Test 2

The nurse is reviewing documentation on a client at risk for developing a pressure injury. Which note in the documentation should indicate to the nurse that the plan of care has been followed​ correctly?

"Client refusing meals. Nutritional consult prescribed"

A client is suspected of having a deep tissue injury. Which intervention should the nurse include in the plan of​ care?

Application of a moisturizing barrier cream, consideration of appropriate support surfaces and other measures to remove all pressure, application of a nonadhesive protective dressing.

The nurse is assisting nursing assistive personnel​ (NAP) reposition a client who is immobile and has been lying on the left side. For which action by the NAP should the nurse​ intervene?

Asks for help pulling the patient back up to the head of the bed.

The nurse identifies that a client is at risk for impaired skin integrity. Which intervention should the nurse add to this​ client's plan of​ care?

Avoid massaging bony prominences, use positioning devices, inspect the skin everyday

The nurse is caring for a client at risk for a pressure injury. Which action should the nurse use to maintain the skin​ integrity?

Cleaning the skin immediately if exposed to urine or feces, assessing the skin upon admission and then daily using the same screening tool, treating dry skin with moisturizing lotions directly applied to moist skin after bathing.

A client has a​ follow-up appointment for treatment of a pressure injury. Which client outcome should indicate to the nurse that treatment goals have been​ met?

Client has enrolled in a smoking cessation program, Wound has decreased in size, Client and family demonstrate an understanding of preventative care measures.

The charge nurse receives report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure​ injuries?

Client on bedrest, Client who is 92 years old, client with history of anorexia, client with type 1 diabetes

The nurse reviewing a​ newborn's chart notes Mongolian spots found on a prior assessment. Which describes the​ nurse's understanding of the​ etiology?

Congenital

the nurse is discussing factors that are attributed to allergic contact dermatitis with a client. Which factor should the nurse include in the​ discussion?

Exposure to perfumes, exposure to soap, exposure to plants.

While applying lotion to the skin of an older adult​ client, the client asks why it is more important to take better care of the skin now than at a younger age. Which aspect of integumentary changes in older adult clients should the nurse include in the​ response?

Greater sensitization to allergens, impaired skin barrier, decreased turnover of the outer skin layer.

The nurse is assessing diffuse bullae and vesicles on a​ client's hands and arms. Which question should the nurse ask the​ client?

Have you been in contact with poison ivy?

A client is in the​ high- Fowler position to facilitate breathing. Which body pressure area should the nurse be most concerned​ about?

Heels

The nurse is preparing a client scheduled for a skin biopsy. The client asks how this will be done. Which procedure should the nurse​ include?

Incision, Excision, Shaving, Punch.

The nurse is reviewing the chart of a client diagnosed with paronychia. Which assessment finding should the nurse​ anticipate?

Infection around the fingernail.

The nurse is caring for a client with acne. Which condition describes the​ nurse's understanding of the classification of​ acne?

Inflammatory

The nurse is planning teaching for a client with infected contact dermatitis. Which information should the nurse include in the​ teaching?

Keep nails trimmed short.

A client with poor nutritional intake is at high risk for developing pressure injuries. Which device should the nurse identify as appropriate for this​ client?

Memory foam chair pad while client is in chair, Gel flotation pads, foam wedges and pillows, static low air loss bed.

The nurse assessing a client notes the client is at risk for candidiasis. Which client behavior observed by the nurse would support this​ conclusion?

The client is on an antibiotic.

The nurse performing a home visit for an older adult client determines the client would benefit from teaching about the promotion of skin integrity. Which assessment finding indicates the need for further​ teaching?

The client uses a body spray perfume.

A client with deep tissue damage develops eschar. Which procedure should the nurse anticipate being​ prescribed?

Surgical debridement

A client who has been sedated and on mechanical ventilation for several days is on a​ low-air-loss bed;​ however, the client has a localized purple area of discoloration over the coccyx that does not blanch. Which pressure injury should the nurse suspect for this​ client?

Suspected deep tissue injury

The nurse is reviewing a​ client's chart who presents to the clinic with report of a​ "skin rash." Which descriptive characteristic indicates a specific skin disorder that the nurse may​ consider?

Vesicle, Macule, Wheal

The nurse is caring for a client with an open pressure injury with minimal necrotic tissue. Which dressing should the nurse identify as most appropriate for the​ client?

Wet-to-dry gauze dressing with sterile normal saline.

The nurse is reviewing the chart of a client who has developed keloids as a result of multiple surgeries. Which assessment finding should the nurse​ anticipate?

Elevated, irregular, darkened area

The nurse reviews alginate dressings with a new nurse. For which type of pressure injury should the nurse identify this dressing is​ used?

Stage 2,3,4 (without eschar)

A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. Which stage should the nurse document this ulcer to​ be?

Stage 4

The nurse is caring for a client admitted with a pressure injury. Which data should the nurse document when assessing the pressure​ injury?

Stage of the ulcer, signs of infection, integrity of the surrounding tissue, color of the wound bed.

The nurse is reviewing the chart of a client diagnosed with neurofibromatosis. Which change in skin pigmentation should the nurse anticipate finding based on the​ client's diagnosis?

Cafe au lait spots

The nurse is caring for a client with incontinence of urine and sudden onset of watery diarrhea. Which action should be included in the plan of care to maintain skin​ integrity?

Clean skin immediately at the time of soiling and routinely, assess skin systematically at least once a day, apply a moisturizing barrier cream to the skin at greatest risk of breakdown, increase humidity in the room to eliminate exposure to cold

A client with a deep tissue injury and white exudate develops a fever. Which test should the nurse anticipate being prescribed by the healthcare​ provider?

Culture and sensitivity of the wound bed.

The nurse manager observes a new nurse talk with a client with a stroke and decreased mobility about ways to prevent pressure injures. For which statement should the nurse manager​ intervene?

Due to decreased mental status you will need to be turned every 2 hours.

The nurse is caring for an adolescent female client who has begun menstruating. Which preexisting disorder should the nurse expect to be exacerbated by the hormonal changes that​ occur?

Eczema

The nurse is reviewing the chart of a client who is pregnant and reports​ "red patches of skin that​ itch." Which assessment finding should the nurse​ anticipate?

Eczematous skin changes around the neck

The nurse is preparing to perform an assessment on a client. Which factor should the nurse include in the integumentary​ assessment?

Nails, Temperatrue, Turgor, Texture

A client asks what effect nutrition has on skin integrity. Which response should the nurse make that explains the relationship of nutrition to pressure injury​ development?

Poor dietary intake of kilocalories, protein, and iron can cause increase the risk of pressure injuries.

The nurse is caring for a client with impaired mobility. Which concern regarding tissue integrity should the nurse​ address?

Pressure ulcer formation, Skin breakdown

While assessing the skin of a client who has undergone​ surgery, the nurse observes erythema to the left scapulae. Which action should the nurse take before reassessing the skin to determine if the erythema is a pressure​ injury?

Reposition the client

The nurse is caring for an older adult client who is significantly underweight. Which intervention should the nurse include in the plan of care for the client to maintain skin​ integrity?

Review safety strategies to prevent injuries and falls.

The nurse notes circular lesions on a​ client's upper back. Which condition should the nurse consider prior to​ examination?

Ringworm, Tinea versicolor

The nurse notes that a client appears to have an integumentary infection. Which diagnostic test should the nurse anticipate will be​ prescribed?

wood lamp