Skin Integrity/ Stages of Pressure Ulcers and hygiene

Reddened area over the left sacral area does not blanch with lightly applied pressure. Epidermal skin is intact. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

Stage 1

3. Which nursing action is essential when providing foot care? a. Wash distal to proximalb. Soak the feet in a basin c. Dry between the toes d. Massage with lotion

c. Dry between the toes

4. What should the nurse check before shaving a patient? a. An electric razor is available b. There is a doctor's order for it c. The patient is on anticoagulants d. The family would like to shave the patient

c. The patient is on anticoagulants

1. A circumcised male patient needs pericare. What should the nurse do? a. Retract the foreskin to clean the glans b. Wash the shaft with short gentle strokes c. Wear sterile gloves during the procedure d. Let the patient do as much as possible

d. Let the patient do as much as possible star material

Reddened area over the left heel does not blanch with light applied pressure. No underlying area of purple or maroon discoloration is noted. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

A. Stage 1

A client being mechanically ventilated has an arterial blood gas analysis that indicates respiratory acidosis. Which change in ventilator settings should the nurse anticipate? 1. Decrease in oxygen delivery 2. Decreased tidal volume of each breath 3. Increased respiratory rate 4. Increase in humidification of inspired air

Answer: 3 Explanation: This client needs to "blow off" more CO2, therefore the respiratory rate would be increased.

A client has a reddened area over the coccyx that disappears after an hour. In which way should the nurse document this area? 1. Reactive hyperemia 2. Stage 1 pressure injury 3. Stage 2 pressure injury 4. Stage 3 pressure injury

Answer: 1 Explanation: If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred.

Upon assessing a pressure injury, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan? 1. Red 2. Yellow 3. Black 4. A combination of all three

Answer: 3 Explanation: When using the RYB color code to guide wound care for a wound that contains more than one of the colors, the nurse plans care for the most serious color, in this case black.

A client has a wound that is going to heal through secondary intention. When instructing the client about this wound, the nurse would include which statements? (Select all that apply.) 1. Minimal tissue loss. 2. Closure of the wound will occur within 5 days. 3. Healing time will be longer. 4. Potential for scarring is greater. 5. Susceptibility to infection is greater.

Answer: 3, 4, 5 Explanation: In secondary intention healing, the repair time is longer. In secondary intention healing, the scarring is greater. In secondary intention healing, the susceptibility to infection is greater.

The nurse has established an expected outcome that the client will demonstrate healing of a stage 2 pressure injury over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome? 1. The rubber doughnut pressure relief device was not delivered by central supply. 2. The client's serum albumin increased over the last month. 3. Nurses did not document disinfection of the wound with alcohol with each dressing change. 4. AAP followed a right side—back—left side—back turning schedule.

Answer: 4 Explanation: Because this expected outcome was not met, the nurse looks for problems in the provision of care or changes in the client's condition. Of the options listed, the only one that would result in poor healing is the right side—back—left side—back turning schedule. This schedule places the client on the back for 50% of the time. The schedule should be right side—back—left side—right side.

Stage III appears as a blister with or without skin intact? A. True B. False

Correct Answer A. True ExplanationStage III pressure ulcers appear as a blister with or without skin intact. This means that at this stage, the skin is broken and there may be a blister formation. The blister can either have the skin intact, meaning it is still covering the area, or it can be open, with the skin broken and exposing the underlying tissue. This is a characteristic feature of stage III pressure ulcers and helps in their identification and classification.

An area of deep maroon discolored skin is located over the heel. The area looks bruised. Skin surface is intact. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

F. Deep Tissue Pressure Injury

In the center of the injury is a localized area of deep purple tissue. Surrounding the deep purple center is an area of non-blanchable reddness. Skin surface is intact. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

F. Deep Tissue Pressure Injury

A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion? A. Vesicle B. Macule C. Nodule D. Wheal

ANS: A Rationale: A vesicle is a primary skin lesion that is elevated and has fluid contained in the dermis. Examples of vesicles would be a blister or insect bite. Wheals, macules, and nodules are not characterized by elevation and the presence of serous fluid.

A client's blistering disorder has resulted in the formation of multiple lesions in the client's mouth. What intervention should be included in the client's plan of care? A. Provide chlorhexidine solution for rinsing the client's mouth. B. Avoid providing regular mouth care until the client's lesions heal. C. Liaise with the primary provider to arrange for parenteral nutrition. D. Encourage the client to gargle with a hypertonic solution after each meal.

ANS: A Rationale: Frequent rinsing of the mouth with chlorhexidine solution is prescribed to rid the mouth of debris and to soothe ulcerated areas. A hypertonic solution would be likely to cause pain and further skin disruption. Meticulous mouth care should be provided and there is no reason to provide nutrition parenterally.

An 80-year-old client is brought to the clinic by one of the client's children. The client asks the nurse why the client has gotten so many "spots" on the skin. What would be an appropriate response by the nurse? A. "As people age, they normally develop uneven pigmentation in their skin." B. "These 'spots' are called 'liver spots' or 'age spots.'" C. "Older skin is more apt to break down and tear, causing sores." D. "These are usually the result of nutritional deficits earlier in life."

ANS: A Rationale: The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Stating the names of these spots and identifying older adults' vulnerability to skin damage do not answer the question. These lesions are not normally a result of nutritional imbalances.

The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor? A. An insect bite B. Dehydration C. Sunburn D. Excessive perspiration

ANS: A Rationale: The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma. Dehydration, sunburn, and excessive perspiration are not examples of penetration of an environmental factor.

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings? A. Hyperkalemia, hyponatremia, elevated hematocrit B. Hypokalemia, hypernatremia, decreased hematocrit C. Hyperkalemia, hypernatremia, decreased hematocrit D. Hypokalemia, hyponatremia, elevated hematocrit ANS: A

ANS: A Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, and hemoconcentration that leads to an increased hematocrit.

Assessment of a client's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion? A. Keloid B. Ulcer C. Fissure D. Erosion

ANS: B Rationale: A pressure ulcer that is stage 2 or greater is one that extends past the epidermal layer and can develop necrotic tissue. Keloids lack necrosis and consist of scar tissue. A fissure is linear, and erosions do not extend to the dermis.

A nurse practitioner working in a dermatology clinic finds an open lesion on a client who is being assessed. What should the nurse do next? A. Obtain a swab for culture. B. Assess the characteristics of the lesion. C. Obtain a swab for pH testing. D. Apply a test dose of broad-spectrum topical antibiotic.

ANS: B Rationale: If acute open wounds or lesions are found on inspection of the skin, a comprehensive assessment should be made and documented. Testing for culture and pH are not necessarily required, and assessment should precede these actions. Antibiotics are not applied on an empirical basis.

The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element? A. A spontaneous separation of dead tissue from the viable tissue B. Removal of eschar until the point of pain and bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed D. Early closure of the wound

ANS: B Rationale: Mechanical débridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical débridement can also be accomplished through the use of topical enzymatic débridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural débridement. Shaving the burned skin layers and early wound closure are examples of surgical débridement.

The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and healing promotion. The nurse determines that the client has understood the teaching by observing the client: A. perform range-of-motion exercises. B. avoid placing body weight on the healing site. C. elevate body parts that are susceptible to edema. D. demonstrate the technique for massaging the wound site.

ANS: B Rationale: The major goals of pressure injury treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the client teaching.

A nurse is doing a shift assessment on a group of clients after first taking report. An older adult client is having the second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the client's chest. The nurse should ask what priority question regarding the presence of a reddened rash? A. "Is the rash worse at a particular time or season?" B. "Are you allergic to any foods or medication?" C. "Are you having any loss of sensation in that area?" D. "Is your rash painful?"

ANS: B Rationale: The nurse should suspect an allergic reaction to the antibiotic therapy. Allergies can be a significant threat to the client's immediate health, thus questions addressing this possibility would be prioritized over those addressing sensation. Asking about previous rashes is important, but this should likely be framed in the context of an allergy assessment.

18. A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones? A. Dermis B. Subcutaneous tissue C. Epidermis D. Stratum corneum

ANS: B Rationale: The subcutaneous tissue, or hypodermis, is the innermost layer of the skin that is responsible for providing a cushion between the skin layers, muscles, and bones. The dermis is the largest portion of the skin, providing strength and structure. The epidermis is the outermost layer of stratified epithelial cells and composed of keratinocytes. The stratum corneum is the outermost layer of the epidermis, which provides a barrier to prevent epidermal water loss.

The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client? 1. Cut toenails in a rounded shape and file. 2. Dry toes thoroughly. 3. Wash feet with water at a temperature of 90-98.6°F. 4. Inspect feet thoroughly once a week.

Answer: 2 Explanation: Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration.

When caring for a client with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what condition(s)? Select all that apply. A. Possible malignancy B. Epidermal necrosis C. Neurologic involvement D. Increased metabolic needs E. Possible gastrointestinal mucosal sloughing

ANS: B, D, E Rationale: Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential because these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and respiratory mucosal sloughing. These factors are less likely to suggest malignancy or neurologic involvement, as these are not common complications of TEN.

When caring for a client with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what condition(s)? Select all that apply. A. Possible malignancy B. Epidermal necrosis C. Neurologic involvement D. Increased metabolic needs E. Possible gastrointestinal mucosal sloughing

ANS: B, D, E Rationale: Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential because these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and respiratory mucosal sloughing. These factors are less likely to suggest malignancy or neurologic involvement, as these are not common complications of TEN.

A nurse in a dermatology clinic is reading the electronic health record of a new client. The nurse notes that the client has a history of a primary skin lesion. What skin lesion may this client have? A. Crust B. Keloid C. Pustule D. Ulcer

ANS: C Rationale: A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin. Crusts, keloids and ulcers are secondary lesions.

A nurse is providing care for a client who has psoriasis. Following the appearance of skin lesions, the nurse should prioritize what assessment? A. Assessment of the client's stool for evidence of intestinal sloughing B. Assessment of the client's apical heart rate for dysrhythmias C. Assessment of the client's joints for pain and decreased range of motion D. Assessment for cognitive changes resulting from neurologic lesions

ANS: C Rationale: Asymmetric rheumatoid factor-negative arthritis of multiple joints occurs in up to 42% of people with psoriasis, most typically after the skin lesions appear. The most typical joints affected include those in the hands or feet, although sometimes larger joints such as the elbow, knees, or hips may be affected. As such, the nurse should assess for this musculoskeletal complication. GI, cardiovascular, and neurologic function are not affected by psoriasis.

An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care? A. Avoid the application of skin emollients B. Apply antibiotic ointment, as prescribed, following baths C. Avoid using hot water during the client's baths D. Administer acetaminophen four times daily as prescribed

ANS: C Rationale: If baths have been prescribed, the client is reminded to use tepid (not hot) water and to shake off the excess water and blot between intertriginous areas (body folds) with a towel. Skin emollients should be applied to reduce pruritus. Acetaminophen and antibiotics do not reduce pruritus.

An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care? A. Avoid the application of skin emollients B. Apply antibiotic ointment, as prescribed, following baths C. Avoid using hot water during the client's baths D. Administer acetaminophen four times daily as prescribed

ANS: C Rationale: If baths have been prescribed, the client is reminded to use tepid (not hot) water and to shake off the excess water and blot between intertriginous areas (body folds) with a towel. Skin emollients should be applied to reduce pruritus. Acetaminophen and antibiotics do not reduce pruritus.

A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care? A. Ensuring that the family knows that impetigo is not contagious B. Teaching about the safe and effective use of topical corticosteroids C. Teaching about the importance of maintaining high standards of hygiene D. Ensuring that the family knows how to safely burst the child's vesicles

ANS: C Rationale: Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be manually burst. Because of the bacterial etiology, corticosteroids are ineffective.

The nurse is performing a comprehensive assessment of a client's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform this component of assessment in what way? A. By examining the client under a Wood light B. By inspecting the client's skin in direct sunlight C. By palpating the client's skin D. By performing percussion of major skin surfaces

ANS: C Rationale: Inspection and palpation are techniques commonly used in examining the skin. A client would only be examined under a Wood light if there were indications it could be diagnostic. The client is examined in a well-lit room, not in direct sunlight. Percussion is not a technique used in assessing the skin.

36. A client has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this client's care, the nurse should include what nursing diagnosis? A. Risk for deficient fluid volume related to excess sebum synthesis B. Ineffective thermoregulation related to occlusion of sebaceous glands C. Disturbed body image related to excess sebum production D. Ineffective tissue perfusion related to occlusion of sebaceous glands

ANS: C Rationale: Seborrhea causes highly visible manifestations that are likely to have a negative effect on the client's body image. Seborrhea does not normally affect fluid balance, thermoregulation, or tissue perfusion.

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care? A. Assess the drainage in the dressing. B. Slowly remove the soiled dressing. C. Perform hand hygiene. D. Don nonlatex gloves.

ANS: C Rationale: The nurse and health care provider must adhere to standard precautions and wear gloves when inspecting the skin or changing a dressing. Use of standard precautions and proper disposal of any contaminated dressing is carried out according to Occupational Safety and Health Administration (OSHA) regulations. Hand hygiene must precede other aspects of wound care.

A nurse is preparing to perform the physical assessment of a newly admitted client. During which of the following components of the assessment should the nurse wear gloves? Select all that apply. A. Palpation of the nailbeds B. Palpation of the client's upper extremities C. Palpation of a rash on the client's trunk D. Palpation of a lesion on the client's upper back E. Palpation of the client's finger joints

ANS: C, D Rationale: Gloves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate a client's extremities or fingers unless contact with body fluids is reasonably foreseeable

A client's health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem? A. Chronic pain B. Impaired skin integrity C. Impaired tissue integrity D. Disturbed body image

ANS: D Rationale: Alopecia areata causes hair loss in smaller defined areas. As such, it is common for the client to experience a disturbed body image. Hair loss does not cause pain and does not affect skin or tissue integrity.

A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections? A. Chronic obstructive pulmonary disease B. Rheumatoid arthritis C. Gout D. Diabetes

ANS: D Rationale: Clients with diabetes are particularly susceptible to skin infections. COPD, RA, and gout are less commonly associated with integumentary manifestations.

A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for pressure injuries. When performing this home visit, the nurse should do which of the following? A. Assess the client for signs of electrolyte imbalances. B. Administer fluids as prescribed. C. Assess the risk for injury recurrence. D. Assess the client's psychosocial state.

ANS: D Rationale: Recovery from pressure injuries can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury? A. I B. II C. III D. IV

ANS: D Rationale: Stage III and IV pressure injuries are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure injuries must be cleaned (débrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

A client with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this client's susceptibility to heat loss is related to atrophy of what skin component? A. Epidermis B. Merkel cells C. Dermis D. Subcutaneous tissue

ANS: D Rationale: The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation. The epidermis is an outermost layer of stratified epithelial cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular.

An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment? A. Increased thickness of the subcutaneous skin layer B. Increased vascular supply to superficial skin layers C. Changes in the character and quantity of bacterial skin flora D. Increased time required for wound healing

ANS: D Rationale: Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds. There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

A client who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Low Self Esteem related to use of facial prosthetic secondary to reconstructive surgery. Which nursing intervention would be appropriate for this diagnosis? A. Referring the client to a speech therapist B. Gradually adding soft foods to diet C. Administering analgesics as prescribed D. Teaching the client how to use and care for the prosthesis

ANS: D Rationale: The process of facial reconstruction is often slow and tedious. Because a person's facial appearance affects self-esteem so greatly, this type of reconstruction is often a very emotional experience for the client. Reinforcement of the client's successful coping strategies improves self-esteem. If prosthetic devices are used, the client is taught how to use and care for them to gain a sense of greater independence. This is an intervention that relates to Disturbed Body Image in these clients. None of the other listed interventions relate directly to the diagnosis of Disturbed Body Image.

The new nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. What should be done before the nurse uses the scale? 1. Receive specific training 2. Be certified 3. Ask the client's permission 4. Obtain special assessment equipment

Answer: 1 Explanation: The nurse should receive specific training in the use of the Braden scale in order for assessment to be accurate.

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing? 1. Materials used in dressing this wound should keep the wound bed moist. 2. The dressing should allow good air circulation through the wound. 3. Dressings should be simple as they will be changed at least every 4 hours. 4. Absorbent material to wick exudates away and support drying should be used.

Answer: 1 Explanation: Wounds that are expected to heal by secondary intention heal by "granulating in." In order to support the growth of granulation tissue, the wound bed should be kept moist and oxygen should be kept out of the wound.

A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linens? (Select all that apply.) 1. Pulse 2. Respirations 3. Urine output 4. Blood pressure 5. Mobility status

Answer: 1, 2, 4, 5

The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client? (Select all that apply.) 1. Poor skin turgor 2. Elevated body temperature 3. Diminished pain sensation 4. Thin epidermis 5. Dry skin

Answer: 1, 3, 4, 5

A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this client's care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache

Answer: 2 Explanation: Because insertion of a subclavian central venous catheter may result in hemothorax, pneumothorax, cardiac perforation, thrombosis, or infection, the priority finding for planning care is tachycardia.

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. In which way should the nurse document this finding? 1. Cyanosis 2. Jaundice 3. Pallor 4. Erythema

Answer: 2 Explanation: Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera of the eye.

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this client's problem? 1. Encourage the client to eat at least 40% of meals. 2. Keep linens dry and wrinkle-free. 3. Restrict fluid intake. 4. Turn client every 3 hours.

Answer: 2 Explanation: Keeping linens dry and wrinkle-free will prevent pressure areas.

The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? 1. The client will be able to name the staff that works on the day shift. 2. The client will eliminate safety hazards in her environment. 3. The client, with supervision, will brush the teeth. 4. The nurse will stress the importance of adequate fluid intake.

Answer: 3 Explanation: A client with cognitive impairment would be able to brush the teeth but only with supervision. The client would not voluntarily brush teeth without prompting from the staff.

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores? 1. Trending can only be accurate if the same scale is used. 2. There is a definite trend of low risk for pressure injury development. 3. Trending would be more accurate if the same scale was used. 4. The scores indicate opposite risks for pressure ulcer development.

Answer: 3 Explanation: All of these scores indicate risk for development of a pressure injury, so some trending is possible, but it would be more accurate if the same scale was always used.

A client has a documented stage 3 pressure injury on the right hip. What nursing diagnosis problem statement is most appropriate for use with this client? 1. Altered Tissue Perfusion 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Injury

Answer: 3 Explanation: Because a stage 3 pressure injury involves tissues, not just skin, this client has criteria for using the problem statement Impaired Tissue Integrity.

A client has a wound that is approximately 10 cm in diameter, surrounded by edematous and boggy tissue, with the edges curling towards the center. Which additional finding would indicate to the nurse that this is a stage 4 pressure injury? 1. There is undermining of adjacent tissues. 2. The crater extends into the subcutaneous tissue. 3. The joint capsule of the hip is visible. 4. The ulcer has thick dark eschar over the top.

Answer: 3 Explanation: Stage 4 injuries demonstrate damage to muscle, bone, tendons, or the joint capsule.

The odor from a hospitalized client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful? 1. Spray the room routinely with a floral room spray. 2. Instill a vinegar solution into the wound. 3. Keep the wound dressing dry and clean. 4. Burn a candle in the room.

Answer: 3 Explanation: The best way to keep odors controlled is to keep the wound dressing dry and clean.

An older client who is incontinent and wears incontinence briefs develops an irritated rash in the perianal area. What care should the nurse provide? 1. Wash the area with soap and hot water at every brief change. 2. Apply a petroleum-based cream to the area after cleaning. 3. Wipe the skin with an alcohol-free barrier film agent after cleaning. 4. Keep the client in bed on absorbent pads until the area clears.

Answer: 3 Explanation: The care should include wiping the skin with an alcohol-free barrier film agent after cleaning.

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin? 1. Keep the head of the client's bed at 30°F. 2. Coat the client's back and buttocks with baby powder after bathing. 3. Use a turn sheet lifted by two staff members to move the client in bed. 4. Dust the linens with cornstarch each morning to allow for easier movement.

Answer: 3 Explanation: The nurse should plan to use a turn sheet lifted by two staff members to move the client up in bed.

A 75 year old white male has a lesion on his left buttock. The lesion is 1.0 cm in width and 0.5 cm in length. There is a partial loss of dermis. The surround tissue is reddened and firm. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

B. Stage 2

A raised blister-like area onthe skin caused by and intradermal injection A. Buccal B. Wheal C. Intradermal D. Suppository

Correct Answe B. Wheal ExplanationA wheal is a raised blister-like area on the skin that is caused by an intradermal injection. This means that when a substance is injected into the skin, it can cause a localized reaction resulting in the formation of a wheal. This can happen due to various reasons such as an allergic reaction or irritation caused by the injected substance.

2. What should the nurse do when providing oral care to a patient with no gag reflex? a. Avoid putting anything in the patient's mouth b. Place the patient in a Fowler's position c. Ensure availability of suction equipment d. Use alcohol free mouthwash

C. Ensure availability of suction equipment Star material

Area of tissue loss extends into the subcutaneous tissue. Wound is 5 cm in length, 3 cm in width, and 0.6 cm in depth. Wound bed contains granulation tissue. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

C. Stage 3

The area of tissue loss over the heel extends into subcutaneous tissue. Wound measure 2.7 cm by 3.5 cm and is 0.5 cm deep. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

C. Stage 3

DTI may first appear as a A. Dry skin B. Laceration C. Bruise D. Scrap

C.Bruise DTI stands for Deep Tissue Injury, which is a type of injury that occurs deep within the tissues of the body. It may first appear as a bruise, which is a discoloration of the skin caused by bleeding underneath the surface. Unlike a dry skin, laceration, or scrape, a bruise indicates damage to the underlying tissues. This could be due to trauma or pressure, leading to the rupture of blood vessels and subsequent bleeding. Therefore, a bruise is a more likely presentation for DTI compared to the other options provided.

What is DTI? A. Deep tissue injury B. Discolored tissue injury C. Detected tissue injury

Correct Answer A. Deep tissue injury ExplanationDTI stands for deep tissue injury. This refers to a type of injury that occurs in the deeper layers of the skin and underlying tissues. It is characterized by damage to the underlying tissues, such as muscles, tendons, or bones, while the surface of the skin may appear intact. This type of injury is often caused by prolonged pressure or shear forces on the skin, leading to damage to the underlying tissues. It is important to recognize and treat DTIs promptly to prevent further complications.

A stage II ulcer is not A. Just red area B. Partial thickness loss of dermis C. Shallow open ulcer D. May be intact or open

Correct Answer A. Just red area ExplanationA stage II ulcer is not just a red area. It involves partial thickness loss of the dermis, meaning that the top layer of the skin is damaged. It can appear as a shallow open ulcer or may still be intact.

Increase in cell death A. Necrosis B. Stratum corneum C. Dermis D. Intradermal

Correct Answer A. Necrosis ExplanationNecrosis refers to the death of cells or tissues due to injury, infection, or lack of blood supply. In the context of the given options, an increase in cell death can lead to necrosis. The other terms mentioned, such as stratum corneum, dermis, and intradermal, are related to the layers of the skin and do not directly explain the concept of necrosis.

In Stage III bone and tendons are visable A. True B. False

Correct Answer B. False ExplanationIn Stage III of bone and tendon injuries, they are not visible. This stage typically involves complete rupture or severe damage to the bone or tendon, resulting in loss of function and significant pain. It may require surgical intervention for repair. Therefore, the correct answer is False.

In stage IV which is flase A. Bone/tendon are visable B. Just a flesh wound C. Osteomylitis is possible D. Slough or eschar may be present

Correct Answer B. Just a flesh wound ExplanationThe statement "just a flesh wound" is the correct answer because it contradicts the other options mentioned in the question. In stage IV, bone/tendon visibility, the possibility of osteomyelitis, and the presence of slough or eschar are all indicative of severe tissue damage and infection, which are not characteristics of a "just a flesh wound."

Drug transfer into the eye A. Viscosity B. Transcorneal transport C. Opthalmic D. Sublingual

Correct Answer B. Transcorneal transport ExplanationTranscorneal transport refers to the movement of drugs across the cornea, which is the transparent outer layer of the eye. This process is important for drug delivery into the eye because the cornea acts as a barrier and limits the penetration of drugs. Understanding transcorneal transport is crucial for developing ophthalmic drugs that can effectively reach the target tissues within the eye. The given answer suggests that transcorneal transport is the most relevant concept in the context of drug transfer into the eye.

Nucrotic ulcers are A. Found on the back B. Found on or around the knee area C. A stage I ulcer D. Found on the foot

Correct Answer D. Found on the foot Explanation Necrotic ulcers are typically found on the foot. Necrotic ulcers refer to areas of dead tissue, which can occur due to various reasons such as poor circulation, pressure, or infection. The foot is particularly susceptible to developing necrotic ulcers because it is often subjected to pressure and friction while walking or standing. Additionally, the foot is prone to reduced blood flow, especially in individuals with diabetes or peripheral artery disease, further increasing the risk of developing necrotic ulcers in this area.

A pressure injury measures approximately 4.5 by 5 cm in size. Wound depth is 3.5 cm. Muscle tissue and bone are visible in the wound bed. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

D. Stage 4

Pressure injury over the left buttock has exposed muscle and tissue. Tunnel in or undermining is present. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

D. Stage 4

A 78 year old patient has a pressure injury on the right heel. Escobar and slough cover the wound bed. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

E. Unstageable

Areas of tissue from pressure are completely covered by slough/Escher. The wound base is not visible. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

E. Unstageable

A 50 year old female has multiple injuries to the tongue from a bite block. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

G. Mucosal Membrane Pressure Injury

A pressure injury was noted on the nasal mucous membrane of the right nares after removing a nasogastric (NG) tube. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

G. Mucosal Membrane Pressure Injury

Sacral pressure injury extend into dermis. Wound is pink red. Periwound skin is reddened. Make a selection. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. Deep Tissue Pressure Injury G. Mucosal Membrane Pressure Injury

Stage 2