PrepU Tissue Integrity

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic?

A cephalohematoma

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?

"You must avoid hyperextending your neck after surgery."

The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as

angioneurotic edema.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?

The early appearance of the burn injury may change.

The nurse is caring for an older adult client who has refused a bath for several days, and has now developed a rash on the buttocks. Which statement by the nurse should be made first?

"Getting a bath helps to remove the bacteria from your skin, which is what is causing the rash on your buttocks."

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?

"The client remains free of signs and symptoms of phlebitis."

A nurse is conducting a presentation for a local women's group about pelvic organ prolapse. When describing the different types, which information would the nurse incorporate into the description of a cystocele?

protrusion of the bladder wall through the anterior vaginal wall

While performing a clinical breast examination, the nurse notes a firm and rubbery nodule that is well circumscribed and moves freely. How should the nurse counsel the client?

"It's most likely a fibroadenoma, but we may need to do a biopsy."

The nurse is discussing acne vulgaris with a group of adolescents. The teenagers make the following statements regarding the topic. Which statement is the most accurate regarding acne vulgaris?

"Sometimes I get acne when I use my sister's makeup."

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27% Chapter 62: Management of Patients with Burn Injury - Page 1848

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

A urine output consistently above 40 ml/hour (40 mL/hour) In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4 lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary

A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which information should the nurse include in client teaching?

Apply deodorant only under the left arm.

In a client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

Avoiding using deodorant soap on the irradiated areas Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water and a mild soap only and leave the area open to air. No deodorants or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.

The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?

Bladder distention

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?

Debridement necrotic tissue prevents wound healing and must be removed. this is accomplished by debridement. incision and drainage, culture, or irrigation wont remove necrotic tissue. incision and drainage drain a wound abscess. a wound culture indentifies organisms growing in the wound and helps the physician determine appropriate therapy. if the wound is infected, the physician may order irrigation usually with an antibiotic solution to treat the infection and clean the wound.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound

Dehisced Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules Hemorrhage is excessive bleeding.

The nurse is examining the back and spinal area of a 14-year-old female. A small dimple is noted. What action is most appropriate?

Document the finding as normal. Chapter 32: Health Assessment of Children - Page 1192

The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation?

Dry skin thoroughly after washing

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:

Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

A 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.

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority?

Impaired skin integrity

A young couple are disappointed that they are not yet pregnant and are seeking assistance at the health clinic. After assessing their medical history, the nurse discovers the female has a history of several episodes of PID. The nurse predicts this may be a source of the infertility related to which factor?

It interferes with the transport of ova due to tubal scarring.

A teenage girl is talking to a nurse about the desire to keep her skin healthy and young throughout her life. Which suggestion should the nurse make?

Keep well hydrated Keeping the client well hydrated helps prevent skin cracking and infection, because intact healthy skin is the body's first line of defense. To help a client maintain healthy skin, the nurse should suggest avoiding strong or harsh detergents and encourage the use of mild soap. Lotions with sunblock are good only if they are SPF > 15 and reapplied every 2 hours. The removal of make-up will prevent breakouts, but not make a difference in the aging of the skin.

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?

Maintain a diet for the client that is high in protein, vitamins, and calories. To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Chapter 68: Management of Patients With Neurologic Trauma - Page 2060

When assessing a client's incision one day after surgery, the nurse sees redness and warmth around the incision site. What action by the nurse is best?

Note the wound edges in the client's chart. Warmth and redness are normal signs of an inflammatory response, and do not require interventions such as a cool compress. There are no infectious processes that would require a culture. Blanching would not demonstrate issues with the wound infection.

A client has been diagnosed with peripheral arterial occlusive disease. In order to promote circulation to the extremities, the nurse should instruct the client to:

Participate in a regular walking program. Explanation: Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

A client has received a dose of dopamine intravenously. The client's IV was infiltrated, and the dopamine was injected into the subcutaneous tissues. Which medication will prevent the vasoconstriction and tissue necrosis based on this action?

Phentolamine mesylate (Regitine)

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair?

Protein

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation?

Turn off Oxytocin

Within an infected wound bed, many cell types are involved in protecting the host and eliminating the "foreign invaders" to promote wound healing. How does the identification of body tissues from foreign substances occur?

Via the immune system Explanation: The immune system detects and eliminates foreign substances that may cause tissue injury or disease.

Parents bring their 9-year-old child to the clinic for a well-child visit. They are concerned because several children in the neighborhood have developed Lyme disease and ask for suggestions on what to do to reduce their child's risk. What would be appropriate for the nurse to suggest? Select all that apply.

Wearing protective clothing when playing in wooded areas. Contacting the health care provider if there is any area of inflammation that might be a bite. Inspecting the skin closely for ticks after the child plays in wooded areas.

There are a variety of problems that can become complications after a fracture. Which is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head?

avascular necrosis

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

gauze Gauze dressings absorb blood or drainage. Montgomery straps are strips of tape with eyelets which are used to secure a gauze dressing that needs frequent changing; they are not necessary for this type of wound. Transparent dressings like OpSite are used to protect intravenous insertion sites. Hydrocolloid dressings like Tegasorb are used to used keep a wound moist. Chapter 31: Skin Integrity and Wound Care - Page 983

A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to:

reposition the client off the reddened skin and reassess in a few hours. A stage I ulcer presents as an area of intact, nonblanchable redness, usually over a bony prominence, caused by pressure. If a reddened area blanches and refills with fingertip pressure, it indicates that there is still some blood flow to the injured area, and the redness may be reversible. It may be appropriate to complete and document a Braden score or consult a wound nurse specialist, but it is imperative to reposition the client off the reddened skin area first. Since there is no break in the skin, it is not appropriate to apply a moist to moist dressing.

During a breast examination, which finding most strongly suggests that a client has breast cancer?

A fixed nodular mass with dimpling of the overlying skin Explanation: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition Chapter 58: Assessment and Management of Patients With Breast Disorders - Page 1732

In chronic osteomyelitis, antibiotics are adjunctive therapy in which situation?

Surgical debridement