tissue integrity questions

A client's blistering disorder has resulted in the formation of multiple lesions in the client's mouth. What intervention should be included in the client's plan of care?

Provide chlorhexidine solution for rinsing the client's mouth.

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?

hand hygeine

A client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to order:

topical agent

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as

18%

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours?

180 g/day advocate protein requirements of 1.5 to 2 g/kg/day

A patient's severe and widespread psoriasis has prompted her care provider to prescribe potent topical corticosteroids. When teaching this patient about her new medication regimen, the nurse should recognize that topical corticosteroids that are applied to large skin surfaces create a risk of:

Adrenal suppression

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?

Albumin 2.8 mg/dL (28.0 g/L) An albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure injury. This indicates that the client is nutritionally deficient. The hemoglobin A1C level of 5% is a normal value. The BUN level is within normal limits. The white blood cell count is also a normal value.

A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?

Assess the client's psychosocial state.

A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client?

Escharotomy Explanation: In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharotomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration.

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?

allograft

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching?

allograft or homograft is a biologic source of skin similar to that of the client that is a temporary wound covering obtained from cadaver skin."

A patient is diagnosed with seborrheic dermatitis on the face and is prescribed a corticosteroid preparation for use. What should the nurse educate the patient about regarding use of the steroid on the face?

avoid using med around the eyelids because it may cause cataracts or glaucoma

During the acute phase of burn injury, the nurse knows to assess for signs of potassium shifting during what time frame?

beginning on day 4-5

Full-thickness burns may be caused

by an electrical current or prolonged exposure to hot liquids.

The nurse is providing care to a team of clients. Which clients are at risk for injury to the skin? Select all that apply.

the client who has a body mass index (BMI) of 34 the client who is emaciated from self-induced vomiting and food deprivation the client who has a temperature of 104°F (40°C) and is perspiring the client who is experiencing an allergic reaction and is scratching the skin

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Reassess the coccyx area for fading of the redness in 60 to 90 minutes.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound. (The depth of the wound cannot be determined, because it is covered entirely with slough) A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.

Which of the following is also known as "jock itch"?

Tinea Cruris TInea corporis is ringworm affecting body. TInea Unguium is ringworm affecting toenails.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

To keep fire and smoke from airway

The spontaneous separation of dead tissue from the viable tissue is an example of

natural débridement.

the nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?

oblique

The nurse is caring for a client diagnosed with herpes zoster. Which statement by the client needs FURTHER clarification by the nurse?

"Once I get the infection, I cannot get it again."

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs?

A patient-controlled analgesia (PCA) system

The nurse is caring for a client with a pressure ulcer. When documenting findings from the assessment, which statement indicates the client has a stage 4 pressure ulcer? Select all that apply.

A strong, foul odor is present Necrotic tissue is present in the wound Temperature is 102.2 F/ 38.9 C

A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster?

Acyclovir

When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?

Administering systemic antibiotics as ordered

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What plan of care needs to be implemented?

C&S test of wound and antibiotic therapy

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps.

Which primary lesions are associated with acne caused by sebum blockage in hair follicles?

Comedones A comedone is the primary lesion of acne caused by sebum blockage in the hair follicle. A furuncle is a localized skin infection of a single hair follicle. A carbuncle is a localized skin infection involving several hair follicles. Striae are bandlike streaks on the skin, distinguished by color, texture, depression, or elevation from the tissue in which they are found.

A nurse is assessing a teenage client with acne vulgaris. The client's mother states, "I keep telling him that this is what happens when you eat as many french fries as he does." What aspect of the pathophysiology of acne should inform the nurse's response?

Diet is not believed to play a major role in acne therapy. A change in diet is not known to exacerbate symptoms. However, there does appear to be a correlation between foods high in refined sugars and acne; therefore, these foods should be avoided.

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply.

Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications.

Pressure ulcers are caused by:

Extrinsic factors

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis?

Grouped vesicles in linear patches along a dermatome

A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client's subsequent care?

Helping the client identify and avoid the offending agent

The nurse notes that the client's lower extremities are covered with very dry skin and that the horny layer of the skin has become thickened. The nurse notes the finding as

Lichenification

Which of the following is a dermatophyte infection of the fingernails or toes?

Onychomycosis

A patient is being treated for chronic venous stasis ulcers of the lower extremities. What medication does the nurse understand will increase peripheral blood flow by decreasing the viscosity of blood and assist with the healing of the ulcers?

Pentoxifylline (Trental) increases peripheral blood flow by decreasing the viscosity of blood. It has some fibrinolytic action and decreases leukocyte adhesion to the wall of the blood vessels.

Which of the following is an appropriate teaching component for the client diagnosed with lice to prevent reinfestation?

Perform hair inspection whenever there is an outbreak, even if asymptomatic.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.

Singed nasal hair Hoarseness Facial burns Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply.

The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot and tender upon palpation a wound that forms exudate due to the inflammatory response

The nurse is triaging a client over the phone who states having a contact dermatitis rash. Which treatment option of over-the-counter preparations does the nurse suggest for the client? Select all that apply.

Topical antihistamines Hydrocortisone cream Moisturizing cream Lanolin based ointment

A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition?

Undermining undermining is the term for a hollow area between the outer wound and the wound bed. It resembles a cave. Eschar is a leathery covering that is dead tissue; it is usually removed by debridement. Tunneling is a cavity or channel formed from a wound. Dehiscence is the opening of a previously closed surgical wound.

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention?

Use clean technique instead of sterile technique if the wound is closed.

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?

antiviral

classic lesion of impetigo manifest as

honey yellow crusted lesions on an erythematous base.

child tips a pot of boiling water onto his bare legs. The mother should:

immerse the child's legs in cool water. The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria?

impetigo

Pediculosis

infestation with lice

Which of the following is the cause of shingles?

reactived virus

Examples of deep partial thickness burns

scalds and flash flames

surgical débridement.

shaving the burned skin layers and early wound closure

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?

stage 3 Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage. Stage IV exposes muscle and bone

Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply.

"Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."

The nurse is changing the dressing of a chronic wound. There is no sign of infection or heavy drainage. How long will the nurse leave the wound covered for?

48-72h The natural wound-healing process should not be disrupted. Unless the wound is infected or has a heavy discharge, it is common to leave chronic wounds covered for 48 to 72 hours and acute wounds for 24 hours.

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client? Select all that apply.

Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. Change the dressing midway between meals. Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done.

Which of the following site is the source of most microbes leading to bacterial infection? You Selected:

Intestinal tract

A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication?

PTSD

A young client has head lice. What are appropriate steps in eradication? Select all that apply.

Repeat combings daily until there is no more evidence of lice or nits. Apply a pediculicide to the hair (detailed directions also accompany this medication). Comb the hair free of tangles while the hair is damp. Use a special lice comb that has narrow stainless steel teeth. Comb through each area of the hair to remove lice.

A young college student recently had her tongue and lip pierced. She has developed a superinfection of candidiasis from the antibacterial mouthwash. Which of the following would be the correct recommendation for her?

Use an antifungal mouthwash or salt water.

Mechanical débridement

achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. or use of topical enzymatic débridement agents.

A heterograft

is a graft obtained from an animal of a species other than that of the recipient.

In assessing a scar, you notice an overgrowth of tissue. It is best described as a

keloid

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

millia

The nurse applies a moisture-retentive dressing to a patient's wound. She understands that the main advantage of this dressing, rather than a wet dressing, is its ability to:

provides autolytic debridment Commercially produced moisture-retentive dressings can perform the same functions as wet dressings but are more efficient at removing exudate because of their higher moisture-vapor transmission rate; some have reservoirs that can hold excessive exudate.

The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk?

Encourage physical activity and range-of-motion exercises Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process.

Which of the following nonsedating antihistamines is appropriate for daytime pruritus?

Fexofenadine (Allegra)

Dermatophytes (also called tinea) are parasitic fungi that invade the skin, scalp, and nails. How is a diagnosis made for this condition? Select all that apply.

visual examination Wood's light

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply.

Hemodilution Increased urinary output Sodium deficit Hemodilution (decreased hematocrit), increased urinary output, metabolic acidosis (not alkalosis), sodium deficit, and hypokalemia (not hypoglycemia) are typical fluid and electrolyte changes that occur in the acute phase (fluid remobilization phase, state of diuresis).

The nurse is discussing home remedies for insect bites with a group of college students. The nurse correctly includes which remedy in the presentation?

aleo

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?

period during which the wound undergoes changes and maturation

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound?

proliferation phase The wound description reveals a beefy red wound bed that bleeds easily. This is the proliferation stage and describes granulation tissue. Hemostasis is the initial phase, involving activation of platelets. In the inflammatory phase, white blood cells and macrophages enter the wound to remove debris. The maturation phase involves collagen remodeling and scar formation.

Which of the following is a potential cause of a superficial partial-thickness burn?

sunburn

A caregiver is preparing to take over wound care for a client being discharged from the hospital. Which teaching will the nurse provide about wound healing for an older adult client? Select all that apply.

"It may take longer for an older adult to heal." "Consider having a home health aide to assist with bathing and personal care." "Older adults with lots of sun exposure may experience delayed healing."

What is the key sign of onset of acute respiratory distress syndrome?

Hypoxemia

What is the best nursing diagnosis to describe a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen?

Impaired Skin Integrity related to open wound

Which of the following is a true statement regarding psoriasis?

It is characterized by patches of redness covered with silvery scales.

What is true about the dermis? Select all that apply.

It is the thickest skin layer. It is responsible for producing the proteins collagen and elastin.

The nurse is caring for an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help detect the potential for pressure injury? Select all that apply.

Nutritional status Mental status Skin moisture Sensory perception

What are functions of the skin? Select all that apply.

Protection Temperature regulation Sensation Immunologic ation: The skin provides multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elimination. It does not produce vitamin C.

The nurse cares for a 30-year-old client who suffered severe head and facial burn injuries. Which action, if completed by the client, indicates the client is adapting to altered body image? Select all that apply.

Wears hats and wigs Participates actively in daily activities The following are indicators that a client is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the client is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured client but is not related to body image disturbance.

The nurse should assess all possible causes of pruritus for a patient complaining of generalized pruritus. What does the nurse understand can be other causes for this condition?

end stage of kidney disease

A day care worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears:

erythematous with raised papules

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound?

has a fistula formation A fistula is an abnormal tubelike passageway that forms from one organ to outside the body. There is no information that would lead to a suspicion that the wound is infected. Wound dehiscence would be indicated by separation of the wound and evisceration would be evidenced by protrusion of abdominal contents through the wound.

the nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing?

hemostasis phase

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply.

Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it.

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?

Hemodilution 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.

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what?

Hemodynamic instability The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water.

An extended care facility has been the site of a breakout of scabies in recent days. The staff at the facility recognize the need for an expedited, coordinated response to this outbreak. This response should include which of the following measures? Select all that apply.

Providing warm, soapy baths to affected residents Applying a topical scabicide to the skin of affected residents

The nurse is preparing the client for mechanical débridement and informs the client that this will involve which of the following procedures?

Removal of eschar until the point of pain and bleeding occurs

The client cut his leg on a gardening tool several days ago and is being seen for an infected wound. The nurse is going to obtain a culture of the wound and then re-dress the wound. What are the steps, in order, for the nurse to obtain the wound culture and re-dress the wound? Arrange the following steps in the correct order. Remove the soiled dressing wearing clean gloves. Clean the wound, wearing sterile gloves and using sterile supplies. Insert the culture swab deep into the wound, wearing clean gloves. Using a different pair of gloves, place a clean dressing on the wound. Dry the surrounding tissue with gauze.

Remove the soiled dressing wearing clean gloves. Clean the wound, wearing sterile gloves and using sterile supplies. Dry the surrounding tissue with gauze. Insert the culture swab deep into the wound, wearing clean gloves. Using a different pair of gloves, place a clean dressing on the wound.

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain?

Secure the drain to the client's gown with a safety pin below the level of the wound.

What should the nurse assess for to determine if a patient using corticosteroids for a dermatologic condition is having local side effects? Select all that apply.

Skin atrophy Striae Telangiectasia

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

all family members need to be treated

A client has developed blisters around the tape securing a dressing. What nursing action would be appropriate to prevent further damage to the tissues?

applying the dressing with a binder Bandages, binders, and stretch nets also can be used to hold gauze dressings in place and will prevent further damage to the tissues

Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body?

autograph Full-thickness autografts and pedicle flaps are commonly used for reconstructive surgery, months or years after the initial injury. An allograft is a graft transferred from one human (living or cadaveric) to another human. A homograft is a graft transferred from one human (living or cadaveric) to another human. A heterograft is a graft obtained from an animal of a species other than that of the recipient.

The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak?

college dormitory

During the course of a health interview, Mrs. Young tells the nurse that she has been using a new perfume because she wants to smell good. She explains that she has had a rash on her arms and neck since she purchased and used the product. What would be an initial diagnosis for Mrs. Young?

contact dermatitis

A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound?

suspected deep tissue injury A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial-thickness loss of dermis that often presents as an open blister. A stage III pressure injury is a full-thickness tissue loss in which subcutaneous tissue is visible. An unstageable wound is covered by slough or eschar. The depth of the wound is unknown because of this covering.

The nurse is working with a group of clients. Which clients are at risk for a skin alteration? Select all that apply.

the client who is a roofer and spends a lot of time outdoors participating in sports the client who has experienced vomiting and diarrhea for several days with a loss of 12 lb (5.4 kg) in weight the client who has paralysis and is unable to move in bed, turned by the nurse every 2 hours the client with newly diagnosed diabetes who requires management education for the disease

the nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because

tissue edema may interfere with drug absorption via other routes IV administration is necessary because of altered tissue perfusion from the burn injury.

allograft (homograft)

transferred from one human (living or cadaveric) to another human

The nurse working at a physician's office is providing teaching to the parent of a child diagnosed with Tinea capitis (ringworm of the head). How often should the nurse instruct the parent to shampoo the child's hair with ketoconazole or a selenium sulfide shampoo?

twice weekly

xenograft

usually rejected by bodys immune response because it is skin taken from animals usually pigs