Deck 32: Stress and Adaptation

Question 1

A student nurse studying anatomy and physiology learns that the largest organ of the body is the:

A) heart
B) lungs
C) skin
D) intestines

Answer 1

C

Question 2

Which of the following are functions of the skin? Select all that apply.

A) protection
B) temperature regulation
C) psychosocial, sensation
D) vitamin C production
E) immunological
F) lipid reduction

Answer 2

A, B, C, E

Question 3

Which of the following statements accurately describes a developmental consideration when assessing skin integrity of patients?

A) In children younger than 2 years, the skin is thicker and stronger than it is in adults.
B) An infant's skin and mucous membranes are injured easily and are subject to infection.
C) A child's skin becomes increasingly at risk for injury and infection.
D) In the older adult, circulation and collagen formation are increased.

Answer 3

B

Question 4

A nurse assessing the skin of patients knows that the following are health states that may predispose patients to skin alterations. Select all that apply.

A) obesity
B) excessive perspiration
C) cataracts
D) hypertension
E) low BMI
F) Jaundice

Question 5

What is the most accurate definition of a wound?

A) a disruption in normal skin and tissue integrity
B) a change in the function of internal organs
C) any injury that results in changes in nervous tissue
D) any trauma resulting in serious damage and pain

Question 6

Which of the following best describes an unintentional wound?

A) clean wound edges, controlled bleeding
B) jagged wound edges, uncontrolled bleeding
C) little risk for infection, shorter healing time
D) the result of surgery, intravenous therapy

Question 7

A nurse documents a closed wound on a patient chart. Which of the following is an example of a closed wound?

A) abrasion
B) ecchymosis
C) incision
D) puncture wound

Question 8

When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

A) friction
B) necrosis of tissue
C) ischemia
D) shearing force

Question 9

A nurse assesses an area of pale white skin over a patient's coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

A) Immediately report to the physician that the patient has a pressure ulcer.
B) Recognize that this is ischemia, followed by reactive hyperemia.
C) Document the presence of a pressure ulcer and develop a care plan.
D) Implement nursing interventions for Altered Skin Integrity.

Question 10

A nurse is assessing wound drainage during the immediate postoperative period for a patient who has had a breast removed. In addition to assessing the dressing, where would the nurse also check for drainage?

A) under the skin
B) under the patient
C) on the output sheet
D) in the axilla

Question 11

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?

A) evisceration
B) infection
C) dehiscence
D) fistula

Question 12

Heat applications are often used to promote tissue healing. What is the rationale for this type of treatment?

A) Physiologic effects of heat accelerate the inflammatory response.
B) Local heat increases cardiac output and pulse rate.
C) Heat reduces blood flow to tissues resulting in decreased edema.
D) Heat reduces muscle tension to promote relaxation.

Question 13

Which of the following considerations should be made when assessing a patient for the application of cold or heat therapy?

A) prolonged exposure decreases tolerance
B) the neck and perineum are less sensitive to thermal change
C) open tissue or abraded skin is less sensitive to thermal changes
D) applications of heat or cold to large areas of the body cause systemic responses