NURS 124 PrepU Tissue Integrity

The nurse is teaching a client about peptic ulcers. The client understands the provided education when stating which of the following?

"Hemorrhage and gastritis are the most common complications."

A client receiving radiation therapy develops wet desquamation of the area. Which intervention(s) will the nurse add to the client's plan of care? Select all that apply.

Apply silver sulfadiazine cream as prescribed.

A nurse assesses a client with dark skin and notes new purple-gray cast to the skin on the chest, back, and arms. Which priority nursing intervention should the nurse implement?

Check the client's oral temperature.

The nurse is caring for a client with a blistering disease. Which action will the nurse take to relieve this client's discomfort? Select all that apply.

Dry the skin carefully after bathing. Apply warmed blankets as necessary. Premedicate with analgesics before skincare.

A client has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the client should adopt what dietary guidelines?

Eat small, frequent meals with high calorie and vitamin content.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

Edema Anemia Diaphoresis

Which term refers to the protrusion of abdominal organs through the surgical incision?

Evisceration

Which factor causes wrinkles among older adults?

Loss of subcutaneous tissue

The nurse is examining the area behind the patient's auricle and sees a flaky scaliness. What disorder does the nurse suspect the patient has?

Seborrheic dermatitis

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?

Sulfadiazine, silver (Silvadene)

The nurse is to administer a vesicant chemotherapeutic drug to a client who had a right mastectomy and inserts the intravenous line

With a soft, plastic catheter

Which term refers to yellowish waxy deposits on the upper and lower eyelids?

Xanthelasma

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as

clean contaminated

An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this?

comminuted

Which type of burn injury requires skin grafting?

full-thickness

A 25-year-old client receives a knife wound to the leg in a hunting accident. Which type of immunity was compromised?

natural immunity

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

After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms?

retinal detachment

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect?

scabies

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

scale

Which of the following would the nurse expect to find when assessing the breasts of a client with fibrocystic breast disease?

soft mass

The nurse is caring for a client who will be having artificial implants for breast reconstruction. The client is arriving at the physician's office for which procedure to be completed before the surgery can be done?

tissue expansion

Which assessment finding would the nurse expect to document for a client with ataxia-telangiectasis?

vascular lesions

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

"I can apply powder under the liner to help with sweating."

Which statement indicates that a client with diabetes mellitus understands proper foot care?

"I'll wear cotton socks with well-fitting shoes."

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

2 to 12 days

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27%

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?

36%

The nurse is instructing the patient in how to apply a corticosteroid cream to lesions on the arm. What intervention can the nurse instruct the patient to do to increase the absorption of the medication?

Apply an occlusive dressing over the site after application.

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

Applying knee splints

An emergency department client is diagnosed with a hip dislocation. The client's family is relieved that the client has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurse's statement?

Avascular necrosis may develop at the site if it is not promptly resolved.

Which of the following is a characteristic of an arterial ulcer?

Border regular and well demarcated

A patient is having a biopsy that will remove the entire mass, plus a margin of surrounding tissue. What type of biopsy will be documented on the operative permit?

Excisional biopsy

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing which effect?

Facial nerve paralysis

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply.

Fingernails Hair Skin

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.

A client has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing their ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication?

Inadequate immobilization

A patient is being evaluated for nodular cystic acne. What systemic pharmacologic agent may be prescribed for the treatment of this disorder?

Isotretinoin (Accutane)

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily

The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about?

Platelet count of 9,000/mm3

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage II pressure ulcer

A client with chronic osteomyelitis has undergone 6 weeks of antibiotic therapy. The wound appearance has not improved. What action would the nurse anticipate to promote healing?

Surgical debridement

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?

The client has experienced extensive full-thickness burns.

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?

Use an electric razor when assisting client with shaving.

When is it advisable for the nurse to apply heat to a sprain or a contusion?

after 2 days

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?

antiviral

The nurse recognizes which condition as an integumentary manifestation of chronic renal failure?

gray-bronze skin color

The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of

organic fruit juice.

A client is scheduled for a renal arteriogram. When the nurse checks the chart for allergies to shellfish or iodine, she finds no allergies recorded. The client is unable to provide the information. During the procedure, the nurse should be alert for which finding that may indicate an allergic reaction to the dye used during the arteriogram?

pruritus

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply.

skin breakdown wound infection pneumonia

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?

Arterial insufficiency

After teaching a group of students about the signs and symptoms of breast cancer, the instructor determines that additional teaching is needed when the group identifies which of the following?

Breast symmetry

The client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education?

Brief, hot daily showers

The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention?

Change the wafer and pouch.

A patient who suffered severe partial thickness burns to the face and trunk is at risk for depletion of essential proteins and immunoglobulins. The stressors associated with this patient's major injury have caused what immune process to occur?

Cortisol is released from the adrenal cortex, which contributes to immunosuppression.

A client sustained second- and third-degree burns over 30% of the body surface area approximately 72 hours ago. What type of ulcer should the nurse be alert for while caring for this client?

Curling's ulcer

When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?

Inspect the skin frequently.

For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?

Inspecting the skin for petechiae once every shift

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water.

An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding?

It is a cherry angioma that is a normal age-related skin alteration.

A client asks the nurse what psoriasis is. What is the best answer?

It is characterized by patches of redness covered with silvery scales.

The nurse is assessing an older adult who has not seen their physician in 2 years. The nurse is assisting the patient into a gown and notices that the patient has edema and pitting of the skin on the right breast. What does the nurse understand is the significance of this finding?

It may result from a neoplasm blocking lymphatic drainage, indicating advanced breast cancer.

The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy?

It removes a wedge of tissue for diagnosis.

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition?

Lymphedema

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein?

biobrane

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists?

dehiscence

A client with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate?

document the findings

A nurse is caring for a client experiencing an exacerbation of plaque psoriasis. The nurse assesses the area and documents a proliferation of which cell type?

epidermal

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client

fluid resuscitation

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?

fluid retention

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?

hypovolemia

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

ischial tuberosity

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?

keloid

A client is considering breast augmentation. Which of the following would the nurse recommend to the client to ensure that there are no malignancies?

mammogram

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?

massaging the feet