Tissue Integrity- Giddens & HESI

After teaching a post-radiation therapy client regarding proper skin care to the treatment area, which client statements indicate understanding? Select all that apply. One, some, or all responses may be correct. 1. "I will wear loose-fitting clothing over the area." 2. "I will avoid using adhesive bandages." 3. "I will avoid exposing the area to cold temperatures." 4. "I will avoid rinsing the area with a saline solution." 5. "I will use lotions to moisten the area when wearing makeup."

Answer: 1. "I will wear loose-fitting clothing over the area." 2. "I will avoid using adhesive bandages." 3. "I will avoid exposing the area to cold temperatures." Clients should avoid tight-fitting clothing such as brassieres and belts in the area of the treatment field. The client should avoid use of adhesive bandages unless permitted by the radiation therapist. Clients should not expose the radiation treatment area to cold temperatures. A client who underwent radiation therapy should regularly rinse the radiation treatment area with saline solution to prevent infection. Clients should also avoid use of lotions, ointments, perfumes, and makeup over the treatment area.

Which component of skin maintains optimal barrier function? 1. Keratin 2. Melanin 3. Collagen 4. Adipose tissue

Answer: 1. Keratin Keratin is a protein produced by keratinocytes that helps maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.

Which is the first-line treatment for Paget's disease? 1. Oral alendronate 2. Oral calcium 3. Intravenous pamidronate 4. Intravenous zoledronic acid

Answer: 1. Oral alendronate Oral alendronate, a bisphosphonate, is the first-line treatment for Paget's disease. Clients with Paget's disease also are given 1500 mg of calcium daily as a supplement to reduce the risk for hypocalcemia. When oral medications are ineffective, pamidronate and zoledronic acid are administered intravenously.

Which changes to the client's skin are caused by the atrophy of eccrine sweat glands? 1. Ecchymosis 2. Dry skin 3. Wrinkles 4. Skin shearing

Answer: 2. Dry skin Atrophy of the eccrine sweat glands will result in dry skin and decreased body odor. Increased capillary fragility and permeability will result in ecchymosis. Decreased subcutaneous fat, degeneration of elastic fibers, and stiffening of the collagen fibers will result in wrinkles. Decreased subcutaneous fat will result in shearing of the skin.

Which synovial joint movement is described as turning the sole away from the midline of the body? 1. Pronation 2. Eversion 3. Adduction 4. Supination

Answer: 2. Eversion Eversion is a synovial joint movement that describes turning the sole outward away from the midline of the body. Pronation is a synovial joint movement that describes turning the palm downward. Adduction is a synovial joint movement that describes movement toward midline of the body. Supination is a synovial joint movement that describes turning the palm upward.

The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury? 1. Hypokalemia and hyponatremia 2. Hyperkalemia and hyponatremia 3. Hypokalemia and hypernatremia 4. Hyperkalemia and hypernatremia

Answer: 2. Hyperkalemia and hyponatremia Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which is the nurse assessing for? 1. Pain tolerance 2. Skin turgor 3. Ecchymosis formation 4. Tissue mass

Answer: 2. Skin turgor Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.

Which instruction would the nurse provide to an older client using ice and heat to treat pain from back strain? Select all that apply. One, some, or all responses may be correct. 1. Switch positions every 4 hours. 2. Use a heating pad for the first 24 hours. 3. Apply for 30-minute time intervals. 4. Place the ice pack directly to injury site. 5. Take ibuprofen every 4 hours PRN.

Answer: 3. Apply for 30-minute time intervals. To prevent skin damage, ice and heat should only be applied for 20- to 30-minute intervals. Clients should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue. The client can take ibuprofen if approved by the health care provider.

How would the nurse describe the exudate characteristic of a serosanguineous wound? 1. Greenish-blue pus 2. Creamy yellow exudate 3. Blood-tinged amber fluid 4. Beige pus with a fishy odor

Answer: 3. Blood-tinged amber fluid Blood-tinged amber fluid is characteristic of serosanguineous wound exudate. Greenish-blue pus, creamy yellow exudate, and beige pus with a fishy odor are characteristics of purulent wound exudate.

Which test is used in the diagnosis of systemic lupus erythematosus? 1. Patch test 2. Photo patch test 3. Direct immunofluorescence test 4. Indirect immunofluorescence test

Answer: 3. Direct immunofluorescence test A direct immunofluorescence test is used in the diagnosis of systemic lupus erythematosus. The patch test and photo patch test are used to evaluate allergic dermatitis and photo allergic reactions. An indirect immunofluorescence test is performed on a blood sample.

Which side effects are associated with systemic antibiotic therapy for acne in adolescents? Select all that apply. One, some, or all responses may be correct. 1. Arthralgia 2. Nasal irritation 3. Photosensitivity 4. Vaginal candidiasis 5. Decreased night vision

Answer: 3. Photosensitivity 4. Vaginal candidiasis Systemic antibiotic therapy may cause photosensitivity and vaginal candidiasis. Arthralgia, nasal irritation, and decreased night vision are side effects of isotretinoin.

A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. Which percentage of total body surface area (TBSA) would the nurse calculate? 1. 20 2. 25 3. 30 4. 36

Answer: 4. 36 Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% total for both arms) and 18% for the anterior trunk; thus the total body surface area burned is 36%. The choices 20%, 25%, and 30% are too low.

Which description is common to zosteriform-type lesions? 1. Wide distribution 2. Diffuse distribution 3. Bilateral distribution 4. Band-like distribution

Answer: 4. Band-like distribution Band-like distribution of lesions would be termed as zosteriform-type lesions. Diffuse-type lesions are described as the wide distribution of the lesions. Generalized-type lesions are identified by the diffused distribution of the lesions. Symmetric-type lesions are the bilateral distribution of the lesions.

Which interventions can be performed by an unlicensed assistive personnel in skin care? Select all that apply. One, some, or all responses may be correct. 1. Assist the client in bathing. 2. Apply wet dressings to the skin. 3. Report changes in the skin appearance. 4. Reinforce teaching as done by the registered nurse. 5. Determine whether the client is taking a medication that increases photosensitivity.

Answer: 1. Assist the client in bathing. 2. Apply wet dressings to the skin. 3. Report changes in the skin appearance. The unlicensed assistive personnel may be responsible for assisting the client in bathing, applying wet dressings to the skin, and reporting changes in the skin appearance. Teaching done by the registered nurse can be reinforced by a licensed practical nurse or a vocational nurse. The registered nurse would be responsible for determining whether the client is taking a medication that increases photosensitivity.

Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. One, some, or all responses may be correct. 1. Burns 2. Skin cancer 3. Osteomyelitis 4. Diabetic ulcers 5. Myocardial infarction

Answer: 1. Burns 3. Osteomyelitis 4. Diabetic ulcers Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue's oxygen concentration. Burns, osteomyelitis, and diabetic ulcers are treated by hyperbaric oxygen therapy. Skin cancer and myocardial infarctions are not treated using hyperbaric oxygen therapy.

Which type of hepatitis virus spreads through contaminated food and water? 1. Hepatitis A virus 2. Hepatitis B virus 3. Hepatitis C virus 4. Hepatitis D virus

Answer: 1. Hepatitis A virus Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products.

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. One, some, or all responses may be correct. 1. Axilla 2. Fingers 3. Ear lobes 4. Forehead 5. Upper thorax

Answer: 2. Fingers 3. Ear Lobes Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

Which surgery is used to treat excessive wrinkling or sagging of facial skin? 1. Rhinoplasty 2. Rhytidectomy 3. Dermabrasion 4. Blepharoplasty

Answer: 2. Rhytidectomy Rhytidectomy is the removal of excess skin and tissue from the face; this is the surgery used to treat wrinkling or sagging of facial skin. Rhinoplasty is the removal of excessive tissue or cartilage from the nose. Dermabrasion is the process of removing the facial epidermis or a portion of the dermis to treat acne scars. Blepharoplasty is the removal of bulging fat in the periorbital area; this is used to treat bags under the eyes.