Module 21 Tissue Integrity & 21.C

6) The nurse is assessing a client with a surgical wound. Which finding indicates that care has been effective for this client? A) The client's temperature is 100°F. B) The client performs wound care independently. C) There is only a scant amount of purulent drainage on the dressing. D) A small area of erythema and edema is present.

Answer: B Explanation: A) Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.

10) A patient with an allergy to latex develops contact dermatitis following an examination during which the nurse wore latex gloves. Which best describes the associated pathophysiology? A) An immune response that leads to issues with tissue integrity B) Impaired tissue integrity that leads to an immune response C) Impaired tissue integrity that leads to an infection D) Decreased perfusion that leads to issues with tissue integrity

Answer: A Explanation: A) Allergic reactions are an example of an immune response that leads to issues with tissue integrity. Impaired tissue integrity, such as a cut, can lead to an immune response, but that is not the case in this scenario. If left untreated or exposed to bacteria or other infectious agents, the dermatitis could lead to an infection, but there is no evidence of that in this scenario. Decreased perfusion can lead to tissue damage or death, but not dermatitis.

8) A nurse is working in a skilled nursing facility and is performing an assessment on an older adult client. The nurse notes that the client has hypopigmentation of the skin on both hands. The nurse should recognize that this condition is related to which age-related skin change? A) Hyperplasia of melanocytes B) Decreased perfusion of the dermis C) Increased permeability of the epidermal layer D) Hyperplasia of capillaries

Answer: A Explanation: A) Hypopigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.

14) Which of the following medications may be discontinued in a client who is experiencing delayed wound healing? A) Oral prednisone B) Topical antibiotics C) Topical growth factors D) Oral antibiotics

Answer: A Explanation: A) Oral prednisone is a steroid. Steroids are known to interfere with healing, so it is likely that use of these drugs may be discontinued. In contrast, topical and oral antibiotics may be appropriate for clients with delayed wound healing, because they can help prevent infection. Topical growth factors may also be applied to a wound in an attempt to "jump start" the healing process.

12) Hemostasis and phagocytosis are characteristic of which stage of the wound healing process? A) Inflammatory phase B) Proliferative phase C) Granulation phase D) Maturation phase

Answer: A Explanation: A) The inflammatory phase of wound healing is initiated immediately after injury and lasts 3-6 days. Two major processes occur during this phase: hemostasis and phagocytosis. The inflammatory phase is followed by the proliferative and maturation phases. There is not a granulation phase of wound healing, although formation of granulation tissue occurs during the proliferative phase.

7) A nurse educator is teaching a group of student nurses about newborn skin and factors that relate to this concept. Which statement will the educator include in the teaching session? A) "The newborn's skin is about 40% to 60% thinner than an adult's skin at birth." B) "The newborn's skin contains less water than an adult's and has tightly attached cells." C) "The newborn's thicker skin decreases absorption of harmful chemical substances and topical medications." D) "The newborn's skin has a greater percentage of underlying subcutaneous fat compared to adults."

Answer: A Explanation: A) The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin has less subcutaneous fat compared to adults.

8) A client has a wound on the left lateral aspect of the thigh. Which action by the nurse would best promote wound healing for this client? A) Positioning the client to keep weight off the wound B) Positioning the client with weight directly on the wound C) Restricting fluids D) Enforcing strict bedrest

Answer: A Explanation: A) To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation, and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.

2) A client recovering from abdominal surgery tells the nurse that "something popped" in his abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What actions by the nurse are appropriate? Select all that apply. A) Notify the client's surgeon. B) Pack the client's wound with nonadherent gauze. C) Turn the client onto his abdomen. D) Position the client in bed with his knees bent. E) Cover the incision with a large, saline-soaked dressing.

Answer: A, D, E Explanation: A) Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound, and the client should not be turned onto his abdomen.

4) A client is admitted to the hospital with a gunshot wound to the leg. Which nursing diagnosis is a priority? A) Situational Low Self-Esteem B) Risk for Infection C) Anxiety D) Ineffective Coping

Answer: B Explanation: A) A client with a gunshot wound is at risk for infection because the wound is severe and caused by trauma. The other nursing diagnoses may or may not be appropriate for the client at this time.

3) An older adult client diagnosed with chronic obstructive pulmonary disease (COPD) is scheduled for a total knee replacement. What should the nurse include in this client's plan of care to address the risk of an alteration in tissue integrity? A) Monitor urine output. B) Assess postoperative wound healing. C) Restrict protein intake. D) Expect purulent drainage.

Answer: B Explanation: A) Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. Furthermore, regardless of their chronic disease status, older adults often experience slowed healing as a result of normal cellular and molecular changes. Thus, it is critical that the nurse regularly assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need adequate protein for wound healing, so protein intake should not be restricted.

4) A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered? A) Skin biopsy B) Culture C) Wood's lamp D) Patch test

Answer: B Explanation: A) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.

11) Which statement about wound care across the lifespan is correct? A) "When applying transparent dressings on older adult clients, do not hold the skin taut, because doing so can cause damage." B) "In young children, staph bacteria and fungi are the most common causes of infection in minor wounds." C) "Pressure injuries and contact irritation are rare among newborns and infants in NICUs." D) "As compared to younger clients, older adults have a heightened inflammatory response, which can contribute to delayed wound healing."

Answer: B Explanation: A) Of these options, the only accurate statement is that the two major infectious agents affecting the skin of children are Staphylococcus and fungi. The rest of the statements are not valid. Specifically, the skin of older adult clients should be held taut when applying transparent dressings; pressure injuries and contact irritation are common among hospitalized newborns and infants; and older adults have a delayed inflammatory response as compared to younger clients.

11) What impact might corticosteroids have on tissue integrity? A) It may increase sensitivity to sunlight, leading to sunburns. B) It may cause thinning of the skin, making skin more easily injured. C) It may make skin appear shiny and lose its hair distribution. D) It may cause the skin to become overly dry.

Answer: B Explanation: A) Some medications, such as corticosteroids, cause thinning of the skin, making it much more easily damaged. Antibiotics, chemotherapy drugs, and some psychotherapeutic drugs increase sensitivity to sunlight and can predispose the individual to sunburns. Impaired peripheral arterial circulation in the lower extremities may produce skin that appears shiny and has lost its hair distribution. Excessive cleansing can cause the skin to become overly dry.

10) A nurse working in the intensive care unit (ICU) is caring for a client who is 10 days postoperative after open abdominal surgery. The client has a well-approximated midline surgical incision that has numerous staples, and the nurse notes a "healing ridge" is present. Based on this information, the incision is currently in which phase of the healing process? A) Inflammatory phase B) Proliferative phase C) Maturation phase D) Synthesis phase

Answer: B Explanation: A) The proliferative phase, which is the second phase in the healing process, extends from day 3 or 4 to about day 21 postinjury. If the wound is sutured, a raised "healing ridge" appears under the intact suture line. There is no synthesis phase in the healing process, and the other choices are incorrect.

1) The nurse is caring for an older adult. Which age-related changes should the nurse identify as increasing the risk of dry skin? Select all that apply. A) Reduction in elastin B) Depleted moisture in epidermal cells C) Decreased size of sebaceous glands D) Thinner subcutaneous skin layer E) Poor nutrition

Answer: B, C, E Explanation: A) As the individual ages, moisture transfer from the dermis to the epidermis declines. This contributes to a dry, rough skin appearance. Sebaceous glands also decrease in size with age, resulting in skin that is dry and easily bruised, damaged, or broken. Poor nutrition could also cause dry skin. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.

3) The nurse presses a finger into swollen skin tissue on a client's feet and ankles and notes that it creates an indentation. The nurse should correctly document a finding of which alteration in skin integrity? A) Poor turgor B) Ascites C) Peripheral edema D) Hypothermia

Answer: C Explanation: A) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Skin turgor is the skin's elasticity and is assessed by gently pinching the skin over the sternum or collarbone. Skin temperature is assessed through palpation.

9) What does the nurse anticipate finding in a client with impetigo? A) An infection in the hair follicles B) Loss of skin color in blotches or sections C) An itchy rash with clusters of fluid-filled vesicles D) A fungal infection in the skinfolds

Answer: C Explanation: A) Impetigo is a superficial skin infection common on the face, arms, and legs of children that presents as an itchy rash with clusters of fluid-filled vesicles that rupture easily. Ruptured vesicles develop a honey-colored crust over the lesions. Folliculitis is an infection of hair follicles. Vitiligo is a loss of skin color in blotches or sections that occur when the cells that produce melanin die or stop functioning. Candidiasis is a fungal infection commonly known as thrush and found in skinfolds.

2) The nurse observes flakes of greasy white dandruff in a client's hair. The nurse should correctly identify this as which type of secondary lesion? A) Nodule B) Macule C) Scales D) Crusts

Answer: C Explanation: A) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, to gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.

7) An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which intervention best addresses the client's nutritional needs? A) Assist with deep-breathing exercises. B) Medicate for pain prior to dressing changes. C) Request a dietary consult. D) Encourage ambulation.

Answer: C Explanation: A) The nurse should consult with a dietitian to identify ways to improve the client's intake to support wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.

12) A nurse is conducting a skin assessment of a patient. Upon palpating skin temperature, the nurse notes the skin is warm and red. This is an abnormal sign that may be indicative of A) decreased hydration. B) decreased blood flow to the skin. C) inflammation and elevated body temperature. D) hypothyroidism.

Answer: C Explanation: A) Warm, red skin indicates inflammation and elevated body temperature. Decreased skin temperature is indicative of decreased blood flow to the skin. Excessively dry skin is indicative of hypothyroidism. Poor skin turgor is indicative of decreased hydration.

9) A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate. Three days after the debridement, the client's surgical wound was closed with staples that are aiding in healing. Given this information, which of the following terms should the nurse use when documenting this client's care? A) Primary intention healing B) Secondary intention healing C) Tertiary intention healing D) Quaternary intention healing

Answer: C Explanation: A) Wounds that are left open for 3-5 days to allow edema or infection to resolve or to permit exudate to drain and then are closed with sutures, staples, or adhesive skin closures undergo tertiary intention healing. Primary intention healing occurs where tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.

1) A client has a laceration that was closed with tissue adhesive. By what process will this wound heal? A) Tertiary intention B) Secondary intention C) Delayed primary intention D) Primary intention

Answer: D Explanation: A) In primary intention wound healing, the edges of the wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds. Secondary intention healing involves wounds that cannot be approximated and that must "heal in." These wounds are at higher risk for infection, take longer to heal, and are more prone to scarring. With tertiary intention healing, also called delayed primary intention healing, wounds are left open for 3 to 5 days to allow edema or infection to resolve before being closed by sutures, staples, or adhesive skin closures.

13) Which of the following findings suggests that a wound is infected with pyogenic bacteria? A) Sanguineous exudate B) Serous exudate C) Serosanguineous exudate D) Purulent exudate

Answer: D Explanation: A) Purulent exudate is more commonly called pus, and it is created by microorganisms known as pyogenic bacteria. In contrast, sanguineous exudate consists of large amounts of red blood cells; serous exudate is clear or straw colored and has few cells; and serosanguineous exudate consists of both clear and blood-tinged drainage.

5) A middle-age adult client states to the nurse, "I do not want to have brown spots on my skin like my parents did as they got older." Which instruction by the nurse is appropriate? A) Spend at least 15 minutes each day in the sun. B) Increase the intake of calcium. C) Increase the intake of dietary fat. D) Avoid the sun or use a sunscreen to reduce skin damage.

Answer: D Explanation: A) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun. The intake of dietary fat or calcium will not affect the development of liver spots.

5) The nurse is planning care for a client with a surgical wound. Which goal related to the surgical wound is most appropriate for this client? A) The client will discharge to home as soon as possible. B) The client will resume independent activities of daily living (ADLs). C) The client will increase ambulation. D) The client will regain intact skin.

Answer: D Explanation: A) This client has impaired skin integrity because of a surgical wound. An appropriate goal of care would be for the client to experience wound healing to achieve intact skin. For a client who otherwise has good health, the other goals are appropriate, but they are not directly related to the surgical wound. However, for some patients, discharge to home, resuming independent ADLs, and increasing ambulation may not be appropriate goals.

6) The nurse is providing care to a client who is experiencing skin inflammation and pruritus. Which of the following medications does the nurse anticipate will be prescribed for this client? Select all that apply. A) Erythromycin B) Bacitracin C) Gentamycin D) Desoximetasone E) Desonide

Answer: D, E Explanation: A) Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.