly dilated. Tenting is the failure of the skin to immediately return to the normal position after a gentle pinch. Angioma is a tumor that consists of blood and lymph vessels. Varicosity is the increased prominence of superficial veins.

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? 1 Equal 2 Unrelated 3 Inversely related 4 Directly proportional

4 There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

Triangular-shaped ulcers in the sacral area are often the result of

significant shearing injury from sliding down in bed.