EAQs Integ

A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at what angle? 1. 30 degrees 2. 45 degrees 3. 60 degrees 4. 90 degrees

1. 30 degrees Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Forty-five degrees, 60 degrees, and 90 degrees raise the head of the bed too high, which contributes to the client sliding down in bed.

A nurse is caring for a client who has a disturbed body image as a result of a burn injury. Which is an important nursing intervention for this client? 1. Conveying a positive attitude toward the client 2. Arranging for the client to meet other clients with burns 3. Removing mirrors until the client's physical appearance has improved 4. Reminding family members to avoid comments about the client's appearance

1. Conveying a positive attitude toward the client Acceptance and a positive attitude by those in contact with the client will support the development of a positive body image by the client. Eventually the client may meet with other clients with burns, but this is not the priority. Removing mirrors from the environment is unrealistic. Avoidance of comments about the client's appearance is an unrealistic expectation.

A client with burns is prescribed polymixin by the primary healthcare provider. Which action should the nurse take? 1. Apply the drug every 2-8 hours 2. leave in place for 7 days 3. use the druge with barrier dressing 4. Refrain from using with oil-based products

1. Apply the drug every 2-8 hours Polymixin should be applied every 2-8 hours to keep the affected area moist. PolyMem, a dressing material containing silver granules, should be left in place for 7 days. Collagenase with polysporin powder can be applied once a day and can be used with barrier dressing such as xeroform. Acticoat should not be used with oil-based products.

While assessing the skin of an older adult, the nurse finds redundant flesh around the eyes. Which changes in the skin are responsible for this condition? Select all that apply. 1. Decrease in muscle laxity 2. Increase in capillary fragility 3. Decrease of subcutaneous fat 4. Decrease of extracellular water 5. Increase in focal melanocytes in basal layer

1. Decrease in muscle laxity 3. Decrease of subcutaneous fat Redundant flesh around the eyes is due to a decrease in muscle laxity and a decrease of subcutaneous fat. Bruising is due to an increase in capillary fragility. Dry, flaking skin with possible signs of excoriation is due to a decrease of extracellular water. Solar lentigines on the face and backs of hands are due to an increase in focal melanocytes in the basal layer.

A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist does what? 1. Helps health care providers to control infections 2. Decides what antibiotics should be prescribed for infections 3. Works in the laboratory identifying bacteria that cause infection 4. Is responsible for collecting specimens of potentially infectious drainage

1. Helps health care providers to control infections The nurse epidemiologist helps to devise an infection control strategy. The role of a primary health care provider is to decide what antibiotics should be prescribed for infections. The role of the laboratory technician or technologist is to work in the laboratory to identify bacteria causing infections. The nurse usually is responsible for collecting specimens of potentially infectious drainage.

A client is diagnosed with a dysfunction of the eccrine gland. Which physiologic abnormality might occur in the client? Select all that apply. 1. Drying of hair 2. Drying of surface cells 3. Decreased synthesis of vitamin D 4. Decreased efficiency to cool the body 5. Decreased excretion of waste products through the skin

2. Drying of surface cells 4. Decreased efficiency to cool the body 5. Decreased excretion of waste products through the skin The eccrine gland is a sweat gland, the main functions of which are to moisturize the surface cells, cool the body by evaporation, and excrete waste products through the pores of the skin. Therefore dysfunction of the eccrine gland may result in drying of surface cells, decreased efficiency to cool the body, and decreased excretion of waste products through the skin. The sebaceous gland secretes sebum, which prevents drying of hair and skin. Therefore dysfunction of the sebaceous gland may lead to drying of hair and skin. Endogenous synthesis of vitamin D occurs by the action of UV light on vitamin D precursors in epidermal cells. Therefore dysfunction of the eccrine gland may not be associated with decreased vitamin D synthesis.

The registered nurse (RN) delegates the tasks of caring for a client with pressure ulcers. The client suffers further tissue necrosis during treatment. What could be the reason for this condition? 1. Cleaning of the wound by the registered nurse (RN) 2. Performing irrigation of the wound by the patient care associate (PCA) 3. Administering of oral analgesics by the licensed practical nurse (LPN) 4. Repositioning the client every 1-2 hours by the licensed practical nurse (LPN)

2. Performing irrigation of the wound by the patient care associate (PCA) The patient care associate (PCA) is not authorized to irrigate the wound as improper technique can lead to tissue damage. The RN is qualified to perform wound care; therefore, cleaning the wound is not likely to lead to tissue necrosis. Pressure ulcers are associated with pain. The LPN administering oral analgesics may relieve the pain, but it will not cause tissue necrosis. Having the licensed practical nurse (LPN) reposition the client every 1 or 2 hours will minimize the risk of tissue necrosis due to pressure ulcers.

Which topical immunomodulator is used to treat a client with atopic dermatitis? 1. Mupirocin 2. Tacrolimus 3. Clindamycin 4. Erythromycin

2. Tacrolimus Tacrolimus is used to treat atopic dermatitis. Mupirocin is used to treat impetigo. Clindamycin and erythromycin are used to treat acne vulgaris.

Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? 1. The nurse should minimize the use of tape on the skin. 2. The nurse should keep the client adequately hydrated. 3. The nurse should change the dressings as soon as they get wet. 4. The nurse should provide rest for the client throughout the day.

2. The nurse should keep the client adequately hydrated. The best practice of the nurse to improve perfusion of the wound to promote healing for an older client after surgery is to keep the client adequately hydrated. The nurse should minimize the use of tape on the skin to protect the fragile skin of the client. The nurse should also change the dressing as soon as they get wet during the protection of fragile skin. The nurse should provide rest to the client throughout the day to conserve the energy required for healing.

A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. The nurse calculates that the rate of intravenous (IV) fluid for the first 8 hours should be: Record your answer using a whole number. __________ mL/hr

450 mL/hour For fluid resuscitation for a burn client, half of the prescribed fluid should be administered during the first 8 hours. For this client 7200 mL/2 = 3600 mL for the first 8 hours. Then divide 3600 ml/8 hours = 450 mL/hour.

A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath? 1. 92° to 94° F 2. 95° to 97° F 3. 98° to 100° F 4. 101° to 103° F

3. 98° to 100° F

A client has a fracture of the tibia and a cast is applied. What should the nurse do when caring for the client? 1. Cover the cast with plastic wrap until dry 2. Assist with weight bearing when the client ambulates 3. Elevate the affected leg above the level of the heart 4. Insert a finger inside the edges of the cast to check for skin abrasions

3. Elevate the affected leg above the level of the heart Elevating the affected leg will help reduce the formation of edema via the principle of gravity. Plastic wrap holds moisture and will interfere with drying of the cast. Full weight bearing should not start until prescribed by the health care provider. Nothing should be inserted under the cast; this can cause tissue injury.

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is what? 1. 20 2. 25 3. 30 4. 36

4. 36 Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% for both arms) and 18% for the chest; thus the total body surface area burned is 36%. Twenty percent, 25%, and 30% are too low.

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? 1. Readiness to discuss the client's deformities 2. Indication of a change in family relations 3. Need for more time to think about the future 4. Beginning realization of implications for the future

4. Beginning realization of implications for the future Once survival needs are met and pain diminishes, there is a realization of lifestyle alterations in the future. The client is not talking about deformities; the client is beginning to realize the implications of going home. Information is not adequate to indicate a change in family relations. The client is expressing a realistic concern and needs to talk about the future.

A nurse is caring for a client with chronic occlusive arterial disease. Which precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions? 1. Emotional stress, which is short lived 2. Poor hygiene and adequate protein intake 3. Stimulants such as coffee, tea, or cola drinks 4. Trauma from mechanical, chemical, or thermal sources

4. Trauma from mechanical, chemical, or thermal sources Diminished sensation decreases awareness of injury. Injured tissue cannot heal properly because of cellular deprivation of oxygen and nutrients; ulceration and gangrene may result. Emotional stress does not cause tissue injury; however, because of vasoconstriction, it may prolong healing. Inadequate hygiene is only one stress that may cause tissue trauma; adequate protein is not related to this disease. Although caffeine stimulates the peripheral vessels to constrict, limiting oxygen to cells, it is not the major cause of ulceration.