Tissue integrity

1.A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching? A. "All recently used clothing, bedding, and towels must be washed in hot water." B. "My child must be free from nits before returning to school." C. "I will treat all the family members to be on the safe side." D. "Toys that can't be dry cleaned or washed must be thrown out."

A. "All recently used clothing, bedding, and towels must be washed in hot water." Rationale:Pediculosis capitis is commonly referred to as head lice. All recently used clothing, bed sheets, and towels need to be washed in hot water. Anything that cannot be washed should be sealed in a plastic bag for 10 to 14 days. Unwashable items can include jackets, sweaters, hats, pillows, bicycle helmets, and stuffed animals. Furniture, carpets, and car seats can be sprayed with a variety of over-the-counter products.

35.A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A. Apply a moisture barrier ointment to the client's skin. B. Clean the client's skin and perineum with hot water after each episode of incontinence. C. Check the client's skin every 8 hr for signs of breakdown. D. Request a prescription for the insertion of an indwelling urinary catheter.

A. Apply a moisture barrier ointment to the client's skin. Rationale:Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.

39.A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? A. Auscultate breath sounds at least every 2 hr. B. Perform range-of-motion (ROM) exercises at least two to three times daily. C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. D. Apply antiembolic stockings.

A. Auscultate breath sounds at least every 2 hr. Rationale: The priority action the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.

2.A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this condition? A. Firmly attached white particles on the hair B. Itching and scratching of the head C. Patchy areas of hair loss D. Thick yellow crusted lesion on a red base

A. Firmly attached white particles on the hair Rationale:Pediculus capitis, or head lice, are tiny parasitic insects that live on the scalp and can be spread by close contact with other people. Their eggs (nits) appear much like flakes of dandruff but stick firmly to the hair shaft instead of flaking off of the scalp.

12.A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Poor nutritional state B. Altered mental status C. Obesity D. Pain medication administration E. Wound infection

A. Poor nutritional state C. Obesity E. Wound infection

40.A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding? A. Report of exposure to a skin irritant B. Denial of pruritus C. Systemic symptoms including elevated temperature D. Report of generalized joint discomfort

A. Report of exposure to a skin irritant Rationale: The most common cause of contact dermatitis is exposure to a topical irritant therefore identifying this irritant is a component of treatment.

21.A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? A. Serum albumin 3.2 g/dL B. Hemoglobin 16 g/dL C. WBC count 8,000/mm3 D. PTT 1.8

A. Serum albumin 3.2 g/dL Rationale:A serum albumin level is a good indicator of the nutritional status of a client. A value less than 3.5 g/dL is an indication of poor nutrition, can delay wound healing, and lead to infection.

22.A nurse is teaching a client who has psoriasis about possible treatment options. Which of the following treatments should the nurse include in the teaching? (Select all that apply.) A. Tar preparations B. Corticosteroids C. Ultraviolet light therapy D. Laser therapy E. Topical antibiotics

A. Tar preparations B. Corticosteroids C. Ultraviolet light therapy

37.A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? A. Transparent dressing B. Wet-to-dry gauze dressing C. Hydrogel dressing D. Alginate dressing

A. Transparent dressing Rationale:A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area.

19.A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma? A. Painless, raised purple nodules on the hard palate B. A firm nodule with a hard crust C. A small macule with a yellow-brown scale D. Yellow-white patches of growth on the tongue

B. A firm nodule with a hard crust Rationale:Squamous cell carcinoma appears as a firm nodule, which can either have a crust or a depressed area in the center. The margins are indurated, and the lesion is fixed to the deeper tissue of the area.

10.A nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names? A. Shingles B. Athlete's foot C. Fever blister D. Valley fever

B. Athlete's foot Rationale:Athlete's foot is the common name for tinea pedis.

25.A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take? A. Apply dry, sterile gauze dressings to affected areas. B. Prepare to administer acyclovir. C. Instruct family members with a history of chickenpox that they are still at risk for contracting the virus. D. Apply topical corticosteroids to the affected areas

B. Prepare to administer acyclovir. Rationale:Acyclovir is effective in the treatment of herpes zoster especially if administered within 24 hr of the eruption.

33.A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? A. Apply a heat lamp twice a day. B. Reposition the client at least every 2 hr. C. Clean the wound with hydrogen peroxide solution. D. Massage reddened areas with dressing changes.

B. Reposition the client at least every 2 hr. Rationale: The nurse should plan to reposition the client at least every 2 hr and to make a schedule to record position changes for the client's medical record.

34.A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? A. Instruct the client about home disposal of contaminated dressings. B. Schedule a follow-up visit by a home health nurse for dressing changes. C. Provide a dietary list of foods which promote wound healing. D. Establish a follow-up appointment with the client's provider

B. Schedule a follow-up visit by a home health nurse for dressing changes. Rationale: The greatest risk to this client is injury from a wound infection. Therefore, the priority action the nurse should take is to schedule a follow-up visit by a home health nurse for dressing changes. Wounds healing by secondary intention are open and have edges that are not approximated, which increases the risk for infection.

30.A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances? A. Serosanguineous drainage at this time is expected after abdominal surgery. B. Serosanguineous drainage at this time is a manifestation of possible dehiscence. C. Serosanguineous drainage at this time is a manifestation of hemorrhage. D. Serosanguineous drainage at this time is a manifestation of infection.

B. Serosanguineous drainage at this time is a manifestation of possible dehiscence. Rationale:Serosanguineous drainage beyond the fifth postoperative day is a manifestation of possible dehiscence and the provider should be notified.

17.A nurse is preparing to teach a parent how to care for a child who has impetigo contagiosa. Which of the following information should the nurse plan to include in the teaching? A. Keep the child on droplet precautions at home B. Wash clothing in hot water. C. Immunize household contacts for the disease. D. Give the child a chlorine bath twice daily.

B. Wash clothing in hot water. Rationale: The nurse should teach the parent to ensure the child changes her clothes every day and to wash all clothing in hot water.

20.A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first? A. Raise the head of the client's bed 15° to 20°. B. Place the client supine with knees bent. C. Assess the client for manifestations of shock. D. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

D. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation. Rationale:According to evidence-based practice, the nurse should first cover the area with a sterile dressing moistened with normal saline to protect the client's internal organs. The nurse should not attempt to reinsert the client's organs or viscera.

32.A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? A. Symmetrical convex sphere shape B. Concave umbilicus C. Bilateral bowel sounds in lower quadrants D. Ecchymosis

D. Ecchymosis Rationale:Ecchymosis is a finding outside of the expected reference range for an abdominal assessment and would require the nurse to further investigate for potential injury, bleeding disorder, or physical abuse.

6.A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? A. Serous B. Purulent C. Sanguineous D. Serosanguineous

D. Serosanguineous Rationale: Watery red drainage should be documented as serosanguineous

11.A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client? A. A negative-pressure isolation room B. A semi-private room with a client who has pediculosis capitis C. A positive-pressure isolation room D. A private room

D. A private room Rationale: The nurse should place a client who has a communicable condition, such as scabies, in a private room to reduce the risk of exposure and possible transmission to other clients. If necessary, the nurse can use a semi-private room with a client who has the same condition.

5.A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? A. Protein B. Calcium C. Vitamin B1 D. Vitamin D

A. Protein Rationale:Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.

9.A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? A. BUN B. Potassium C. RBC count D. WBC count

D. WBC count Rationale:An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.

4. While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? A. Discontinue the existing IV line. B. Initiate a new IV line in the other extremity. C. Apply a hot pack to the irritated site. D. Determine if the client needs to continue IV therapy.

A. Discontinue the existing IV line. Rationale: The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line.

8.A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage the skin over the client's bony prominences. D. Elevate the head of the bed no more than 45°.

A. Use a transfer device to lift the client up in bed. Rationale: Using a lifting

16.A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply.) A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin D E. Vitamin K

A. Vitamin A B. Vitamin B12 C. Vitamin C E. Vitamin K

18.A nurse is providing teaching about lice to the parents of a school-age child at a well-child visit. Which of the following information should the nurse include in the teaching? A. "Lice can jump from one child to another." B. "Encourage your child to avoid sharing hats with other children." C. "Live lice can survive for 2 weeks away from the host." D. "Washing your child's hair daily will prevent lice."

B. "Encourage your child to avoid sharing hats with other children." Rationale:Lice are transmitted from person to person on personal items, such as hats, hair ornaments, scarves, combs, and brushes.

28.A nurse is providing teaching to a client who has widespread psoriasis and a prescription for phototherapy. The nurse should include which of the following information in the teaching? A. "You will have a morning and afternoon session on each treatment day." B. "Treatment might be interrupted if areas of redness and tenderness develop." C. "Treatments will be given in a series of three days on and three days off." D. "You should purchase dark glasses in case the light bothers your eyes."

B. "Treatment might be interrupted if areas of redness and tenderness develop." Rationale: The nurse should instruct the client that treatment must be interrupted if areas of redness with edema and tenderness develop. Treatment can resume after these manifestations subside.

24.A nurse in a provider's office is caring for a client who reports pruritus and reddened, oozing lesions on her lower leg. The nurse should suspect which of the following disorders? A. Alopecia B. Contact dermatitis C. Pediculosis D. Tinea pedis

B. Contact dermatitis Rationale: These findings are consistent with contact dermatitis, which is skin inflammation that results from direct skin contact with chemicals or causative agents.

29.A nurse is teaching an older adult client who has herpes zoster about the order of occurrence of findings associated with this disorder. Identify the order in which the findings typically occur. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Crusted lesions B. Paresthesia C. Postherpetic neuralgia D. Redness and swelling E. Vesicles F. Weeping blisters

B. Paresthesia D. Redness and swelling E. Vesicles F. Weeping blisters A. Crusted lesions C. Postherpetic neuralgia

3.A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A. Check the client's vital signs. B. Assess the client's pain level. C. Cover the wound with a moist, sterile gauze dressing. D. Obtain a culture and sensitivity of the wound drainage.

C. Cover the wound with a moist, sterile gauze dressing. Rationale: The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority

26.A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take? A. Apply additional scabicide to the affected area. B. Assist the client to take a hot shower. C. Provide mittens for the client to wear at night. D. Encourage the client to gently rub the affected area.

C. Provide mittens for the client to wear at night. Rationale:Intense itching is a manifestation of scabies that is often reported by clients as unbearable at night. For this reason, the nurse should provide mittens for the client to wear at night to protect the integrity of the skin.

15.A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Reposition the client every 3 hr. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry

C. Provide the client with a diet high in protein. Rationale:Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.

14.A nurse is planning care for a client who is confined to bed. Which of the following actions should the nurse include in the plan? A. Massage the client's red bony prominences. B. Assess the client's skin for increased coolness. C. Reposition the client every 2 hr. D. Keep the client's skin moist.

C. Reposition the client every 2 hr. Rationale: The nurse should change the client's position every 2 hr to stimulate circulation and prevent pressure ulcers.

38.A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? A. Exposed bone B. Blood filled blisters C. Partial-thickness skin loss. D. Necrotic subcutaneous tissue

D. Necrotic subcutaneous tissue Rationale: Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic subcutaneous tissue.

36.A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? A. One cup of brown rice B. One cup of orange juice C. One cup of pureed avocado D. One cup of lentils

D. One cup of lentils Rationale: The nurse should determine that nuts and legumes, such as lentils, are the best foods to recommend for protein intake for this client. One cup of lentils contains 17.86 g of protein. A diet high in protein and calories is required to promote wound healing. Nuts and legumes are good sources of protein to include in a plant based diet such as a vegan diet.

31.A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply a light layer of talcum powder with each diaper change. B. Change to cloth diapers until the skin is healed. C. Expose the excoriated area to hot air frequently. D. Use a moisturizer to wipe urine from the skin.

D. Use a moisturizer to wipe urine from the skin. Rationale:It is appropriate for the nurse to use a moisturizer to wipe urine from the skin. This will prevent further breakdown of the skin.

23.A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client? A. Use friction when washing the affected area. B. Use an oil-based soap to wash affected areas daily. C. Express the larger comedones periodically. D. Use a new cosmetic pad with each limited application of makeup.

D. Use a new cosmetic pad with each limited application of makeup. Rationale: Use of a new cosmetic pad with each makeup application decreases the risk of reinfection. Makeup should be applied on a limited basis, as many are oil-based products, clog pores, and exacerbate acne.

7.A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? A. An adolescent who has a cervical fracture and is in a halo brace B. A young adult who has a femur fracture and is in skeletal balanced suspension traction C. A middle adult who has a fractured radius and an arm cast D. An older adult who has a hip fracture and is in Buck's traction

D. An older adult who has a hip fracture and is in Buck's traction Rationale:According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

13.A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. B. Irrigate the wound with an antiseptic prior to obtaining the specimen. C. Include intact skin at the wound edges in the culture. D. Swab an area of skin away from the wound to identify the usual flora.

A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. Rationale: The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

27.A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan? A. Maintain occlusive dressings on the lesions throughout the day and remove them at bedtime. B. Eliminate the use of products containing salicylic acid. C. Avoid friction over scaly lesions while bathing. D. Identify effective stress reduction techniques.

D. Identify effective stress reduction techniques. Rationale:Psoriasis is significantly aggravated by stress. The use of effective stress reduction techniques is appropriate to manage this chronic disorder.