AH I Final - Skin Integrity

A nurse is describing the concept of habilitation to a group of families who have members in need of these services. Which of the following statements would the nurse include in this description?

"Habilitation focuses on the person's abilities."

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?

Stage III

A type of therapeutic exercise performed by the patient where the muscle contracts and relaxes is

isometric.

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

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

The nurse is performing a skin assessment on a bedbound patient who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than which of the following timeframes?

1 hour

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance

An elderly woman diagnosed with osteoarthritis has been referred for care. The patient has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention may the nurse use to best promote the patient's mobility?

Administer an analgesic as ordered to facilitate the patient's mobility.

An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patient's healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?

Albumin

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity

Which nursing intervention can help a client maintain healthy skin?

Keeping the client well hydrated

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

Lubricating the skin with a non-irritating lotion

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

Moisture

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

Nutrition support and orthotics

A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter?

Overall risk of developing pressure ulcers

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation?

Priority setting is helpful in dealing with the impact of the disability.

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair?

Protein

A nurse is caring for a client who requires a wheelchair. Which piece of equipment impedes circulation to the area it's meant to protect?

Ring or donut

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage II pressure ulcer

You have been referred to the care of an extended care resident who has been diagnosed with a stage III pressure ulcer. You are teaching staff at the facility about the role of nutrition in wound healing. What would be the best meal choice for this patient?

Steak, baked potato, spinach and strawberry salad

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?

Turning the client every 2 hours and providing a low-air-loss mattress

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing?

Vitamin C

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:

document the condition of the client's skin.

You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers?

Post a turning schedule at the patient's bedside and ensure staff adherence.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

• Edema • Anemia • Diaphoresis