HCC Exam 1 (Tissue Integrity and Thermoregulation)

A parent hears the health care provider using the word extravasation. The parent asks the nurse what extravasation means. What would be a correct answer?

"Extravasation is when fluid escapes from a blood vessel into the surrounding tissue."

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response?

"The operating table is a firm surface; we need to be sure your skin looks okay."

The nurse is teaching parents of a 2-year-old toddler with cellulitis about temperature measurement. Which statement by the parents demonstrates the need for further teaching?

"We should verify any fever using a rectal thermometer for accuracy."

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area?

1

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?

37.0° C (98.6° F)

Normal temp. for adults?

97-99

Creutzfeldt-Jakob disease

A fatal degenerative disease affecting nerve cells in the brain, causing mental, physical, and sensory disturbances such as dementia and seizures. Caused by prions.

Infants are at greater risk of hypothermia than children because of which of the following?

A high ratio of surface area to body mass.

A nurse is caring for a client with a leg wound. When planning care for the client, the nurse considers that the injured cells have impaired flow of substances through the cell membrane as a result of:

Altered permeability.

First-pass effect

An important term of metabolism, refers that some drugs are metabolized in the liver immediately after absorption and then are excreted in the bile, leaving less active drug available to the site of action.

The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?

Apply a hydrocolloidal dressing.

The nurse is instructing a client who is at risk for peripheral artery disease how to use knee-length elastic stockings (support hose). What instructions should the nurse include in the teaching plan? Select all that apply.

Apply the elastic stockings before getting out of bed. Remove the stockings every 8 hours, elevate the feet, and reapply in 15 minutes.

Serous exudates

Are watery fluids low in protein.

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process?

Attach a cardiac monitor.

Fibrinous exudates

Contain large amounts of fibrinogen.

The loss of heat from the body through the circulation of air currents is known as:

Convection

Dry gangrene

Dry gangrene occurs when the blood supply to tissue is cut off. The area becomes dry, shrinks, and turns black. Wet gangrene occurs if bacteria invade this tissue.

Stage one pressure ulcer

Epidermis

Stage two pressure ulcer

Epidermis Dermis

Stage three pressure ulcer

Epidermis Dermis Subcutaneous fat

Stage four pressure ulcer

Epidermis Dermis Subcutaneous fat First signs of muscle all the way down to the bone in some cases.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?

Evaporative

The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as:

Exudate containing white blood cells, protein, and tissue debris.

A nursing assessment of a client who has been diagnosed with neuroleptic malignant syndrome (NMS) would most likely reveal which signs?

Hyperpyrexia, severe hypertension, and diaphoresis.

What is the most common cause of drug fever?

Hypersensitivity reaction to medication.

A client in the operating room goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is what?

Hypothalamus

The nurse is caring for a child in the early stages of burn recovery. Which nursing diagnosis does the nurse prioritize?

Impaired skin integrity.

Osteomyelitis

Inflammation or swelling that occurs in the bone.

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention?

Instruct the client to swish prescribed nystatin solution for 1 minute.

Clinical investigation of a 40-year-old female client with diverse dermatologic signs and symptoms has focused on the woman's basement membrane. Which skin function would a clinician most likely attribute to a region of the integument other than the basement membrane?

Lack of sensory nerve impulse conduction.

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?

Lack of subcutaneous fat.

Incontinence

Lack of voluntary control over urination or defecation.

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. The outside temperature is 55°F (12.8°C). Which action should the nurse prioritize?

Move the infant away from the window.

Sickle cell anemia

Mutated forms of hemoglobin distort the red blood cells into a crescent shape at low oxygen levels. It is most common in people of African descent.

A client has a fever that was induced by damage to the hypothalamus due to inter-cranial bleeding. The nurse plans care for which type of fever?

Neurogenic

Hemorrhagic exudates

Occur when there is severe tissue injury that causes damage to blood vessels or when there is significant leakage of red cells.

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take?

Place a cap on the neonate's head, and offer the neonate to the mother for skin-to-skin.

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone?

Stage IV

The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a burn induced by child abuse (child maltreatment)?

Stocking-glove pattern on hands or feet.

Extravasation

The leakage of blood, lymph, or other fluid, such as an anticancer drug, from a blood vessel or tube into the tissue around it.

Epithelialize

To cover or become covered with epithelial tissue during the healing of a wound.

stage five pressure ulcer

Unstageable

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour.

A nurse is admitting a pregnant woman with sickle cell anemia to the emergency department. Which findings would lead the nurse to suspect the client is in crisis? Select all that apply.

fever joint pain fatigue

At what age should a woman with no risk factors begin mammography screening for breast cancer?

40

Normal temp. for babies?

97.9-100.3

Bartholin cysts

A cyst that occurs only on the outside of the vagina, specifically on the vulva. Also can appear to be swollen, fluid-filled, and sac-like.

Stevens-Johnson syndrome

A disorder of the skin and mucous membranes. It usually starts with flu like symptoms, followed by a painful rash that spreads and blisters. Commonly seen in the lips and results in red bloodshot eyes.

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

A late preterm newborn may have more clinical problems compared with full-term.

Biotransformation

A metabolic process that takes place mainly in the liver and helps to facilitate the excretion of both exogenous and endogenous substances.

Surgical debridement

A procedure for treating a wound in the skin. It involved thoroughly cleaning the wound and removing all hyperkeratotic (thickened skin or callus), infected, and nonviable (necrotic) tissue, foreign debris, and residual material from dressings.

Purulent exudate

A purulent or suppurative exudate contains pus, which is composed of degraded white blood cells, proteins, and tissue debris.

Proliferation

A rapid growth of cells, part, or organism.

Zollinger-Ellison syndrome

A rare digestive disorder that results in too much gastric acid.

Roseola

A rose-colored rash occurring in measles, typhoid fever, syphilis, and some other diseases; a disease of young children in which a fever is followed by a rash, caused by a herpes virus.

Appendicitis

A serious medical condition in which the appendix becomes inflamed and painful. Symptoms include bleeding, infection with redness and swelling, blocked organs, and injury to nearby organs.

The nursing instructor is teaching about Bartholin cysts and informs the students that Bartholin cysts are the most common cystic growth in the vulva. She describes this type of cyst as being:

A swollen, fluid-filled, sac-like structure.

Caseous necrosis

A unique form of cell death in which the tissue maintains a cheese-like appearance. The dead tissue appears as a soft and white proteinaceous dead cell mass.

enzyme induction

An increase in the rate of hepatic metabolism.

Lyme disease

An inflammatory disease characterized at first by a rash, headache, fever, and chills, and later by possible arthritis and neurological and cardiac disorders, caused by bacteria that are transmitted by ticks.

Fistula

An opening that leads into a tunnel under the skin that can either be very short or very long. Approximated - To bring together approximate cut edges of tissue.

Rotavirus infection

Any group of RNA viruses, some of which cause acute enteritis (inflammation of the small intestine) in humans. Decreased urinations, dry mouth and throat, feeling dizzy, crying with few or no tears, unusual fussiness/ sleepiness, and dehydration.

The skin covers the body, and it is exposed to a number of potentially damaging agents in the external environment. What effect(s) do ultraviolet rays of sunlight have on the skin? Select all that apply.

Causing potential for directly damaging the skin. Accelerating the effect of aging on the skin. Predisposing to the development of skin cancer.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?

Continue to monitor the woman's temperature every 4 hours; this finding is normal.

A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for...

Decreased body temperature and cold intolerance.

When assessing a client's incision, the nurse notes that the edges of the once approximated incision has begun to pull apart. The nurse documents that the client's incision has:

Dehisced

A group of teenagers spent an entire day on the beach without using sunscreen. The first night, their skin was reddened and painful to touch. The second day, they awoke to find large fluid-filled blisters over several body areas. The nurse recognizes the development of blisters as which type of inflammatory response?

Delayed response

Parents of a 20-month-old infant report that he refuses food or eats poorly and that he grimaces when he swallows. He also is irritable and cries a lot. The mother is worried that he ate something inappropriate this morning, because he vomited something that looked like coffee grounds. Which health problem would the care team first suspect?

Esophagitis from gastrointestinal reflux.

A specific type of gram-negative bacteria contains endotoxin in the bacterial cell envelope. What is the likely clinical manifestation if these bacteria become pathogenic?

Fever

The nurse is instructing a client with cancer who is receiving chemotherapy about reporting signs of infection. Which is the most reliable early indicator of infection in a client who is neutropenic?

Fever

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

Fish

A 48-year-old man who has been HIV positive for 6 years has just learned that he has been diagnosed with Kaposi sarcoma (KS). Which fact most accurately conveys an aspect of his diagnosis?

He is likely to have lesions on his skin, mouth, or GI tract.

Which organism causes peptic ulcers?

Helicobacter pylori

A woman who gave birth 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, the nurse notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this client?

Increased intake will rehydrate the client and decrease her skin temperature.

A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority?

Ineffective thermoregulation related to decreased amount of subcutaneous fat.

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply.

Irregular edges. Larger than 1/4 inch in diameter. Change in the mole.

Hirschsprung disease

Is a condition that affects the large intestine and causes problems with passing stools. Symptoms include a swollen belly, vomiting (green and brown substances), constipation or gas (may make newborns fussy), diarrhea, and delayed passage of meconium (a newborns first bowel movement).

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?

It is a normal skin finding in a newborn.

Lichenified

Lichenified means the skin has become thickened and leathery.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?

Limited voluntary muscle activity.

Gas gangrene

Most commonly caused by an infection with a bacterium called Clostridium perfringens. The bacteria gather in an injury or surgical wound that has no blood supply. The bacterial infection produces toxins that release gas and cause tissue death.

A client comes to the clinic with multiple bug bites to the legs bilaterally and severe pruritus. The nurse prepares to educate the client about which medication commonly prescribed for pruritus?

Non-sedating antihistamines.

Normal temp. for adults over 65?

Normal temp. is usually lower than 98.6

Hypothermia may occur as a result of...

Open body wounds.

Diaphoresis

Profuse sweating. Often times can occur as a side effect of a drug, or a symptom of a disease

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied?

Remove elastic stockings once per day and observe lower extremities.

A nurse is monitoring a client closely for malignant hyperthermia because the client received which NMJ blocker?

Succinylcholine

A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for:

Temperature

A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?

Temperature instability

A nurse conducting a community education program on hyperthermia determines that the participants understand the information when they identify that the heat index is which of the following?

Temperature sensed when temperature and humidity are combined.

Liquefaction necrosis

The affected cell is completely digested by hydrolytic enzymes leading to a soft, circumscribed (restricted within an area) lesion which can consist of fluid with remains of necrotic tissue or pus.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded.

Passive diffusion

The process by which molecules diffuse from a region go higher concentration to a region of lower concentration. It is the most important mechanism for passage of drugs through membranes.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

Dehisced

To gape or burst open.

A client with right-sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?

Turn the client regularly.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature?

Wrap the infant in a warm, dry blanket.

A rare condition caused by gastrin-secreting tumors most commonly found in the small intestine or pancreas is called:

Zollinger-Ellison syndrome

A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing:

neuroleptic malignant syndrome.

The nurse is recording vital signs in the client diagnosed with complications of anorexia nervosa. Which findings are consistent with the condition? Select all that apply.

orthostatic hypotension hypothermia weak pulse