tissue intergrity prepU

A patient's blood work reveals a platelet level of 17,000/mm3. When inspecting the patient's integumentary system, what finding would be most consistent with this platelet level?

Petechiae

A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones?

Subcutaneous tissue

A client from a nursing home arrives at an acute care facility for treatment related to complications of chronic obstructive pulmonary disease. A nurse performing the admission assessment notes the presence of a large stage III pressure ulcer. The client's child asks if the hospital can "treat the sore." What is the nurse's best initial response?

"We will collaborate with the physician to obtain an order for the wound care nurse to see the client."

The nurse is caring for a resident in a long-term care facility who has venous stasis ulcers and is being treated with an Unna boot. Which of the nursing activities is best for the nurse to delegate to a unlicensed assistive personnel (UAP)?

Assist the client in cleaning around the Unna boot.

The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?

Asymmetry

A client on a prescribed medication for a skin disorder visits the clinic complaining of a skin rash. Which of the following would explain the client's condition?

Drug allergy

Which nursing intervention can help a client maintain healthy skin?

Keeping the client well hydrated

A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely?

Patch testing

The nurse is caring for a hospitalized client who has class II obesity and who has limited mobility. The nurse should address the client's risk for skin breakdown by:

cleaning and drying regularly within the client's skin folds.

Based on an established plan of care, a nurse turns a patient every 2 hours. What part of the nursing process is the nurse using?

implementing

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at the greatest risk for skin breakdown?

incontinence and right-sided hemiparesis

A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy?

maintaining the client's fluid and electrolyte balance

A hospitalized patient has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition?

poor wound healing, apathy, edema

A client has entered an environment where there are numerous infectious microorganisms. The body's first line of defense against these organisms is considered to be what?

skin

A client is diagnosed with contact dermatitis. Which medication should the nurse expect to be prescribed to treat this disorder?

topical corticosteroid

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?

By protecting older adults against shearing injuries

A client in a semiprivate room is diagnosed with pediculosis corporis. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. How should the nurse respond?

"I'm sorry, but I can't share confidential information."

Which diagnostic test would be used if a malignancy is suspected?

Biopsy

A client has joined a rowing team and has been enjoying the activity for approximately 1 month. The client comes to the clinic for a routine physical examination and shows the nurse the hands, which are observed to have thickened areas in several areas. What does the nurse recognize these are in response to the repeated friction of the oars?

Calluses

A nurse is repositioning a patient who has physical limitations due to recent back surgery. How often would the nurse turn the patient in bed?

Every two hours.

Thickened nails may be indicative of which type of infection?

Fungal

A client with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy?

Skin biopsy

A nurse visits the employee health department because of mild itching and a rash on both hands. During the assessment interview, the employee health nurse should focus on

chemical and latex glove use.

A nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

wash and inspect the feet daily.

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan?

Use a topical skin moisturizer daily.