Tissue Integrity module

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

**Serosanguineous - Watery red drainage should be documented as serosanguineous. serous- Watery red drainage should not be documented as serous which is yellowish. purulent - Watery red drainage should not be documented as purulent which is thick and odorous. sanguineous - Watery red drainage should not be documented as sanguineous which is bloody.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should document this as which of the following types of wounds? abrasion contusion laceration puncture

-Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged and irregular. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound. -An abrasion is an open wound that occurs when the skin is scraped or rubbed off, such as an injury resulting from a fall in which the knees are scraped. -A contusion is a closed wound; the result of a blunt force impact. The wound appears ecchymotic (bruised) as a result of trauma to the vascular system. -A puncture is an open wound usually caused by a sharp object that penetrates the skin leaving a small surface opening.

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? shingles athlete's foot fever blisters valley fever

athlete's foot -Shingles is the common name for varicella zoster. -Fever blister is the common name for herpes simplex virus type I. -Valley fever is the common name for coccidioidomycosis.

A nurse is assisting 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? exposed bone blood filled blisters partial-thickness skin loss necrotic subcutaneous tissue

necrotic subcutaneous tissue- Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic subcutaneous tissue. exposed bone - Manifestations of a stage 4 pressure ulcer can include full-thickness skin loss with exposed or palpable bone or muscle. blood filled blisters - Manifestations of a stage 1 pressure ulcer can include reddened intact skin and blood filled blisters. partial-thickness skin loss - Manifestations of a stage 2 pressure ulcer can include partial-thickness skin loss and a superficial ulcer.

A nurse is caring for an older 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?

provide client with a diet high in protein

A nurse in a community health clinic is caring for a client who has a new diagnosis of plantar warts. The nurse should include which of the following in the teaching plan for this client? Soak feet in an antiseptic solution daily. They may be painful with ambulation. They are related to excessive foot perspiration. A biopsy will be prescribed to rule out malignancy.

they may be painful with ambulation -Plantar warts are a result of an infection with the human papillomavirus; therefore, antiseptic solutions are ineffective as a means of treatment. -Foot odors are a result of excessive perspiration of the feet. This is not a finding associated with plantar warts. -Plantar warts are a result of an infection with the human papillomavirus and are benign growths of the skin. A biopsy is not necessary unless obvious changes in the appearance of the wart are present.

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? Vitamin a vitamin B12 vitamin c vitamin d vitamin e

vitamin a- important for tissue synthesis, wound healing, and immune function vitamin c- important for capillary formation, tissue synthesis, and wound healing vitamin e- functions as an antioxidant to protect from cell damage, and enhances Vitamin A utilization.

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 indicate an understanding of the teaching? "All recently used clothing, bedding, and towels must be washed in hot water." "My child must be free from nits before returning to school." "I will treat all the family members to be on the safe side." "Toys that can't be dry cleaned or washed must be thrown out."

"All recently used clothing, bedding, and towels must be washed in hot water." - 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. -The American Academy of Pediatrics opposes requiring children to stay out of school until all nits are gone and instead recommends allowing children to return to school after treatment. -Only family members who actually have lice should be treated because there are potential adverse effects associated with the treatment. -Items that cannot be dry cleaned or washed can be closed up inside a plastic bag for 10 to 14 days.

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

Apply a moisture barrier ointment to the client's skin - 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. -The nurse should wash the client's skin with mild soap and warm water and pat it dry gently. Hot water can be irritating and can dry the skin. -Clients who are incontinent are at a high risk for skin breakdown. Examining the skin at least every 2 hr and providing hygiene are two initial defenses against skin breakdown. -Although it is true that clients who have a urinary catheter in place have less risk for skin breakdown due to incontinence, this is an invasive procedure that poses significant risks. The catheterization of the bladder can introduce bacteria into the bladder, creating a risk for bacteremia, a life-threatening bacterial infection of the blood.

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? Alopecia Contact dermatitis Pediculosis Tinea pedis

Contact dermatitis - These findings are consistent with contact dermatitis, which is skin inflammation that results from direct skin contact with chemicals or causative agents. - Alopecia is a condition in which balding patches appear on the scalp and hair becomes brittle and breaks easily. - Pediculosis is the presence of a parasite on the body, which may be on the scalp, in pubic hair, or on clothing, which results in itching and skin breakdown due to scratching. - Tinea pedis is a fungal infection of the toes and feet resulting in skin breakdown, cracking, and small, fluid-filled blisters.

A school nurse is assessing a school-age child and notices white flakes that don't brush off the hair and a rash on the back of the child's neck. The nurse should suspect which of the following disorders? pediculosis capitis impetigo contagiosa folliculitis tinea capitis

Pediculosis capitis -Pediculosis capitis - head lice, and its nits (eggs) are cemented to the hair shaft. The nits are silvery to white in color, similar to dandruff. They are typically seen on hair on the back of the head near the nape of the neck. A papular rash might be present at the nape of the neck secondary to scratching. -Impetigo contagiosa is a reddish macule that ruptures easily leaving exudate that forms a honey-colored crust. -Folliculitis is an infection of the hair follicles that look like small red or white bumps around the hair follicles. -Tinea capitis or ringworm causes scaly patches on the scalp with alopecia.

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?

Report of exposure to a skin irritant -Pruritus is one of the primary findings associated with contact dermatitis. -Contact dermatitis does not commonly produce systemic findings unless the skin eruptions are widespread. -Generalized joint discomfort is associated with musculoskeletal disorders such as arthritis.

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?

Reposition the client every 2 hr.- The nurse should change the client's position every 2 hr to stimulate circulation and prevent pressure ulcers. -The nurse may cause deep tissue trauma by massaging red bony prominences. -The nurse should asses the client's skin for increased warmth. -The nurse should use moisturizers on dry skin but should keep the client's skin dry and free of prolonged moisture or drainage to prevent skin breakdown.

A nurse in a clinic is caring or 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? Use friction when washing the affected area. Use an oil-based soap to wash affected areas daily. Express the larger comedones periodically. Use a new cosmetic pad with each limited application of makeup.

Use a new cosmetic pad with each limited application of makeup. - 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. -The client should avoid using friction due to the risk of spreading bacterial debris on unaffected areas of the face and worsening of inflammation. -The client should use warm water and noncomedogenic (non-oil based) soap daily to wash the affected areas. -This intervention increases the risk for scarring and an increased number of comedones.

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? Use a transfer device to lift the client up in bed. Apply cornstarch to keep sensitive skin areas dry. Massage the skin over the client's bony prominences. Elevate the head of the bed no more than 45°.

Use a transfer device to lift the client up in bed.