nurs310 exam 2
The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an "itching rash." Which question would be most important for the nurse to ask?
"Are you allergic to foods, medications, or other substances?"
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?
"Dehiscence is when a wound has partial or total separation of the wound layers."
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?
"Do you experience incontinence?"
The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?
"It provides a way to remove drainage and blood from the surgical wound."
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?
"That is necrotic tissue, which must be removed to promote healing."
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?
"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern?
"These are considered a normal age-related change in the skin."
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
"Very little scar tissue will form."
The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?
2
A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?
3
An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor?
Adipose tissue is poorly vascularized.
A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development?
Albumin 2.8 mg/dL (28.0 g/L)
The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?
Apply saline solution-moistened gauze over the protruding area
A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?
Assess the client's wound and vital signs.
A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma
Asymmetrical shape
A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area?
Broken with the presence of a blister
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
Clean the wound from the top to the bottom and from the center to outside.
A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?
Cushing's disease
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?
Dehiscence of the wound
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?
Discontinue the therapy and assess the client.
the nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?
Have a nurse who is the same sex as the client examine him
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?
Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:
Milia
A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?
Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?
Psoriasis, fungal infections, trauma
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen
A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have?
Tetanus, infection, wound care, and pain control
A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?
Tinea corporis
A 19-year-old construction worker presents for evaluation of a rash. He says that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He has been sweating more than before, because being outdoors is part of his job. Physical examination reveals dark tan and reddish patches with sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is the most likely diagnosis?
Tinea versicolor
What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?
To splint the area when engaging in activit
Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?
Urticaria or hives
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?
Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown
The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?
a client sitting in a chair who slides down
A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:
a rash related to a yeast infection.
The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?
a sterile, flexible applicator moistened with saline
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges
A client's tongue and oral mucosa are blue-tinged in color. What health problem should the nurse suspect this client is experiencing?
advanced lung disease
An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis?
alopecia
A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?
applying sterile dressings with normal saline over the protruding organs and tissue
The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola
the nurse prepares an educational program for the families of clients recovering from burns. whats the area where fat cells, blood vessels, and nerves are located
bottom of picture
A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?
braden scale
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?
chronic hypoxia
The nurse is admitting a 79-year-old man for outpatient surgery. The client has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?
client may have been abused
Hair follicles, sebaceous glands, and sweat glands originate from the
dermis
The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?
desiccation
When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse?
document the findings
The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?
dry and rough
The apocrine glands are stimulated by what?
emotional stress
The nurse's assessment of an adult female client reveals the presence of excessive hair on her face and chest. The nurse should plan further evaluation of which body system?
endocrine
The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause?
extensive collagen formation
A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?
fingers and toes
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?
fish
An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of
fissures
A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection?
foul-smelling drainage that is grayish in color
A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?
high
What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?
hydrocolloid
A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of
hypothyroidism
The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse?
hypoxia
While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of
hypoxia
A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?
iffuse dermatitis accompanied by pruritus
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?
incision
A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?
inspect
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of
macules
You are using the Braden Scale to measure risk factors for pressure sores. What risk factors will you assess? Select all that apply.
moisture, activity, nutrition
The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?
pressure ulcer
Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?
preventing the client from sliding in bed
A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?
psoriasis
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
removing dead or infected tissue to promote wound healing
An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?
sebum production
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that
squamous cell carcinomas are most common on body sites with heavy sun exposure.
A Penrose drain typically exits a client's skin through a ______ wound created by the surgeon.
stab
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?
stage 1 pressure injury
A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?
stage 2
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
stage 2
Connecting the skin to underlying structures is/are the
subcutaneous tissue
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?
transparent
An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?
transparent
To assess an adult client's skin turgor, the nurse should
use two fingers to pinch the skin under the clavicle.
What is the most important focus area for the integumentary system?
uv radiation exposure
The nurse is assessing a dark-skinned client whose forearms and hands have distinct regions of depigmentation. The nurse should document the presence of what health problem?
vitiligo
What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?
woods light
