Tissue Integrity Adaptive quizzing

Which factor contributes to a client's slow rate of healing? SELECT ALL THAT APPLY A) diabetes B) cataract C) smoking D) dermatitis E) alcohol abuse

A) diabetes C) smoking E) alcohol abuse

Which documentation would the nurse utilize to report that a client's degree of edema has a depth of 8mm? A) 1+ B) 2+ C) 3+ D) 4+

D) 4+

Which reaction is an example of a type 1 hypersensitivity reaction? A) anaphylaxis B) serum sickness C) contact dermatitis D) blood transfusion reaction

A) anaphylaxis

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? A) atrophy of the sweat glands B) decreased subcutaneous fat C) stiffening of the collagen fibers D) degeneration of the elastic fibers

B) decreased subcutaneous fat

Which predisposing condition may be present in a client with pitting edema? A) shock B) kidney disease C) hypothyroidism D) severe dehydration

B) kidney disease

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? A) urticaria B) a medication reaction C) atopic dermatitis D) contact dermatitis

D) contact dermatitis

When performing a client's skin assessment, the nurse identified a thickening of the skin with accentuated normal skin markings over the axillary regions. Which etiology would the nurse associate this client's skin? A) dehydration B) parasitic infection C) pruritus causing irritation D) interruption of venous return

C) pruritus causing irritation

Which statement made by the client about sleeping positions to follow to prevent pressure ulcers indicates effective learning? SELECT ALL THAT APPLY A) "I should use pressure-relieving pads" B) "I should place a rubber ring under the sacral area" C) "I should place pillows between two bony surfaces" D) "I should keep the head of the bed elevated above 30 degrees" E) "I should keep my heels off the bed surface using a bed pillow under the ankles"

A) "I should use pressure-relieving pads" C) "I should place pillows between two bony surfaces" E) "I should keep my heels off the bed surface using a bed pillow under the ankles"

Which statement made by the nursing student about interventions that reduce the risk of pressure ulcers in a client indicates effective learning? SELECT ALL THAT APPLY A) "I will elevate the head of the client's bed to no more than 30 degrees" B) "I will ensure that the client is turned and repositioned at least every 2 hours" C) "I will advise the client to apply talc directly on the perineum" D) "I will ensure that the client's fluid intake is 2000 to 3000 mL/day" E) "I will teach the client to refrain from eating a high-protein and calorie diet"

A) "I will elevate the head of the client's bed to no more than 30 degrees" B) "I will ensure that the client is turned and repositioned at least every 2 hours" D) "I will ensure that the client's fluid intake is 2000 to 3000 mL/day"

Which statement describes negative pressure wound therapy? SELECT ALL THAT APPLY A) a suction pump is used B) necrotizing infections are treated C) oxygen is administered under high pressure D) a low-voltage current is applied to a wound area E) chronic ulcers are reduced by removing fluids from the wound

A) a suction pump is used E) chronic ulcers are reduced by removing fluids from the wound

A client is hospitalized with pressure injuries. Which task(s) could be delegated to an unlicensed assistive personnel (UAP)? SELECT ALL THAT APPLY A) empty wound drainage containers B) report changes in wound appearance C) apply prescribed dressings and medications D) assess and record data about wound appearance E) choose dressings and therapies for wound treatment

A) empty wound drainage containers B) report changes in wound appearance

Which action is likely to help prevent pressure injuries for a client who has paraplegia? A) inspecting the skin every day B) providing a rubber seat cushion C) massaging body lotion over reddened areas D) applying a heating pad to bony prominences

A) inspecting the skin every day

Which key feature is associated with a stage 2 pressure ulcer? A) presence of non-intact skin B) development of sinus tract C) damage to the subcutaneous tissues D) appearance of a reddened area over a bony prominence

A) presence of non-intact skin

Which clinical manifestation would the nurse observe in a client experiencing anaphylactic shock from a type 1 latex allergic reaction? SELECT ALL THAT APPLY A) stridor B) fissuring C) hypotension D) dyspnea E) cracking of skin

A) stridor C) hypotension D) dyspnea

An emaciated older adult with dementia develops a large pressure injury after refusing to change position for extended periods. The family blames the nurses and threatens to sue. Which factor is considered when determining the source of blame for the pressure injury? A) the client should have been turned regularly B) older clients frequently develop pressure injuries C) the nurse is not responsible to the client's family D) nurses should respect a client's right not to be moved

A) the client should have been turned regularly

Which feature is associated with the "maturation phase" of normal wound healing? A) the scar is firm and inelastic on palpation B) fibrin strands form a scaffold or framework C) white blood cells migrate into the wound D) epithelial cells are grown over the granulation tissue bed

A) the scar is firm and inelastic on palpation

Which action would the nurse take initially after discovering a client has a stage 1 pressure ulcer upon admission? A) turn and reposition the client every 2 hours B) cover the ulcer with an occlusive, transparent dressing C) clean the ulcer with hydrogen peroxide and leave it open to the air D) provide the client with a diet high in Vit C, zinc, and protein

A) turn and reposition the client every 2 hours

Which action would be included in an organization's policy for hand hygeine? SELECT ALL THAT APPLY A) wash hands before applying sterile gloves B) wash hands before touching any of the client's personal items C) wash with either soap and water or alcohol-based hand rub (ABHR) before client contact D) wash with soap and water when hands are visibly soiled with blood E) wash with ABHR if hands are not visibly soiled F) wash hands, between fingers, and under the nails for 60 seconds

A) wash hands before applying sterile gloves C) wash with either soap and water or alcohol-based hand rub (ABHR) before client contact D) wash with soap and water when hands are visibly soiled with blood E) wash with ABHR if hands are not visibly soiled

While inspecting her healthy newborn just delivered at 37 weeks' gestation, the client asks, "What's this sticky white stuff all over the baby?" How would the nurse respond? A) "It's a secretion from the baby's fat cells called milia." B) "This is vernix. It helps protect the baby while it's in the uterus" C) "Your baby was born several weeks early, so we expect to see this" D) "It's nothing to be concerned about. Most newborns are covered with it"

B) "This is vernix. It helps protect the baby while it's in the uterus"

Which statement by the student nurse about the use of a suction pump in negative-pressure wound therapy indicates the need for further teaching? A) "The wound site should be monitored at least every 2 hours" B) "This treatment is used mostly for areas of skin cancer" C) "The foam dressing should be changed every 48 to 72 hours" D) "A continuous low-negative pressure should be maintained"

B) "This treatment is used mostly for areas of skin cancer"

Upon pressure application, which degree of edema would the nurse document for a 6-mm deep indentation? A) 4+ B) 3+ C) 2+ D) 1+

B) 3+

Which data would the nurse use to determine a client's score on the Braden Scale to predict a client's risk for developing pressure injuries? SELECT ALL THAT APPLY A) age B) anorexia C) hemiplegia D) history of diabetes E) urinary incontinence

B) anorexia C) hemiplegia D) history of diabetes E) urinary incontinence

Which items would the nurse include in assessment of the integumentary system for a preoperative client? SELECT ALL THAT APPLY A) inspect the neck for distended veins B) assess the skin turgor for signs of dehydration C) examine the skin for rashes or lesions D) question the client about any skin disorders E) palpate the chest for heaves or lifts

B) assess the skin turgor for signs of dehydration C) examine the skin for rashes or lesions D) question the client about any skin disorders

Which nursing interventions require the nurse to wear gloves? SELECT ALL THAT APPLY A) giving a back rub B) cleaning a newborn immediately after delivery C) emptying a portable wound drainage system D) interviewing a client in the emergency department E) obtaining the blood pressure of a client who is positive for human immunodeficiency virus (HIV)

B) cleaning a newborn immediately after delivery C) emptying a portable wound drainage system

Which action would the nurse take when a client with chronic venous insufficiency has ankle edema? A) restrict fluids B) elevate the legs C) apply a Unna boot D) discuss sclerotherapy

B) elevate the legs

Which physiological activity is associated with the "proliferative phase" of normal wound healing? A) white blood cells migrate into the wound B) epithelial cells grow over the granulation tissue C) scar tissue gradually becomes thinner and pale D) vasodilation occurs with increased capillary permeability

B) epithelial cells grow over the granulation tissue

Which nursing intervention assists in decreasing the potential occurrence of pressure ulcers when providing care for a client with quadriplegia? A) avoid massaging the client's legs B) frequently reposition the client on a scheduled basis C) increase the fiber content in the client's food D) encourage the client to participate in weight-bearing exercises

B) frequently reposition the client on a scheduled basis

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, and the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of which? A) binder B) ice bag C) elastic bandage D) warm compress

B) ice bag Rationale: application of ice directly to a soft tissue causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain.

The RN delegates the tasks of caring for a client with pressure injuries. The client suffers further tissue necrosis during treatment. Which factor could result in further tissue damage? A) cleaning of the wound by the RN B) irrigation of the wound by the unlicensed assistive personnel (UAP) C) administering oral analgesics by the licensed practical nurse (LPN) D) repositioning the client every 1-2 hours by the LPN

B) irrigation of the wound by the unlicensed assistive personnel (UAP)

Which intervention would be included in the plan of care for the prevention of a pressure injury? A) positioning a client directly on the trochanter B) keeping the client's skin directly off plastic surfaces C) keeping the head of the bed elevated above 30 degrees D) placing a rubber ring or donut under the client's sacral area

B) keeping the client's skin directly off plastic surfaces ALL others should be avoided

Which parent education would the nurse provide the parents of a 9-month-old about the cause of diaper dematitis? A) use of disposable diapers B) prolonged contact with an irritant C) decreased pH of the infant's urine D) too-early introduction of solid foods

B) prolonged contact with an irritant

Which mechanism of action would a nurse recall when using wet-to-damp saline-moistened gauze for wound debridement? A) promoting the dilution of viscous exudate B) removing the necrotic tissue mechanically C) causing a breakdown of the denatured protein of the eschar D) promoting the spontaneous separation of necrotic tissue

B) removing the necrotic tissue mechanically

When providing care for a client with diarrhea, in which clinical indicator would the nurse anticipate a decrease? A) pulse rate B) tissue turgor C) specific gravity D) body temperature

B) tissue turgor

Which statement shows ineffective learning after the nurse teaches self-management tips on the safety and quality care for skin cleaning to a client with a pressure ulcer? A) "I will use tepid rather than hot water" B) "I will clean my skin as soon as soiling occurs" C) "I will apply powders and talc on the perineum" D) "I will pay my skin gently rather than rubbing it dry"

C) "I will apply powders and talc on the perineum"

Which education would the nurse provide the parent of a preschool child with atopic dermatitis? A) "scratching causes lesions to become more contagious" B) "scratching spreads dermatitis to other areas of the body" C) "scratching results in skin breaks that can lead to infection" D) "scratching produces changes that are precursors to skin cancer"

C) "scratching results in skin breaks that can lead to infection"

Which event occurs in the proliferative phase of wound healing? A) Thinning of scar tissue B) Strengthening of collagen C) Formation of granulation tissue D) Increase in capillary permeability

C) Formation of granulation tissue

Which term would the nurse use to describe the exudate characteristic of a serosanguineous wound? A) greenish-blue pus B) creamy yellow exudate C) blood-tinged amber fluid D) beige pus with a fishy odor

C) blood-tinged amber fluid

Which condition would the nurse suspect when a client, who underwent a physical examination two days ago, reports itching? A) eczema B) hypersensitivity C) contact dermatitis D) anaphylactic shock

C) contact dermatitis

Which condition is a possible cause of pitting edema on the dorsum of the foot? A) endocrine imbalance B) excessive collagen production C) fluid and electrolyte imbalance D) autonomic nervous system stimulation

C) fluid and electrolyte imbalance

The nurse is caring for a client who had an above-the-knee amputation 1 week ago. Which action would the nurse take to control edema of the residual limb? A) administer a diuretic as needed B) restrict the client's oral fluid intake C) rewrap the elastic bandage as necessary D) keep the residual limb elevated on a pillow

C) rewrap the elastic bandage as necessary Rationale: compresses the residual limb, preventing edema and promoting residual limb shrinkage and molding

A registered nurse (RN) is teaching a nursing student how to assess for edema. Which statement made by the student is incorrect? A) "edema results in the separation of skin from pigmented and vascular tissue" B) "pitting edema leaves an indentation on the site of application of pressure" C) "trauma or impaired venous return should be suspected in clients with edema" D) "if the pressure on an edematous site leaves an indentation of 2mm, a score of 2+ is given"

D) "if the pressure on an edematous site leaves an indentation of 2mm, a score of 2+ is given"

A 9-year-old child who has cerebral palsy, scoliosis, contractures of elbows and wrists and is also incontinent. Which nursing action will BEST achieve the goal of skin integrity? A) padding the child's lower extremities B) repositioning the child every 4 hours C) replacing the bed linens with sterile linens D) changing disposable diapers every 2 to 3 hours

D) changing disposable diapers every 2 to 3 hours

Which predisposing condition would the nurse anticipate in the client observed to have edema at the dorsum of the foot and ankle? A) neurotrauma B) hypothyroidism C) hyperthyroidism D) congestive heart failure

D) congestive heart failure

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. Which rationale for the treatment would the nurse provide? A) to limit the formation of blood clots B) to decrease the phantom limb sensation C) to prevent hemorrhage and cover the incision D) to support the soft tissue and minimize swelling

D) to support the soft tissue and minimize swelling

Which stage of pressure ulcer would the nurse document for a client who has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia? A) stage 1 B) stage 2 C) stage 3 D) unstageable

D) unstageable