Week 8 Skin Integrity: Assess and Recognize Cues; Analyze Cues and Prioritize Hypotheses; Plan and Generate Solutions

Which statements by the nurse caring for a postoperative patient who suffered a spinal cord injury indicate correct understanding about assessment tools? Select all that apply. "I can use the Braden Scale to assess for the risk for infection." "The Norton Scale is used to assess for pressure injury risk." "I can use the Braden Scale to assess my patient's surgical incision." "When assessing for open wounds, I can use the Wound Characteristic Instrument." "The Pressure Ulcer Scale for Healing tool is used to track wound healing."

"I can use the Braden Scale to assess for the risk for infection."The Braden Scale is a tool used to assess risk for developing pressure injuries, not for developing wound infections. **"The Norton Scale is used to assess for pressure injury risk."The Norton Scale is a tool used to assess risk for developing pressure injuries, and it indicates a correct understanding about assessment tools. "I can use the Braden Scale to assess my patient's surgical incision."The Braden Scale is a tool used to assess risk for developing pressure injuries, not to assess surgical incisions. **"When assessing for open wounds, I can use the Wound Characteristic Instrument."Wound Characteristic Instrument is a tool used to assess open wounds and to track wound healing. "The Pressure Ulcer Scale for Healing tool is used to track wound healing."The Pressure Ulcer Scale for Healing (PUSH) is an instrument to track pressure injury healing (not wound healing), and it assigns a numerical score based on three characteristics.

Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound? "My participation is not needed for position changes." "I will be infection-free by the time I go home." "I will need to meet with the mental health professional before discharge." "My wound will look beefy red within 1 week."

"My participation is not needed for position changes."The patient's participation is needed for position changes; this statement does not indicate successful teaching. "I will be infection-free by the time I go home."The wound is healing and should not become infected while the patient is in the hospital. The wound should be infection-free the entire time the patient is in the hospital. "I will need to meet with the mental health professional before discharge."There is no indication that the patient is experiencing emotional issues related to the wound; thus, this requirement is unnecessary. Correct "My wound will look beefy red within 1 week."If the wound looks beefy red within 1 week, that indicates granulation tissue is forming and the wound is healing, which is normal. This statement indicates successful teaching.

Which cues would the nurse observe for a patient with an infected lateral malleolus wound? Select all that apply. Erythema noted on the superior portion of the wound Purulent, malodorous drainage 1.5-cm wound with serous drainage and tissue epithelialization Temperature of 102°F (38.9°C) Pain level of 2/10

**Erythema noted on the superior portion of the woundErythema of the superior portion of the wound indicates the wound may be infected. **Purulent, malodorous drainagePurulent, malodorous drainage is a sign of an infected wound. 1.5-cm wound with serous drainage and tissue epithelializationA 1.5-cm wound with serous drainage and tissue epithelialization is a normal finding. Serous drainage is clear and watery fluid from plasma. None of these findings indicates an infection. **Temperature of 102°F (38.9°C)A temperature of 102°F (38.9°C) is a sign of an infection, and it would be a cue that the nurse observes. Pain level of 2/10The patient's pain level would be increasing; it would not be a 2.

Match the unexpected skin assessment finding to its description. 1-Blue skin 2-Pinpoint, flat, red spots 3-Red skin 4-Bruise A-Cyanosis B-Jaundice C-Purpura D-Petechiae E-Ecchymosis F-Erythema

1-A 2-D 3-F 4-E

Match the wound bed condition to its cues. 1-Pale, soft, wrinkled 2-Beefy red, shiny, moist 3-Black, hard, dry 4-Purulent yellow A-Necrotic B-Macerated C-Infected D-Granulated

1-B 2-D 3-A 4-C

Match the type of wound drainage to the color of fluid the nurse would observe on a patient's dressing. 1-Clear and watery 2-Pink to pale red 3-Bright red 4-Greenish, yellow A-Serosanguineous B-Sanguineous C-Serous D-Purulent

1-C 2-A 3-B 4-D

Which Braden Scale score range would alert the nurse that a patient is at moderate risk for pressure injury development? Record your answer as whole numbers separated by a hyphen. Use numbers only.

13-14 If the patient is at moderate risk for pressure injury development, the Braden score will be 13‐14.

Which assessment technique indicates the nurse properly determined if the patient's incision is healing or is becoming infected? Asking the patient health history questions Charting the incision line's color and tenderness Removing all sutures and/or staples around the wound Palpating the area of induration around the incision line

Asking the patient health history questionsAlthough asking the patient health history questions is a component of assessment, it will help determine past medical information, not whether the patient's incision is healing or becoming infected. Charting the incision line's color and tendernessCharting the incision line's color and tenderness will not help determine if the incision is healing or becoming infected. The nurse must observe and palpate. Removing all sutures and/or staples around the woundRemoving all sutures and/or staples around the wound is not the best way to assess how the incision is healing, as the staples and sutures may need to stay in place to keep the wound closed. Correct Palpating the area of induration around the incision linePalpating the area of induration is an effective way to assess if an incision is healing or becoming infected; an infected incision will have induration (hardness) around the incision.

Which patient situations are of immediate concern? Select all that apply. A patient is experiencing shock. A patient is profusely bleeding from a wound. A patient has an infected wound. A patient has an eviscerated wound. A patient has a stage 4 pressure injury.

Correct A patient is experiencing shock.A patient experiencing shock is of immediate concern because the condition is life-threatening. Correct A patient is profusely bleeding from a wound.A patient who is bleeding profusely is of immediate concern because the situation is life-threatening. A patient has an infected wound.A patient with an infected wound is of urgent concern, but not an immediate concern because an infected wound is not life-threatening. Correct A patient has an eviscerated wound.A patient who has an eviscerated wound is of immediate concern because the situation is a medical emergency. A patient has a stage 4 pressure injury.A patient with a stage 4 pressure injury is not of immediate concern because a stage 4 pressure injury is not life-threatening.

Which factors can place a patient at risk for a pale, dry wound? Select all that apply. Anemia Diabetes Wound infection Vascular disease Nutritional deficiencies

Correct AnemiaWhen a wound bed is pale or dry, it can indicate anemia, which is when the blood does not contain enough red blood cells. Correct DiabetesDiabetes can contribute to a nonhealing wound that presents with a pale, dry wound bed. Wound infectionWound infection would not result in a pale, dry wound bed. Warmth, redness, and increased drainage may be present. Correct Vascular diseaseVascular disease can be a contributing factor that presents with a pale, dry wound bed because of the decreased perfusion to the wound. Correct Nutritional deficienciesNutritional deficiencies can cause a wound bed to be dry and pale. Nutritional deficiencies can delay wound healing.

Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity? Select all that apply. Bone Tendon Muscle Dermis Epidermis

Correct BoneBone is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate. Correct TendonTendon is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate. Correct MuscleMuscle is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate. DermisDermis is skin, and it would not be a primary area that would be damaged. Dermis is damaged in Impaired Skin Integrity, not Impaired Tissue Integrity. EpidermisEpidermis is skin, and it would not be a primary area that would be damaged. Epidermis is damaged in Impaired Skin Integrity, not Impaired Tissue Integrity.

Which cues related to skin integrity may reflect an overall health problem? Select all that apply. Cracking Tenting Warm skin temperature Pathogens identified in a wound culture Immunocompetence

Correct CrackingExtreme dryness or cracking adversely affects skin integrity, indicating an overall health problem. Correct TentingTenting indicates the patient is dehydrated and reflects an overall health problem. Warm skin temperatureWarm skin temperature is expected, and it indicates healthy skin integrity, not an overall health problem. Correct Pathogens identified in a wound cultureA wound with pathogens indicates an infection, which is an overall health problem. ImmunocompetenceImmunocompetence indicates good health, not an overall health problem. Immunocompromise indicates an overall health problem.

Which term would the nurse use to describe excessive moisture on the patient's skin? Diaphoresis Ashen Purpura Icterus

Correct DiaphoresisDiaphoresis is excessive moisture on the patient's skin, and it is usually visible to the nurse and patient. AshenAshen describes a greyish skin color, not excessive skin moisture. PurpuraPurpura describes a patch of purplish-red discoloration that is larger than petechiae but smaller than a bruise; it does not indicate excessive skin moisture. IcterusIcterus is a yellow skin color, not excessive moisture on the skin.

For which patient hypotheses would the nurse select turning and positioning as a solution? Select all that apply. Impaired Skin Integrity Risk for Pressure Ulcer/Injury Malignant Wound Impaired Tissue Integrity Risk for Impaired Skin Integrity

Correct Impaired Skin IntegrityTurning and positioning is a solution for Impaired Skin Integrity. Correct Risk for Pressure Ulcer/InjuryTurning and positioning is a solution for Risk for Pressure Ulcer/Injury. Malignant WoundTurning and positioning is not a solution for Malignant Wound; specific wound care is needed. Correct Impaired Tissue IntegrityTurning and positioning is a solution for Impaired Tissue Integrity. Correct Risk for Impaired Skin IntegrityTurning and positioning is a solution for Risk for Impaired Skin Integrity.

Which interpretation would the nurse make about a patient's wound culture that is positive? It is infected. It is hemorrhaging. It is eviscerated. It is nonhealing.

Correct It is infected.A positive wound culture indicates the patient's wound is infected. It is hemorrhaging.A positive wound culture does not indicate hemorrhage, which is excessive bleeding. It is eviscerated.A positive wound culture does not indicate evisceration. A wound that has eviscerated has opened and is exposing internal organs. It is nonhealing.A positive wound culture does not indicate a nonhealing wound. A nonhealing wound is not progressing through the phases of healing.

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity? Select all that apply. Low prealbumin levels Immobility Inexperience with wound care Stage 2 pressure injury Stage 4 pressure injury

Correct Low prealbumin levelsLow prealbumin level is a cue for Impaired Skin Integrity because it can affect healing. Correct ImmobilityImmobility is a cue for Impaired Skin Integrity because it can lead to prolonged pressure. Inexperience with wound careInexperience with wound care is a cue for inadequate knowledge of wound care, not Impaired Skin Integrity. Correct Stage 2 pressure injuryA stage 2 pressure injury is a cue for Impaired Skin Integrity because it affects the epidermal and dermal layers of the skin. Stage 4 pressure injuryA stage 4 pressure injury is a cue for Impaired Tissue Integrity, not Impaired Skin Integrity, because it affects subcutaneous tissue and underlying tissue of bone, tendon, muscle, and cartilage.

Which steps would the nurse take to measure the dimensions of a sacral pressure injury? Select all that apply. Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. Measure the width laterally from left to right at the widest portion of the wound. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. Measure the length vertically from the top to the bottom at the widest open area of the wound. Measure the width laterally by using a clean cotton-tipped applicator at the largest portion of the wound from left to right.

Correct Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound.The depth of a wound is found by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. Correct Measure the width laterally from left to right at the widest portion of the wound.The width is found by measuring laterally from left to right at the widest portion of the wound. Correct Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining.The depth of the undermining constitutes part of measuring the depth of the wound, and it is found by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. Correct Measure the length vertically from the top to the bottom at the widest open area of the wound.The length of a sacral pressure injury is determined by measuring vertically from the top to the bottom at the widest open area of the wound. Measure the width laterally by using a clean cotton-tipped applicator at the largest portion of the wound from left to right.Although it is correct to use a cotton-tipped applicator to measure the dimensions of a sacral pressure injury, the applicator must be sterile, not clean.

Which patient is likely at risk for developing a pressure injury? Patient with unrelieved pressure who has a fractured hip Patient with a history of sports-related injuries and concussions Left-handed patient with a broken left wrist Paralyzed patient who is being turned and repositioned every 2 hours

Correct Patient with unrelieved pressure who has a fractured hipThe patient with unrelieved pressure is most at risk for developing a pressure injury, because tissue ischemia can form and lead to pressure injuries. Patient with a history of sports-related injuries and concussionsThe patient with a history of sports-related injuries and concussions is not at risk for developing a pressure injury, although this patient may be at risk for other types of skin integrity conditions. Left-handed patient with a broken left wristThe left-handed patient with a broken left wrist is not likely to develop a pressure injury. The question of hand dominance has no bearing on the development of a pressure injury. Paralyzed patient who is being turned and repositioned every 2 hoursThe paralyzed patient who is being turned and repositioned every 2 hours is not at risk for developing pressure injuries because of the consistent turning and repositioning schedule.

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound? Select all that apply. Repositioning the patient Administering medication for wound pain Assessing and evaluating a patient's skin and wounds Reporting any changes in patient's skin integrity or condition Applying a nonsterile dressing for chronic wounds with an established treatment plan

Correct Repositioning the patientRepositioning the patient is a task the UAP can perform for a patient with a wound. Administering medication for wound painThe UAP cannot administer medications for pain; this is a nursing responsibility. Assessing and evaluating a patient's skin and woundsAssessing and evaluating a patient's skin and wounds are nursing responsibilities; they cannot be delegated. Correct Reporting any changes in patient's skin integrity or conditionThe UAP can report any changes in the patient's skin condition or integrity to the nurse. Correct Applying a nonsterile dressing for chronic wounds with an established treatment planApplication of nonsterile dressings for chronic wounds with an established treatment plan is a task the UAP can perform.

Which hypothesis would the nurse develop for an immobile patient who has intact skin? Risk for Impaired Skin Integrity Traumatic Wound Risk for Impaired Tissue Integrity Pressure Ulcer/Injury

Correct Risk for Impaired Skin IntegrityBecause the patient is immobile but still has intact skin, the hypothesis is a Risk for Impaired Skin Integrity. Traumatic WoundTraumatic Wound is inappropriate because the patient has intact skin; there is no evidence of a wound. Risk for Impaired Tissue IntegrityAlthough Risk for Impaired Tissue Integrity is a "risk for" hypothesis, the patient would have altered skin integrity before altered tissue integrity. Pressure Ulcer/InjuryPressure Ulcer/Injury is inappropriate because the patient still has intact skin. The appropriate hypothesis is a "risk for" hypothesis.

Which factors may impact the development of pressure injuries or nonhealing wounds? Select all that apply. Smoking Diabetes Specific gender Urinary incontinence Skin tone

Correct SmokingSmoking can contribute to development of a nonhealing wound by causing vasoconstriction. Correct DiabetesDiabetes alters circulation of blood, oxygen, and nutrients to skin and body tissues, and it can contribute to nonhealing wounds. Specific genderA specific gender has no effect on either pressure injuries or a nonhealing wound. All genders can be affected by pressure injuries and nonhealing wounds. Correct Urinary incontinenceUrinary incontinence may cause skin breakdown and lead to the development of pressure injuries. Skin should always be kept clean and dry. Skin toneSkin tone is not a factor that impacts the development of pressure injuries or nonhealing wounds.

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days? Select all that apply. Therapies consistent with guidelines for treatment of wounds Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) Ability of the patient to maintain a pain rating of 8/10 during activities of daily living Agreement of the patient with the treatment plan Capability of the patient to purchase supplies for home care as required

Correct Therapies consistent with guidelines for treatment of woundsTherapies consistent with guidelines for treatment of wounds and pressure injuries are an appropriate component to include. Correct Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN)Recommendations from collaborating health care professionals, such as a WOCN, are appropriate components to include. Ability of the patient to maintain a pain rating of 8/10 during activities of daily livingAbility of the patient to maintain a pain rating of 8/10 during activities of daily living is inappropriate. The patient would be in too much pain to complete activities of daily living. Correct Agreement of the patient with the treatment planThe patient should agree with the established treatment plan to encourage compliance, and this agreement would be included. Correct Capability of the patient to purchase supplies for home care as requiredCapability of the patient to purchase supplies for home care is an appropriate component of care to include.

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum? Select all that apply. Wound, ostomy, and continence nurse (WOCN) Social worker Surgeon Nutritionist X-ray technician

Correct Wound, ostomy, and continence nurse (WOCN)A WOCN would be consulted in this situation to ensure proper healing of the pressure injury. Correct Social workerA social worker would be part of the collaboration team in this situation to ensure the homeless patient has access to community resources and finances. SurgeonA surgeon does not need to be consulted yet, as wounds are only in stage 2. Correct NutritionistA nutritionist should be consulted because the patient is thin. X-ray technicianAlthough the x-ray technician is an employee, the technician is not a multidisciplinary team member.

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat? Ingest 25% of each meal during hospitalization. Report that pain management regimen lowers pain level to 6/10 or lower within the shift. Show acceptance of the change in body image by continuing to have the nurse change the dressing after 1 week. Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

Ingest 25% of each meal during hospitalization.It is not sufficient for a patient who is not hungry to ingest 25% of meals. The percent should be higher (at least 50% or more). Report that pain management regimen lowers pain level to 6/10 or lower within the shift.Reporting that pain management regimen reduces pain to 3/10 or lower (not 6/10 or lower) within the shift is a more appropriate outcome. Show acceptance of the change in body image by continuing to have the nurse change the dressing after 1 week.To show acceptance of change in body image, the patient should be helping with dressing changes within 1 week. Correct Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.Because the overall outcome is healing of the wound, this outcome demonstrates progressive healing of wound.

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Patient who just had an incision eviscerate Patient with a stage 4 pressure injury Patient who is experiencing shock from a profusely bleeding wound

Patient who is experiencing shock from a profusely bleeding wound Patient who just had an incision eviscerate Patient with a stage 4 pressure injury The patient experiencing shock from a profusely bleeding wound is seen first because this is life-threatening, and the wound is bleeding (ABCs). Next is the patient with an evisceration; although still a medical emergency, it is not as critical as active bleeding. The patient with a stage 4 pressure injury is seen last because it is a chronic condition.

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound? Select all that apply. Patient will be infection-free. Patient will eat a high-protein diet at every meal. Patient will help with transfers within 24 hours. Patient's wound will heal normally. Patient's incision will have proper healing.

Patient will be infection-free.A SMART outcome has a time parameter; this outcome of being infection-free has no time parameter. Correct Patient will eat a high-protein diet at every meal.A SMART outcome is specific, measurable, achievable, and relevant (high-protein diet). It also must have a time frame (at every meal). Correct Patient will help with transfers within 24 hours.A SMART outcome is specific, measurable, achievable, and relevant (help with transfers). It also must have a time frame (within 24 hours). Patient's wound will heal normally."Normally" is not measurable, making it an invalid SMART outcome. Also, there is no time frame and no way to measure the healing. Patient's incision will have proper healing."Proper healing" is not measurable, making it an invalid SMART outcome. Also, there is no time frame and no way to measure the healing.

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident? Patient's pressure injury will decrease at least 1 to 2 cm in size per week. Patient's wound will exhibit granulation tissue in the wound by 1 week. Patient will demonstrate wound care after receiving teaching. Patient will have intact skin throughout hospital stay.

Patient's pressure injury will decrease at least 1 to 2 cm in size per week.Pressure injuries are a result of prolonged pressure and tissue ischemia, not trauma or accidents; thus, this goal would not directly relate to a break in the skin from external forces. Correct Patient's wound will exhibit granulation tissue in the wound by 1 week.A break in the skin from external forces, such as trauma or an accident, indicates a wound; thus, this goal would directly relate to the break in skin from external forces. Patient will demonstrate wound care after receiving teaching.While it is appropriate for a patient to demonstrate wound care after receiving teaching, this goal does not relate directly to a break in the skin from external forces; it relates to inadequate knowledge. Patient will have intact skin throughout hospital stay.The patient cannot have intact skin because there is already a break in the patient's skin from external forces; thus, this outcome would not directly relate to the break in skin from external forces.

Which type of fluid would the nurse likely observe if the patient was hemorrhaging? Serous Serosanguineous Sanguineous Purulent

SerousSerous fluid (clear and watery) would not be observed in hemorrhaging. SerosanguineousSerosanguineous fluid (pink to pale red) would not be observed in hemorrhaging. **SanguineousSanguineous fluid is bright red, and it indicates bleeding that is observed in hemorrhaging. PurulentPurulent fluid (greenish, yellow, or beige) would not be observed in hemorrhaging but would be observed in an infection.

Which reasoning explains why a nurse measures wound size during an initial wound assessment? To determine the proper medication amount for the wound To help assess progression of wound healing To provide evidence for the presence of infection To reassure patients they are receiving proper care

To determine the proper medication amount for the woundWound size has no direct relation to medication amount; medication and dosing are prescribed by the health care provider. Correct To help assess progression of wound healingMeasuring wound size helps assess the progression of wound healing. As the wound heals, it becomes smaller. To provide evidence for the presence of infectionThe size of the wound does not indicate whether a wound is infected. Other factors determine infection. To reassure patients they are receiving proper careAlthough wound assessments can reassure patients, this is not the reason a nurse measures the wound size.