SKIN

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse? "The drainage is an indication that the sutures were not tight enough." "If a wound heals on the surface but infection remains, it will open and drain." "The drainage contains enzymes that are necessary for wound healing." "Antibiotics cause the cells of the tissues to produce purulent drainage."

"If a wound heals on the surface but infection remains, it will open and drain."

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? 1 2 3 4

1

Which condition is an example of wound healing by secondary intention? Abdominal wound with staples An infected burn of the arm Sacral skin tear closed with Steri-Strip Leg laceration with sutures

An infected burn of the arm

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action? Stomatitis Bone pain Nausea and vomiting Extravasation

Extravasation

A client comes in with a mild sunburn. Which term best describes the sunburn? First-degree burn Second-degree burn Photosensitivity reaction Immune reaction to UV light

First-degree burn

The nurse is developing a plan of care for a client with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome. Which action should the nurse include? Frequently inspect the oral cavity. Use friction when repositioning the client. Limit fluids. Apply a continuous current of warm air.

Frequently inspect the oral cavity.

The nurse is caring for a client with genital herpes experiencing a reoccurrence. Which nursing diagnosis would be the priority? Powerlessness Anxiety Knowledge Deficit Impaired Skin Integrity

Impaired Skin Integrity

A young lifeguard has been prescribed moxifloxacin (Avelox). The nurse understands that the focus on education would be which adverse reaction? Weakness Fatigue Muscle cramping Photosensitivity

Photosensitivity

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? White with long, thin areas of scar tissue Pink to red and soft, noting that it bleeds easily Pale yet able to blanch with digital pressure Necrotic and hard

Pink to red and soft, noting that it bleeds easily

A client is admitted to the hospital with first- and second-degree burns. Which assessment findings are associated with first-degree burns? Select all that apply. Full-thickness burn Red or pink Wet Painful

Red or pink Painful

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? Moist perineal skin Presence of smegma Reddened perineal skin Absence of discharge

Reddened perineal skin

The nurse is reading the previous shift's documentation of an open area on the client's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the client's sacrum will reveal a pressure ulcer in which stage? Stage III Stage IV Stage II Stage I

Stage II

2. Which of the following factors does not specifically place critically ill patients at increased risk for pressure ulcers? a. Presence of multiple devices and equipment b. Infusion of vasoactive agents for hypotension c. Length of time receiving mechanical ventilation d. Increased incidence of urinary incontinence

a. Presence of multiple devices and equipment

A client has sustained serious first degree, second degree, and third degree burns in a fire. Which best describes this full-thickness burn and the burned area that involves subcutaneous tissue, muscle, and bone? First- and second-degree burns Second-degree burn Second- and third-degree burns Third-degree burn

Third-degree burn

During a physical assessment, a nurse determines that a client has excessively dry skin. Which term would the nurse use to document this condition? Seborrhea Xerosis Alopecia Pruritus

Xerosis

8. Which of the following should be considered when selecting a mattress to reduce the risk of pressure ulcers? a. Low-air-loss mattresses are beneficial for patients with excessive moisture. b. Air fluidized beds are preferred for patients receiving mechanical ventilation. c. Mattresses with pressure redistribution are considered superior to low-air-loss surfaces. d. Rotational surfaces eliminate the need for turning.

a. Low-air-loss mattresses are beneficial for patients with excessive moisture.

5. Which statement is true regarding the 4 most common pressure ulcer risk assessment scales? a. None of the scales fully reflect the additional risk factors present in ICU patients. b. All of the scales are recommended by the Agency for Health Care Policy and Research. c. Only the Waterlow Scale specifically addresses hemodynamic instability. d. The Braden Scale is most effective for assessing risk in critically ill patients.

a. None of the scales fully reflect the additional risk factors present in ICU patients.

10. Which of the following statements is true regarding device-related pressure ulcers? a. They account for approximately 10% of pressure ulcers. b. They only occur when the manufacturer's directions are not followed. c. They occur more frequently with endotracheal tubes than other devices. d. They have been well-defined in a number of research studies.

a. They account for approximately 10% of pressure ulcers.

4. The Kennedy terminal ulcer describes which of the following? a. A nationally recognized ulcer that is unique to the critical care setting b. A rapidly progressing ulcer seen in terminal patients just before deathterm-24 c. A chronic ulcer that develops primarily in long-term care facilities d. A preventable ulcer generally associated with patients in septic shock

b. A rapidly progressing ulcer seen in terminal patients just before death

1. Which of the following describes why there is increased concern over the development of hospital-acquired pressure ulcers (HAPUs)? a. There is little that can be done to treat a pressure ulcer once it occurs. b. Medicare and Medicaid Services will not pay for costs associated with a HAPU. c. Development of a stage I or II pressure ulcer is now considered a "never event." d. The established cost of a pressure ulcer is more than $50 000 per event.

b. Medicare and Medicaid Services will not pay for costs associated with a HAPU.

6. Which of the following statements does not describe the pathophysiology underlying the development of pressure ulcers? a. Compression of vessels prevents the supply of oxygen and nutrients to the tissues. b. Metabolic wastes accumulate at the tissues, leading to further vasoconstriction. c. Moisture contributes to maceration, making the skin more vulnerable to pressure. d. Friction and shear may remove epidermal layers, making the skin vulnerable to injury.

b. Metabolic wastes accumulate at the tissues, leading to further vasoconstriction.

A client was involved in an auto accident and suffered massive internal injuries that resulted in a large blood loss. Select the type of anemia the client is at greatest risk to develop. Aplastic Iron deficiency Hemolytic Blood loss

blood loss

9. Which of the following indicates an increased nutritional risk for development of pressure ulcers? a. An admission albumin level of 38 g/L b. Initiation of enteral nutrition c. A decreasing trend in prealbumin levels d. Infusion of vasodilators

c. A decreasing trend in prealbumin levels

7. Positioning strategies to prevent pressure ulcers include which of the following? a. Turning patients every 4 hours b. Maintaining the head of bed at an elevation greater than 30° c. Elevating patients' heels off the mattress d. Avoiding the supine position whenever possible

c. Elevating patients' heels off the mattress

11. Which of the following interventions is recommended to reduce pressure ulcers in patients with medical devices? a. Repositioning of the endotracheal tube every 4 hours b. Removing cervical collars every shift to perform a thorough skin assessment c. Supporting ventilator tubing to prevent torque on the tracheostomy tube d. Applying hydrocolloid dressings on the face to reduce pressure from continuous positive airway pressure/bilevel positive airway pressure masks

c. Supporting ventilator tubing to prevent torque on the tracheostomy tube

3. Which of the following statements correctly describes deep tissue injury? a. The injury always progresses to a full-thickness pressure ulcer. b. This classification excludes superficial blood blisters. c. The injury appears as a bluish or purple discoloration over an area of pressure. d. The depth of the injury is clearly apparent at the time of identification.

c. The injury appears as a bluish or purple discoloration over an area of pressure.

13. Which of the following is true regarding unit-based quality improvement projects for pressure ulcer prevention? a. They have little impact on pressure ulcer outcomes. b. They focus primarily on teaching staff how to stage ulcers. c. They are effective in heightening staff awareness of pressure ulcer risk. d. They help identify staff who are not following hospital policies.

c. They are effective in heightening staff awareness of pressure ulcer risk.

12. Bariatric patients are at higher risk for pressure ulcers because of which of the following? a. Prolonged need for mechanical ventilation b. Decreased blood supply to adipose tissue c. Impaired gastrointestinal absorption of nutrients d. Increased reluctance to perform position changes

d. Increased reluctance to perform position changes

When trying to discern the extent of a burn, the nurse will note that second-degree full-thickness burns are characterized by: extending into the subcutaneous tissue. noting that blood vessels have clotted and can be seen under the burned skin. extensive pain along with waxy white areas with blister formation. redness or pinkness noted but no blister formation is present on the epidermis.

extensive pain along with waxy white areas with blister formation.

While the nurse is performing a skin assessment on a dark-skinned client, the nurse notes that the client has a healed wound on the leg but that the wound has an excess of scar tissue. The nurse documents this as: epithelialization. proud flesh. remodeling. keloid.

keloid

The nurse is instructing unlicensed personnel on gerontologic considerations of the skin. The nurse finds that the participants understand the instructions when they know that the elderly are at a higher risk for shear injuries due to loss of rete ridges. decreased capillary loops. loss of subcutaneous tissue. sun damage over time.

loss of rete ridges.

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis? meconium-stained skin and fingernails few creases on soles Wharton's jelly abundant vernix caseosa and lanugo

meconium-stained skin and fingernails

In explaining a papule to a client, a nurse defines it as being a: small, raised solid mass with a circumscribed border. flat-topped, solid lesion. small abscess. closed, rounded space containing fluid.

small, raised solid mass with a circumscribed border.