Med Surg - Chapter 24 - Assessment of the Skin, Hair, and Nails

Which layer of skin is responsible for helping to maintain strong bones? 1 Fat 2 Dermis 3 Epidermis 4 Subcutaneous tissue

3 Epidermis Each layer of the skin has a specific function. The epidermis is the outer layer of skin. Vitamin D is activated in the epidermis by ultraviolet light, such as sunlight, and distributed by the blood to the intestinal tract, where it promotes uptake of dietary calcium. Vitamin D and calcium together help in maintaining healthy bones. The dermis, fat, and subcutaneous tissue do not have any function in the production of vitamin D.

What cells aid in skin suppleness and turgor? 1 Fat cells 2 Mast cells 3 Fibroblasts 4 Keratinocytes

3 Fibroblasts Fibroblasts produce a ground substance, a lubricant that contributes to skin suppleness and turgor. Fat cells insulate the body and absorb shock by padding internal structures. Mast cells help to prevent infections. Keratinocytes undergo cell division and differentiation to continuously renew skin tissue.

What cells are responsible for the production of scar tissue? 1 Fat cells 2 Mast cells 3 Fibroblasts 4 Keratinocytes

3 Fibroblasts Fibroblasts produce collagen, which increases in the areas of tissue injury and helps form scar tissue. Fat cells insulate the body and absorb shock. Mast cells play an important role in shielding the body against infection. Keratinocytes undergo cell division and differentiation to continuously renew the skin.

Which additional thick epidermal layer is present on the palms of the hands and soles of the feet? 1 Stratum lucidum 2 Stratum corneum 3 Stratum spinosum 4 Stratum germinativum

1 Stratum lucidum The stratum lucidum is an additional thick epidermal layer present on the hands and soles of feet. The stratum germinativum is the outermost horny skin layer; it is formed by keratinocytes. The stratum corneum is a horny outer epidermal layer. The stratum spinosum is formed when basal cells divide and keratinocytes are pushed upward.

When managing the care of a patient with a major full-thickness burn, when would the nurse begin to see fluid shifts resulting in edema? 1 Within 12 hours 2 After 24 hours 3 After 30 hours 4 After 36 hours

1 Within 12 hours Fluid shifts occur after initial vasoconstriction; the leakage of fluid and electrolytes from the vascular spaces leads to extensive edema. Fluid shift with extensive weight gain occurs within the first 12 hours after the burn and continues for 24 to 36 hours.

Which of the following skin grafts are obtained from human cadavers? 1 Porcine 2 Allograft 3 Xenograft 4 Heterograft

2 Allograft Homografts, also called allografts, are human skin obtained from a cadaver and provided through a skin bank. Heterografts, also called xenografts, are skin obtained from another species. Pigskin (porcine) is the most common heterograft and is compatible with human skin.

A patient's nail bed is edematous and spongy, and the fingertips have a drumstick-like appearance. What is this condition known as? 1 Pitting 2 Clubbing 3 Koilonychia 4 Beau's grooves

2 Clubbing Clubbing of the nails is a condition in which the nail bed becomes edematous and spongy, and the fingertips look like drumsticks. The angle between the nail plate and the nail fold is greater than 180 degrees. In pitting, there are multiple small pits on the nails. Koilonychia is flattening of the nails. Beau's grooves are horizontal grooves in the nails due to growth arrest.

What skin layer provides protection from injury by corrosive materials? 1 Corium 2 Epidermis 3 Adipose tissue 4 Stratum corneum

2 Epidermis The epidermis consists of a protein called keratin, which provides protection from injury by corrosive materials. The corium (dermis) provides mechanical strength with the help of elastin and collagen fibers. Adipose tissue acts as a mechanical shock absorber. The stratum corneum renews skin integrity and maintains optimal barrier function.

The nurse is evaluating a novice nurse after teaching about changes in the integumentary system related to aging. What statements of the novice nurse indicate effective learning? Select all that apply. 1 "Use fingernails to assess capillary refill if the nails overhang the toes." 2 "Avoid the use of tape or tight dressings if there is an increased dermal thickness." 3 "Teach patients to dress appropriately for the weather if there is a decreased vasomotor responsiveness." 4 "Teach patients to avoid exposure to skin irritants if there is decreased epidermal permeability." 5 "Assist patients confined to a bed to change positions every 2 hours if there is a thickened subcutaneous layer."

1 "Use fingernails to assess capillary refill if the nails overhang the toes." 3 "Teach patients to dress appropriately for the weather if there is a decreased vasomotor responsiveness." 5 "Assist patients confined to a bed to change positions every 2 hours if there is a thickened subcutaneous layer." Poor blood flow to the toes can result in thickening and overhanging of the toenails. Capillary refill is the amount of blood that returns after a pressure is released from the nail bed and is used to assess blood flow to the fingers. Therefore, the nurse should assess capillary refill if the patient has thickened nails. Decreased vasomotor responsiveness may increase the risk of heat stroke and hypothermia. Therefore, the nurse should teach the patient to dress appropriately for the weather. The nurse should avoid the use of tape or tight dressings when there is decreased dermal thickness, as it may increase the susceptibility to trauma. The nurse teaches the patient to avoid exposure to skin irritants if there is increased epidermal permeability because this condition leaves the skin vulnerable to irritation. The nurse repositions a bedridden patient every 2 hours if there is a thickening subcutaneous layer to reduce the risk for pressure injury.

How does the nurse accurately assess a dark-skinned patient for inflammation of the skin? 1 Check for areas that are taut and shiny. 2 Palpate with the fingertips for increased warmth. 3 Palpate with the back of the hand for a "woody" feeling. 4 Check for areas that appear lighter than normal skin tone.

1 Check for areas that are taut and shiny. Inflamed skin is tender and edematous, so the nurse should check for areas on the skin that are taut and shiny. Inflammation in the dark-skinned patient appears excessively warm and changes the skin's consistency or texture. The nurse palpates with the back of the hand for increased warmth that occurs when blood flow to the skin increases. A skin area where inflammation has resolved appears darker than the normal skin tone; this change is due to stimulation of melanocytes during the inflammatory process. The nurse palpates with the fingertips for a "woody" feeling in hardened areas deep in the tissue.

When assessing a patient's nails, the nurse finds that the patient has drumstick-shaped fingertips. Upon palpation, the nail base is visibly edematous and spongy. Which condition does the nurse suspect based on this data? 1 Cystic fibrosis 2 Iron deficiency 3 Alopecia areata 4 Developmental abnormality

1 Cystic fibrosis Enlargement of the soft tissue of the fingertips gives them a drumstick appearance with a visibly edematous and spongy nail base. When this occurs, the shape of the nail is described as late clubbing, which is a symptom of cystic fibrosis. Iron deficiency results in flattening of the nail surface with increased smoothness. Small, multiple pits in the nail plate indicate alopecia areata. Late clubbing of the nails does not result in small, multiple pits in the nail plate. Concave curvature of the nail plate is caused by a developmental abnormality.

What layer helps in the exchange of heat and oxygen? 1 Dermis 2 Epidermis 3 Stratum corneum 4 Subcutaneous layer

1 Dermis The dermis has capillaries and lymph vessels that help in the exchange of oxygen and heat. The epidermis does not have its own blood supply; instead, it receives nutrients by diffusion from blood vessels in the dermal layer. The stratum corneum helps to protect the internal organs from injury due to corrosive materials. The subcutaneous fat layer consists of capillary networks that supply nutrients and remove waste.

Which degree of burn may result in reduced excretory ability of the skin? 1 Full-thickness wound 2 Partial-thickness wound 3 Superficial-thickness wound 4 Deep partial-thickness wound

1 Full-thickness wound The skin excretes through sweating. In full-thickness burns, the sweat glands are destroyed and the skin has a reduced ability to excrete. Partial-thickness wounds may involve the loss of the entire epidermis and varying depths of dermis; it does not totally reduce the excretory function of the skin. Superficial-thickness wounds have the least amount of damage because the epidermis is the only part of the skin that is injured. Deep partial-thickness wounds also do not reduce the excretory ability of the skin because there is no dermal damage.

Which descriptions characterize dandruff? Select all that apply. 1 It causes hair loss if not treated. 2 It can affect the skin of the face and neck. 3 It is a manifestation of hormonal imbalance. 4 It is caused by excessive dryness of the scalp. 5 It is a collection of diffuse white scales on the scalp.

1 It causes hair loss if not treated. 2 It can affect the skin of the face and neck. 5 It is a collection of diffuse white scales on the scalp. Dandruff is a collection of diffuse white scales on the scalp. Dandruff can cause hair loss. Severe inflammatory dandruff can extend up to the eyebrows and the skin of the face and neck. Dandruff is not caused by excessive dryness of the scalp; it is a problem of excessive oil production. Hirsutism is a manifestation of hormonal imbalance; it results in excessive growth of body hair or hair growth in abnormal body areas.

A patient has a herpetic skin lesion that appears in a straight line. What is the correct term used for this lesion pattern? 1 Linear 2 Diffuse 3 Circinate 4 Universal

1 Linear Lesions occurring in straight lines are called linear lesions. Diffuse lesions are widespread with intervening areas of unaffected skin. A circinate lesion is a circular lesion. Universal lesions are spread all over the body.

What body substance is mildly bacteriostatic and contains fat? 1 Sebum 2 Keratin 3 Melanin 4 Collagen

1 Sebum Sebum is a mildly bacteriostatic, fat-containing substance that lubricates the skin and reduces water loss, thereby regulating body temperature. Keratin is a protein produced by keratinocytes that makes the horny layer waterproof. Melanin is a pigment produced by melanocytes; it gives color to the skin and accounts for ethnic differences in skin tone. Collagen is a substance produced by fibroblasts that helps in the formation of scar tissue in tissue injuries.

Which substance reduces water loss from the skin surface? 1 Sebum 2 Keratin 3 Melanin 4 Collagen

1 Sebum Sebum provides lubrication to the skin and reduces water loss from the skin surface. Keratin makes the skin layer waterproof. Melanin provides color to the skin and accounts for ethnic differences in skin tone. Collagen helps in scar tissue formation and wound healing.

Which of the following factors alter nail growth and appearance? 1 Serious illness 2 Genetic factors 3 Hormonal changes 4 Chronic sun exposure

1 Serious illness Serious illnesses or systemic diseases may alter nail growth and appearance due to insufficient oxygen in the blood. Genetic factors, hormonal changes, and chronic sun exposure lead to degenerative changes in the skin.

The nurse is assessing a patient's nails for color alterations and suspects that the patient has chronic liver disease. Which clinical finding supports the nurse's conclusion? 1 Dark red nail beds 2 Horizontal white banding 3 Red discoloration of the lunula 4 Diffuse yellow to brown discoloration

2 Horizontal white banding Presence of horizontal white banding on the nails is referred to as hypoalbuminemia. This occurs when blood albumin levels are abnormally low, which can occur with chronic liver or kidney disease. Dark red nail beds indicate polycythemia vera. Cardiac insufficiency is indicated by red discoloration of the lunula. Diffuse yellow to brown discoloration of the nails indicates jaundice.

What is a risk that may occur in an older patient with decreased sebum production? 1 Increased risk for sunburn 2 Increased size of nasal pores 3 Increased risk for hypothermia 4 Increased susceptibility to dry skin

2 Increased size of nasal pores Increased size of nasal pores and large comedones may occur in a patient with decreased sebum production due to skin clogging. A patient with decreased melanocyte activity is at a higher risk for sunburn. A thin subcutaneous layer may increase the risk of developing hypothermia. Increased susceptibility to dry skin may occur due to decreased dermal blood flow.

Which substance makes the horny layer waterproof? 1 Sebum 2 Keratin 3 Melanin 4 Collagen

2 Keratin Keratin plays a protective role by making the horny skin layer waterproof. Sebum is a mildly bacteriostatic fat-containing substance that lubricates the skin and reduces the water loss through evaporation. Melanin is a pigment produced by melanocytes, which gives color to the skin and accounts for ethnic differences in skin tone. Collagen is a substance produced by fibroblasts that helps to form scar tissue.

Which structure of the skin appendage is useful for grasping and scraping? 1 Hair 2 Nails 3 Cuticle 4 Hair follicles

2 Nails Fingernails and toenails have cosmetic value and are useful for grasping and scraping to identify fungal infections. The rate of growth and color of the hair occur due to melanocytes that protect the skin from sunlight. The cuticle attaches the nail plate to the soft tissue of the nail fold. Within each hair follicle, a round column of keratin forms the hair shaft.

While providing teaching to a patient undergoing excisional biopsy, which statement does the nurse include? 1 "The dressing must remain in place for the first 48 hours." 2 "Redness and swelling at the puncture site are expected." 3 "Administration of local anesthetic agents may cause burning." 4 "The biopsy results will be available within 2 hours of the procedure."

3 "Administration of local anesthetic agents may cause burning." Local anesthetic agents may cause a burning sensation for the patient. Biopsy results are typically available 2 to 3 days, or even several weeks, after the procedure. Typically, dressings must remain in place for 8 hours, not 48 hours. Redness and swelling are unexpected after an excisional biopsy and may be an indication of infection.

The nurse finds that a patient's entire toenail has come off after an injury to the foot. How long will it take before the toenail is completely replaced? 1 1 month 2 4 months 3 12 months 4 24 months

3 12 months Nails grow continuously but the process is very slow. Under normal conditions, complete replacement of a toenail in a healthy individual may take up to a year (12 months). Fingernail replacement requires only 3 to 4 months.

A skin lesion with which characteristic can potentially develop into skin cancer? 1 Elevated and symmetrical 2 Elevated and around 2 mm in diameter 3 8 mm in diameter and often changes color 4 Presents as an erosion and is 5 mm in diameter

3 8 mm in diameter and often changes color According to the guidelines established by the Skin Cancer Foundation, skin lesions should be checked for certain criteria. These include asymmetry of shape, border irregularities, color variation, a diameter greater than 6 mm, and evolving in any feature. If any of these features are present, it indicates that the lesion has a potential to form a malignant skin lesion. A simple erosion in the skin, which is about 5 mm in diameter, may not be malignant; it may indicate a pressure ulcer or vesicle, bulla, or pustule.

Which intervention would the registered nurse (RN) delegate to the nursing assistant in the care of an older adult patient who has areas of breakdown in the skin folds and the perineal area? 1 Evaluating the patient's ability to provide skin hygiene independently. 2 Assessing the patient's skin weekly for areas of redness or breakdown. 3 Bathing the patient and applying a protective barrier to skin folds and perineum. 4 Teaching the patient and family about the importance of good hygiene in skin folds.

3 Bathing the patient and applying a protective barrier to skin folds and perineum. Assisting patients with personal hygiene is included in a nursing assistant's scope of practice. Evaluation, assessment, and teaching interventions are more complex, higher-level skills that require the education and scope of practice of licensed nursing staff.

The nurse is teaching a patient about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the patient? 1 Self-suctioning 2 Respiratory protection 3 Body image counseling 4 Tobacco cessation education

3 Body image counseling The epidermis is the outer layer of the skin. Damage to the epidermis can cause body image disturbance for patients. Respiratory protection, self-suctioning, and tobacco cessation education are not related to damage to the epidermis.

Which type of burn injury is caused by an open flame? 1 Scald 2 Contact 3 Dry heat 4 Electrical

3 Dry heat Dry heat injuries are caused by an open flame. Moist heat injuries are caused by hot liquids or steam, which results in scalding. Electrical injuries are burns occurring when electricity enters the body. Contact burns occur when a hot surface contacts the skin.

In skin assessment, how is plaque described? 1 Vesicles filled with cloudy or purulent fluid 2 Small, firm elevated lesions less than 1 cm in diameter 3 Elevated, plateau-like patches more than 1 cm in diameter 4 Nodules filled with either liquid or semisolid material that can be expressed

3 Elevated, plateau-like patches more than 1 cm in diameter Plaque is identified as elevated, plateau-like patches more than 1 cm in diameter. It is seen in psoriasis or seborrheic keratosis. Papules such as warts or moles are small, firm, elevated lesions less than 1 cm in diameter. Cysts are nodules filled with either liquid or semisolid material that can be expressed. Pustules are vesicles filled with cloudy or purulent fluid; they are found in acne and acute impetigo.

Which nursing documentation is correct in describing multiple lesions with well-defined borders that are located in one area? 1 Clustered round lesions to the chest 2 Five diffuse circinate lesions on the chest 3 Five clustered circumscribed lesions on the chest 4 Several lesions in one area that have well-defined borders

3 Five clustered circumscribed lesions on the chest "Five clustered circumscribed lesions on the chest" is specific with correct terminology. "Clustered round lesions to the chest" and "five diffuse circinate lesions on the chest" use incorrect terminology. "Several lesions in one area that have well-defined borders" is too vague to describe the condition accurately.

In assessing an 81-year-old patient, where does the nurse assess skin turgor? 1 Cheek 2 Forearm 3 Forehead 4 Abdomen

3 Forehead Skin turgor helps determine the skin's elasticity and can be altered by a number of factors, including water content and aging. Normally it can be checked on the hand or forearm, but in older adults, skin elasticity is reduced and turgor cannot be accurately assessed in all skin areas. Therefore in older adults, turgor should be checked on the forehead or chest because the skin in these areas is taut and is over the underlying bones. Skin covering the cheek, forearm, and abdomen is lax, and turgor cannot be accurately assessed.

The RN is performing an assessment on an older adult patient who is in congestive heart failure. Which skin finding during palpation of the extremities is the nurse specifically concerned about? 1 Slight tears on the forearms 2 Fairly widespread dry flakiness 3 Marked dependent pitting edema 4 Several smaller bruises on the extremities

3 Marked dependent pitting edema Dependent pitting edema may indicate venous and cardiac insufficiency in patients with congestive heart failure. Skin tears may occur where adhesive tapes or dressings have been applied and removed, especially in older patients with fragile skin. Dry skin usually has scaling and flaking, and may be especially marked in areas of limited circulation such as the feet and lower legs. It is a common problem during the winter months when the air contains less moisture, in geographic areas with little humidity, and in the hospital environment where humidity is often low. In older adults, bruising is common after minor trauma to the skin.

Which substance protects the skin from ultraviolet (UV) light? 1 Sebum 2 Keratin 3 Melanin 4 Collagen

3 Melanin Melanin protects the skin from damage by UV light. Sebum lubricates the skin and reduces water loss from the skin surface. Keratin makes the horny layer of the skin waterproof. Collagen is a protein produced by fibroblast cells that is involved in tissue injury and helps form scar tissue.

A patient's nail plate has been separated from the nail bed. What is this condition known as? 1 Paronychia 2 Koilonychia 3 Onycholysis 4 Beau's grooves

3 Onycholysis The condition is which the nail plate is separated from the nail bed is medically known as onycholysis. Paronychia is the inflammation of skin around the nail. Koilonychia refers to flattening of the nails. Beau's grooves are horizontal grooves in the nails caused by growth arrest.

What is the outermost horny skin layer? 1 Dermis 2 Epidermis 3 Stratum corneum 4 Subcutaneous layer

3 Stratum corneum The outermost horny skin layer is called the stratum corneum; this structure is formed by the enlargement and flattening of keratinocytes. The dermis, or corium, is the layer present below the epidermis. The epidermis is the outermost skin layer but not horny skin layer. The subcutaneous layer is the innermost layer of the skin, lying over muscle and bone.

A patient develops a skin injury after working in the sunlight for a long time. Which type of wound does the nurse suspect? 1 Full-thickness wound 2 Deep full-thickness wound 3 Superficial-thickness wound 4 Superficial partial-thickness wound

3 Superficial-thickness wound Superficial-thickness wounds are usually caused by prolonged exposure to sunlight. Full-thickness wounds are caused by flames and prolonged exposure to hot objects. Deep full-thickness wounds can be caused by flames or electricity. Superficial partial-thickness wounds are caused by flames and brief contact with hot objects.

A registered nurse is precepting a student nurse who is educating the parents of a child with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the nursing student's statements requires correction? 1 "Keep your child off any upholstered furniture." 2 "Make sure your child avoids close contact with others." 3 "Change the bandage whenever drainage seeps through it." 4 "Stop giving your child the antibiotics once the wound has healed."

4 "Stop giving your child the antibiotics once the wound has healed." To prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) infection, the student nurse will teach the patient's parents precautions. The parents should ensure the patient takes all of the prescribed antibiotics, even if the dosage continues after the wound has appeared to heal. The other statements are correct. The child should avoid close contact with others and stay off upholstered furniture. The parents should also change the bandage any time drainage has seeped through it.

What is the most important factor that causes degenerative changes in the skin? 1 Disease 2 Genetic factor 3 Hormonal change 4 Chronic sun exposure

4 Chronic sun exposure Chronic sun exposure is the most important factor that causes degeneration of the skin components. This occurs due to the alteration of elastin fibers, collagen fibers, and ground substance that provide mechanical strength. Disease, genetic factors, and hormonal changes may bring changes in skin over time but to a lesser extent.

The nurse notes an area of petechiae on the patient's lower extremity. Which condition does the nurse suspect the patient has? 1 Scabies 2 Chronic renal failure 3 Deep vein thrombosis 4 Chronic venous insufficiency

4 Chronic venous insufficiency Areas of petechiae often indicate increased capillary fragility related to chronic venous insufficiency. Scabies are small insects that imbed themselves under the patient's skin and do not cause petechiae. Dry, flaky skin is seen in patients with chronic renal failure. Redness, swelling, and pain are often indicators of a deep vein thrombosis.

Which cells are responsible for the secretions of eccrine sweat glands? 1 Fat cells 2 Melanocytes 3 Keratinocytes 4 Epithelial cells

4 Epithelial cells Epithelial cells aid in eccrine sweat gland secretions. Eccrine sweat glands arise from the epithelial cells and are found over the entire skin surface. Fat cells are produced in the adipose tissue, which is the innermost layer of the skin. Melanocytes are found near the basement membrane and help in melanin secretion. Keratinocytes are found attached to the basement membrane; these cells renew skin tissue integrity and maintain optimal barrier function.

While examining an older patient for changes in the integumentary system, the nurse identifies decreased eccrine and apocrine gland activity. What nursing actions would be beneficial? Select all that apply. 1 Tell the patient to use a bath thermometer. 2 Check skin turgor on the forehead or chest. 3 Avoid taping or using tight bandages to the skin. 4 Instruct the patient to use a moisturizer after bathing. 5 Tell the patient to avoid frequent hot water baths and showers.

4 Instruct the patient to use a moisturizer after bathing. 5 Tell the patient to avoid frequent hot water baths and showers. Decreased eccrine and apocrine gland activity may increase the susceptibility to dry skin. Moisturizers can hydrate the body and reduce the risk of dry skin in the body. Frequent bathing with hot water makes the skin dry; instructing the patient to avoid this activity is beneficial. The nurse should avoid taping or using tight bandages on the patient's skin if there is skin transparency and fragility. Assessing skin turgor on the forehead or chest is performed if there is a decreased tone and elasticity of the dermis. Reduced sensory perception can make the patient unable to sense hot or cold objects. For this condition, the nurse should tell the patient to use a bath thermometer and lower the water temperature to prevent scalds.

What cells renew skin tissue integrity and maintain optimal barrier function? 1 Fat cells 2 Mast cells 3 Fibroblasts 4 Keratinocytes

4 Keratinocytes Keratinocytes undergo cell division and differentiation to continuously renew skin tissue integrity and maintain optimal barrier function. Fat cells insulate the body and absorb shock. Mast cells help to protect against infection. Fibroblasts aid in the formation of scar tissue.

Which cells are involved in the formation of the horny layer, malpighian layer, and cellular layer? 1 Fat cells 2 Fibroblasts 3 Melanocytes 4 Keratinocytes

4 Keratinocytes Keratinocytes undergo cell division and differentiation to form the horny layer, malpighian layer, and cellular layer. Fat cells are involved in the formation of adipose tissue. Fibroblasts help in the formation of scar tissue. Melanocytes give color to the skin and account for ethnic differences in skin tone.

Skin lesions known as vesicles typically have a diameter of how many centimeters (cm)? 1 1 to 2 cm 2 2 to 3 cm 3 3 to 4 cm 4 Less than 1 cm

4 Less than 1 cm Vesicles are blisters filled with clear fluid less than 1 cm in diameter. Blisters more than 1 cm and that are filled with clear fluid are known as bullae.

What color will a patient's skin be with an elevated bilirubin level? 1 Blue 2 White 3 Brown 4 Orange

4 Orange Increased bilirubin causes a patient to appear jaundiced or to have an orange skin color. Blue skin color indicates poor oxygenation. White skin color indicates anemia. Brown skin color indicates Addison disease or exposure to sunlight.

During the postoperative patient assessment, which skin condition discovered by the nurse requires an urgent response? 1 Cool extremities 2 Café au lait spots 3 Clubbing of the nail beds 4 Reddish-blue area on the calf

4 Reddish-blue area on the calf A reddish-blue area on the calf is indicative of decreased tissue perfusion and requires urgent attention. Clubbing of the nail beds is a chronic symptom, not a postoperative concern. Cool extremities are a normal postoperative occurrence. Cafe au lait spots are not a postoperative concern.

The nurse is assessing the nails of an older patient for vascular alterations. What action does the nurse take? 1 Palpates the fingertips. 2 Observes the nail for color change. 3 Inspects the soft tissue folds around the nail plate. 4 Squeezes the end of the finger and exerts downward pressure.

4 Squeezes the end of the finger and exerts downward pressure. The nurse assesses the nails for vascular alteration by squeezing the end of the finger and exerting downward pressure. Color caused by vascular alterations changes as pressure is applied and returns to its original state when pressure is released. The nurse palpates the fingertips to define areas of sponginess, tenderness, or edema. Change in color can be caused by chemical damage that occurs with some occupations and long-term use of nail polish. The soft tissue folds around the nail plate are inspected to assess for inflammation of the nail.

What skin layer provides protection through insulation? 1 Corium 2 Epidermis 3 Stratum corneum 4 Subcutaneous tissue

4 Subcutaneous tissue Fat cells in the subcutaneous tissue protect the skin by insulating the body and absorbing shock. The corium, or dermis, protects the skin by providing cells for wound healing. The epidermis provides protection through intercellular bonds. The stratum corneum protects the skin by maintaining optimal barrier function.

Which description of minor burn wound care defines open technique? 1 The wound is cleaned with hot water. 2 The wound is cleaned every 48 to 72 hours. 3 The medication is applied without the use of cotton. 4 The medication is applied on the burn without the dressing.

4 The medication is applied on the burn without the dressing. In the open technique, the medication (a topical antibiotic) is applied directly on the wound, and the wound is left uncovered. The wound must be cleaned every 8 to 24 hours to avoid infection. The wound must be cleaned with water that is at room temperature. Hot water can damage the underlying tissues and should be avoided. Medications must be applied with cotton to avoid secondary infection from direct contact with the applicator's hand.