Proctored PrepU Ch 31-35

A nurse is visiting the home of a first-time mother and her newborn. The nurse is teaching the mother about the newborn's sleep needs. The nurse would inform the mother that newborns sleep approximately how many hours per day?

14 to 20 hours

Which is not considered a skin appendage?

Connective tissue

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

A nurse is caring for a client who has a Jackson-Pratt drain. Which of the following is the order in which the nurse should carry out these interventions?

Empty the drain chamber's contents Use a gauze pad to clean the drain's outlet Fully compress the chamber and replace the cap Measure and record the character and amount of drainage Change gloves Change dressing to drain site

An older adult client with mild hypothermia has been admitted to the health care facility. What should the nurse do to provide an appropriate environment to an older adult client?

Ensure that the environment is warmer.

The nurse has a client who has been under stress due to a sick spouse. The client reports difficulty sleeping and a feeling of daytime sleepiness. Using the nursing process, place the following nursing steps in the correct order.

Nurse states to client, "Tell me about your sleep problem." Nurse makes the diagnosis Disturbed Sleep Pattern. Nurse plans with the client an outcome of reporting adequate sleep in one week. Nurse teaches the client relaxation techniques. Nurse evaluates the client in 1 week for outcome achievement.

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel.

A nurse working in a health clinic assesses sleep patterns during each health assessment. Based upon the nurse's knowledge regarding sleep needs, the nurse recognizes which age group as generally needing the least amount of sleep?

Older adults

A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain?

Provides drainage for bile

A client begins snoring and is sleeping lightly. The stage of sleep is:

Stage 2

A client's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

Stage II

A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

Stage III

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage?

Supports the area around the wound

A nurse is caring for a client who has an avulsion of her left thumb. Which of the following descriptions should the nurse understand as being the definition of avulsion?

Tearing of a structure from its normal position

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which is a finding related to this condition?

There is an unintentional separation of the wound.

A female patient who is being treated for self- inflicted wounds tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk?

Total lymphocyte count of 1,500/mm3

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

Transparent

The nurse is performing pressure ulcer assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure ulcer?

a critical care client

The nurse is performing an intake assessment of a 60-year-old client who admits to having a "nightcap" of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep?

decreased REM sleep

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by

primary intention.

A client calls a sleep clinic "helpline" and describes her 46-year-old husband's sleep patterns: snoring loudly, then becoming startled and waking up 5 or 6 times a night. The wife is asking how to improve his sleep patterns. The nurse concludes:

the husband may be exhibiting signs of sleep apnea.

A nurse is caring for a client who has recently undergone hernial surgery. What are possible causes of complications with regard to surgical wounds? Select all that apply.

• insufficient protein and vitamin C intake • distension of the abdomen from accumulated intestinal gas • weak tissue and muscular support due to obesity

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?

"I will squeeze the chamber and apply the cap to maintain negative pressure."

A client's risk for the development of a pressure ulcer is most likely due to which lab result?

Albumin 2.5 mg/dL

A nurse is caring for a client who has a 6-cm × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which dressing does the nurse anticipate is best to be ordered by the primary care provider?

Alginate

The nurse is caring for a client who has a stage IV pressure ulcer. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order.

Hemostasis Inflammatory Proliferation Maturation

A nurse understands the client's stage of sleep that requires the greatest stimulus to awaken a client is:

REM sleep

Which of these is a physiological change during NREM sleep?

decreased brain activity from wakefulness

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? Select all that apply.

• Use whirlpool treatments, if ordered, until the ulcer is considered clean. • Keep the ulcer tissue moist and the surrounding skin dry. • Use a dressing that absorbs exudate but maintains a moist healing environment.

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains?

A Penrose drain promotes drainage passively into a dressing.

For which of the following clients would the nurse most likely administer a benzodiazepine-like drug?

A client who is being treated for short-term insomnia

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?

Biosurgical debridement

What factor has been hypothesized by researchers regarding current thoughts on sleep?

Chronic sleep deprivation is present

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care?

Cleanse with a new gauze for each stroke

Which best describes the third phase of the wound healing process: proliferative?

Epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization.

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication?

Evisceration

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing?

Fish

A nurse is providing wound care for a client who has a pressure ulcer on the right buttock. Which of the following is the correct order of nursing interventions the nurse should perform during this dressing change?

Give pain medication Use nonsterile gloves Remove old dressing Apply sterile gloves Cleanse the wound with normal saline Apply wound covering

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?

Hydrocolloid dressings

A nurse is providing community education about the importance of getting enough sleep. Which information about REM sleep is most accurate?

It plays a role in memory.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which of the following is not one of these factors?

Local capillary pressure must be lower than external pressure.

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

Mechanical debridement

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

A client diagnosed with hypothyroidism is suffering from fatigue, lethargy, depression, and difficulty executing the tasks of everyday living. What type of sleep deprivation would the nurse suspect is affecting this client?

NREM deprivation

When a client tells the clinic nurse that he has irresistible sleep attacks throughout the day lasting from 10 to 15 minutes, the nurse suspects that the client may be experiencing what?

Narcolepsy

The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patters?

Newborns sleep 16 to 17 hours per day.

When a nurse notes that the client appears to be sleeping, is demonstrating irregular respirations, and is showing eye movement, the nurse identifies the stage of sleep the client is experiencing as:

Rapid eye movement (REM)

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which of the following modifications is most appropriate?

Reduce the time interval between dressing changes.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing describes this?

Secondary intention

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage?

Serosanguineous

What is a possible outcome criterion that addresses the goal that the client will demonstrate physical signs of being rested?

The client has decreases in circles under her eyes and excessive yawning by 1 week

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure ulcer?

Use pillows to maintain a side-lying position as needed.

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow". Based on this classification which of the following nursing actions should the nurse perform?

Wound irrigation

Which client condition indicates the presence of a parasomnia?

a child who wets his bed each nigh

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

true

A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn?

usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown

The mother reports her 4-year-old child wakes up frequently at night screaming. She also reports this occurs shortly after her son has fallen asleep. The nurse determines that the child takes a tub bath and the mother reads a story to her son prior to bedtime at 8 p.m. The nurse intervenes by stating what to the mother? Select all that apply

• "It is common for this to occur in this age group." • "Comforting your child when this occurs may help." • "You may find a nightlight in his room is helpful."

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.)

• A wound that requires wound cleaning and irrigation • A wound with drainage that is a beige color • A wound that is characterized by oozing from the tissue covering the wound

What are characteristics of rapid eye movement sleep? Select all that apply.

• Blood pressure and pulse rate show wide variations and may fluctuate rapidly. • A person is unable to move during this stage. • Theta waves often have a sawtooth or notched appearance.

The client reports unpleasant sensation in the legs with an urge to move his legs. The nurse assesses for the following

• Client use of tobacco products • Ingestion of an antihistamine • If massaging the legs provides relief

The client reports unpleasant sensation in the legs with an urge to move his legs. The nurse assesses for the following:

• Client use of tobacco products • Ingestion of an antihistamine • If massaging the legs provides relief

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply

• Cover wound with a gauze moistened with normal saline. • Place client in low-Fowler's position. • Use sterile techniques.

A nurse caring for a client with hypersomnia investigates the cause of the sleep disorder. What are possible causes to consider? Select all that apply.

• Depression • Another sleep disorder, such as sleep apnea • Some medications • Alcohol abuse

The nurse is managing the environment for clients on a busy hospital ward. Which interventions would the nurse perform to facilitate a more restful environment? Select all that apply.

• Maintain a brighter room during daylight hours and dim lights in the evening. • Decrease the volume on alarms, pages, telephones, and staff conversations. • Medicate for pain if needed.

A medical-surgical nurse is assessing wounds of clients. Which wound complications are accurately described below? Select all that apply.

• Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site • Evisceration, which occurs when the viscera protrudes through the incisional area • Dehiscence, which is present when there is a partial or total disruption of wound layers

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply.

• The nurse fills an ice bag with small pieces of ice to about two-thirds full. • The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. • The nurse makes more frequent checks of the skin of an older adult using a heating pad