Tissue integrity questions

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? a. Kidney beans b. Grilled salmon c. Peanut butter d. Raw spinach

Grilled salmon Poultry, fish, eggs, and beef are complete proteins and are optimal sources of protein to support wound healing.

A nurse is preparing to teach a parent how to care for a child who has impetigo contagiosa. Which of the following information should the nurse plan to include in the teaching? a. Keep the child on droplet precautions at home b. Wash clothing in hot water. c. Immunize household contacts for the disease. d. Give the child a chlorine bath twice daily.

Wash clothing in hot water. The nurse should teach the parent to ensure the child changes her clothes every day and to wash all clothing in hot water.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? a. An adolescent who has a cervical fracture and is in a halo brace b. A young adult who has a femur fracture and is in skeletal balanced suspension traction c. A middle adult who has a fractured radius and an arm cast d. An older adult who has a hip fracture and is in Buck's traction

An older adult who has a hip fracture and is in Buck's traction According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

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 indicates an understanding of the teaching? a. "All recently used clothing, bedding, and towels must be washed in hot water." b. "My child must be free from nits before returning to school." c. "I will treat all the family members to be on the safe side." d. "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.

A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this condition? a. Firmly attached white particles on the hair b. Itching and scratching of the head c. Patchy areas of hair loss d. Thick yellow crusted lesion on a red base

Firmly attached white particles on the hair Pediculus capitis, or head lice, are tiny parasitic insects that live on the scalp and can be spread by close contact with other people. Their eggs (nits) appear much like flakes of dandruff but stick firmly to the hair shaft instead of flaking off of the scalp.

A nurse is assessing 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? a. Exposed bone b. Blood filled blisters c. Partial-thickness skin loss. d. Necrotic subcutaneous tissue

Necrotic subcutaneous tissue Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic subcutaneous tissue.

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

Serosanguineous Watery red drainage should be documented as serosanguineous.

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? a. Transparent dressing b. Wet-to-dry gauze dressing c. Hydrogel dressing d. Alginate dressing

Transparent dressing A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? a. Apply a moisture barrier ointment to the client's skin. b. Clean the client's skin and perineum with hot water after each episode of incontinence. c. Check the client's skin every 8 hr for signs of breakdown. d. 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.

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take? a. Place the head of the client's bed in the flat position. b. Gently reinsert the bowel back into the client's wound. c. Apply moistened sterile gauze to the site. d. Position the client on his left side.

Apply moistened sterile gauze to the site. The nurse should apply moistened sterile gauze to the site to reduce the risk for further injury and infection.

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? a. Shingles b. Athlete's foot c. Fever blister d. Valley fever

Athlete's foot Athlete's foot is the common name for tinea pedis.

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan? a. Maintain occlusive dressings on the lesions throughout the day and remove them at bedtime. b. Eliminate the use of products containing salicylic acid. c. Avoid friction over scaly lesions while bathing. d. Identify effective stress reduction techniques.

Identify effective stress reduction techniques. Psoriasis is significantly aggravated by stress. The use of effective stress reduction techniques is appropriate to manage this chronic disorder.

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? a. Pediculosis capitis b. Impetigo contagiosa c. Folliculitis d. Tinea capitis

Pediculosis capitis Pediculosis capitis is 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.

A nurse is caring for an older adult 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? a. Reposition the client every 3 hr. b. Massage bony prominences to promote circulation. c. Provide the client with a diet high in protein. d. Apply cornstarch to keep the skin dry.

Provide the client with a diet high in protein. Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.

A school nurse is performing a routine health assessment for a school-age child. Which of the following findings indicates the nurse should investigate further for pediculosis capitis? a. Bald patches on the scalp b. Blisters on the scalp c. Pruritus of the scalp d. Dry patches on the scalp

Pruritus of the scalp Pediculosis capitis is an infestation of head lice. Generally, the only manifestation is scalp itchiness.

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? a. Apply a heat lamp twice a day. b. Reposition the client at least every 2 hr. c. Clean the wound with hydrogen peroxide solution. d. Massage reddened areas with dressing changes.

Reposition the client at least every 2 hr. The nurse should plan to reposition the client at least every 2 hr and to make a schedule to record position changes for the client's medical record.

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? a. Serum albumin 3.2 g/dL b. Hemoglobin 16 g/dL c. WBC count 8,000/mm3 d. PTT 1.8

Serum albumin 3.2 g/dL A serum albumin level is a good indicator of the nutritional status of a client. A value less than 3.5 g/dL is an indication of poor nutrition, can delay wound healing, and lead to infection.

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

Use a transfer device to lift the client up in bed. Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan? a. Wash the affected area with hot water. b. Treatment focuses on pain management. c. Use bath oils to soften and soothe the skin. d. Apply warm, moist compresses twice daily.

Use bath oils to soften and soothe the skin. The nurse should instruct the client to use bath oils or emollient cleansing agents to comfort sore and scaling skin areas. Softening the skin and prevent skin fissures.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) a. Massage over erythematous bony prominences. b. Implement turning schedule every 4 hr. c. Use pillows to keep heels off the bed surface. d. Keep the client's skin dry with powder. e. Minimize skin exposure to moisture.

Use pillows to keep heels off the bed surface is correct. The nurse should keep the heels off the bed to prevent skin breakdown on the client's heels. Minimize skin exposure to moisture is correct. The nurse should minimize skin exposure to moisture to prevent skin breakdown.

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? a. BUN b. Potassium c. RBC count d. WBC count

WBC count An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.

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? a. Massage the client's red bony prominences. b. Assess the client's skin for increased coolness. c. Reposition the client every 2 hr. d. Keep the client's skin moist.

Reposition the client every 2 hr. The nurse should change the client's position every 2 hr to stimulate circulation and prevent pressure ulcers.

A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings? a. Unilateral lesions b. Serous drainage c. Intense pain d. Silvery, white scales

Silvery, white scales The characteristic lesions of psoriasis are thick, erythematous plaques covered by silvery scales.

A nurse in a provider's office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect? a. Report of recent exposure to poison ivy b. Scaling and redness between the client's toes c. Circular, erythematous patches on the scalp d. Report of a recent prescription for an antiseizure medication

Scaling and redness between the client's toes Scaling and redness between the toes are expected findings of tinea pedis, which is commonly referred to as athlete's foot.

A nurse is providing teaching to a client who has psoriasis and a new prescription for the topical corticosteroid cream betamethasone valerate. Which of the following information should the nurse include in the teaching? a. The medication should be applied in a thick layer to completely cover the lesions. b. The medication should be applied every 2 hr. c. Rubbing the medication vigorously into the lesions will increase its absorption. d. Wrapping plastic around the site can increase the medication's effectiveness.

Wrapping plastic around the site can increase the medication's effectiveness. The provider might prescribe occlusive dressings to be applied over the site after the topical corticosteroid is applied in order to increase the medication's effectiveness.

A nurse is providing teaching about lice to the parents of a school-age child at a well-child visit. Which of the following information should the nurse include in the teaching? a. "Lice can jump from one child to another." b. "Encourage your child to avoid sharing hats with other children." c. "Live lice can survive for 2 weeks away from the host." d. "Washing your child's hair daily will prevent lice."

"Encourage your child to avoid sharing hats with other children." Lice are transmitted from person to person on personal items, such as hats, hair ornaments, scarves, combs, and brushes.

A nurse is providing teaching to a client who has widespread psoriasis and a prescription for phototherapy. The nurse should include which of the following information in the teaching? a. "You will have a morning and afternoon session on each treatment day." b. "Treatment might be interrupted if areas of redness and tenderness develop." c. "Treatments will be given in a series of three days on and three days off." d. "You should purchase dark glasses in case the light bothers your eyes."

"Treatment might be interrupted if areas of redness and tenderness develop." The nurse should instruct the client that treatment must be interrupted if areas of redness with edema and tenderness develop. Treatment can resume after these manifestations subside.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? a. Protein b. Calcium c. Vitamin B1 d. Vitamin D

Protein Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.

A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take? a. Apply a light layer of talcum powder with each diaper change. b. Change to cloth diapers until the skin is healed. c. Expose the excoriated area to hot air frequently. d. Use a moisturizer to wipe urine from the skin.

Use a moisturizer to wipe urine from the skin. It is appropriate for the nurse to use a moisturizer to wipe urine from the skin. This will prevent further breakdown of the skin.

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? a. A reddened area over the sacrum b. Stiffness in the lower extremities c. Difficulty moving the upper extremities d. Difficulty hearing some types of sounds

A reddened area over the sacrum A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? a. Instruct the client about home disposal of contaminated dressings. b. Schedule a follow-up visit by a home health nurse for dressing changes. c. Provide a dietary list of foods which promote wound healing. d. Establish a follow-up appointment with the client's provider.

Schedule a follow-up visit by a home health nurse for dressing changes. The greatest risk to this client is injury from a wound infection. Therefore, the priority action the nurse should take is to schedule a follow-up visit by a home health nurse for dressing changes. Wounds healing by secondary intention are open and have edges that are not approximated, which increases the risk for infection.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? a. Check the client's vital signs. b. Assess the client's pain level. c. Cover the wound with a moist, sterile gauze dressing. d. Obtain a culture and sensitivity of the wound drainage.

Cover the wound with a moist, sterile gauze dressing. The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

A school nurse conducting a screening for pediculosis capitis identifies several children who require treatment. Which of the following instructions should the nurse give the children's parents? a. Soak all combs and hairbrushes in alcohol. b. Inspect any dogs or cats at home for lice. c. Seal nonwashable items in airtight plastic bags. d. Spray countertops and sinks with insecticide.

Seal nonwashable items in airtight plastic bags. Parents should seal items they cannot wash, vacuum, or dry clean in airtight plastic bags for 14 days to kill any lice on them.