Tissue Integrity-EXAM2

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?

"I'll eat plenty of fruits and vegetables."

The nurse provides teaching on postoperative wound care to a client being discharged from a surgical unit. Which of the following statements documented by the nurse indicates that the client understood the teaching?

"Client verbalized to the nurse the steps to follow if wound becomes red and warm."

A nursing student working today on the cardiac unit asks the instructor why loss of the "atrial kick" causes a decrease in cardiac output, because ventricles are still contracting. The instructor's best answer is which of the following?

"The atrial contraction fills the ventricles and accounts for nearly one third of the volume ejected during ventricular contraction."

A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Record your answer as a whole number.

250

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which of the following clients has the highest risk for developing a pressure ulcer?

65-year-old incontinent client with a hip fracture on bed rest

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 of the following stages should the nurse assign to this client's wound?

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 of the following stages should the nurse assign to this client's wound?

For which of the following patients is foot care likely the highest priority?

A patient who is obese and has a diagnosis of type 1 diabetes

A student is making a poster of the repeated use of various substances within the human body. What body structures have keratin as part of their composition?

All options are correct: hair, skin & nails

Which of the following is the term for a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?

Chancre

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform post-mortem care for the client. Which of the following interventions should the nurse perform when providing post-mortem care?

Cleanse drainage from the skin.

A client with diabetes is explaining to the nurse how he cares for the feet at home. Which statement indicates the client needs further instruction on how to care for the feet properly?

I inspect my feet once a week for cuts and redness."

The priority nursing diagnosis for a client who has just been admitted to the hospital with burns would be which of the following?

Impaired skin integrity

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline and inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method

Depth

Which of the following is the primary symptom of achalasia?

Difficulty swallowing

Which of the following is an example of a topical anesthetic?

EMLA cream: EMLA cream is a topical anesthetic. Bacitracin, Silvadene, and Garamycin are topical antibiotics.

The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do?

Enroll in a supervised exercise training program.

Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure?

Fasciotomy

A patient with an abdominal surgical wound sneezes and states, "Something doesn't feel right with my wound." The nurse asses the upper half of the surgical wounds edges are no longer approximated and the lower half remains well approximated. What documentation by the nurse is most appropriate?

Following a sneeze, the wound dehisced.

Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have?

Full thickness (third degree)

In order to maintain a healthy and hygienic integumentary system, a nurse is clipping the overgrown nails of an elderly client. Which other part should the nurse check to maintain the hygiene of the client's integumentary system?

Hair

When assessing a child for impetigo, the nurse expects which assessment findings?

Honey-colored, crusted lesions

When educating a client in the postoperative period, it is important to educate the client to consume a diet high in

Protein

Which nursing intervention is essential in caring for a client with compartment syndrome?

Removing all external sources of pressure, such as clothing and jewelry

Which change in the integumentary system is associated with normal aging?

Subcutaneous fat and extracellular water decrease.

Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.

Which of the following data is most important for the nurse to record while assessing a patient with an open wound?

Time when the patient last received a tetanus immunization

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency

A client diagnosed with cancer is receiving chemotherapy. The nurses should assess which diagnostic value while the client is receiving chemotherapy?

bone marrow cells

Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which contradiction to administering the drug?

history of cerebral hemorrhage

Hypothermia may occur as a result of

open body wounds.

Which indicates hypovolemic shock in a client who has had a 15% blood loss?

systolic blood pressure less than 90 mm Hg

A 23-month-old child pulls a pan of hot water off the stove and spills it onto her chest and arms. Her mother is right there when it happens. What should the mother do immediately?

Place the child in a bathtub of cool water

The nurse is caring for a client who had a bowel resection one week ago. Which of the following interventions are most appropriate to promote wound healing and reduce risk of infection at the incision site? Select all that apply.

Provide the client with Ensure supplements. • Increase intake of protein and vitamin C in the diet. • Teach the client to wash hands before touching the incision.

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

Remove elastic stockings once per day and observe lower extremities.

Which of the following errors has the nurse made in formulating the nursing diagnosis: Prolonged Immobility related to impaired skin integrity AEB one-inch diameter open area on right buttocks surrounded by a one-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.

Reversed the health problem and the etiology

Which nursing action is appropriate when providing foot care for a patient?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency?

Scurvy

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings?

Hand that is insensitive to touch

The nurse is conducting a community education program on basal cell carcinoma (BCC). Which of the following statements should the nurse make?

It begins as a small, waxy nodule with rolled translucent, pearly borders.

The nurse assesses the patient and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which of the following conditions?

Kaposi's sarcoma: Kaposi's sarcoma is a frequent comorbidity of the patient with AIDS. With platelet disorders, the nurse observes ecchymosis (bruising) and purpura (bleeding into the skin). Urticaria (wheals or hives) is the manifestation of allergic reactions. A painless chancre or ulcerated lesion is a typical finding in the patient with syphilis.

The nurse is teaching an adolescent how to treat acne. What would the nurse include as a teaching point?

Keep hair off the face and wash hair daily.

Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

Nutrition support and orthotics

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?

Keeping the perineal area clean and dry

The nurse is caring for a patient receiving radiation therapy for laryngeal cancer. A late complication of radiation therapy includes which of the following?

Laryngeal necrosis

Which of the following techniques is used to surgically revascularize the myocardium?

Minimally invasive direct coronary bypass

Which of the following discharge instructions for self-care should the nurse provide to a patient who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure?

Monitor the site for bleeding or hematoma.

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour care ride, what should the nurse should advise the client to do?

Perform ankle pumps and foot range-of-motion exercises.