Question 1

What is the purpose of the hydrocolloid dressing applied to a clean stage II pressure ulcer? (Select all that apply.)

Accepted Answer

The hydrocolloid dressing prevents shear force trauma to the ulcer while granulation tissue and reepithelialization are occurring during healing. It also forms an air-occlusive seal,protects the ulcer from infection,and absorbs exudate. If there were eschar present,it would soften it.

Question 2

What would be the most effective intervention to prevent pressure ulcers in the bedridden patient?

Accepted Answer

Repositioning is the most effective intervention. Long periods of pressure over bony prominences are the primary cause of pressure ulcers,not wet linens,frequent assessments,or not using a draw sheet.

Question 3

The older man complains of a hard white patch that has developed on the side of his tongue. What would be the most appropriate action of the nurse?

Accepted Answer

Leukoplakia is a precancerous condition that requires a medical consultation.

Question 4

On the admission assessment of an 80-year-old to a long-term care facility, the nurse notes that the resident's toenails are dark, thick, and brittle; extremely misshapen; and growing at an angle from the toe. What does the nurse suspect has caused the changes in the nails?

Accepted Answer

Fungal nail infections cause nails to be dark,brittle,and misshapen. The nails grow at odd angles from the toes because they are lifted from the nail bed by the infection.

Question 5

The nurse assesses an area of skin on the patient's upper thigh that is different in appearance than the surrounding skin. What documentation would be the most informative?

Accepted Answer

The second option describes color and texture alterations,location,size,and subjective and objective data related to the lesion.

Question 6

The male patient who has been on long-term antibiotic therapy inquires what may have caused his thrush. What is the most informative response of the nurse?

Accepted Answer

Long-term antibiotic therapy destroys the normal flora of the oral cavity,allowing opportunistic infections to occur. Thrush is a common yeast infection.

Question 7

An 80-year-old woman complains of pruritus from dry skin. What would be an appropriate bathing schedule for the patient?

Accepted Answer

A weekly shower with sponge baths in between provides adequate cleanliness and decreases dryness. Soap should be completely rinsed off. Hot showers and detergent soaps dry the skin.

Question 8

When the patient complains of dry mouth, what should the nurse assess for?

Accepted Answer

Xerostomia causes difficulty in chewing and swallowing because food sticks to the mucous membranes and tooth surfaces.

Question 9

The admitting nurse gives the new long-term care facility resident a score of 20 on both the Norton Risk Assessment Scale and the Braden Scale for Predicting Pressure Sore Risk. These scores indicate that the resident has

Accepted Answer

Scores of 20 on the Norton and Braden Scales indicate a very low probability of developing a pressure ulcer.

Question 10

The long-term care facility resident who has not worn his dentures for several months complains that the dentures no longer fit. Why do the dentures no longer fit?

Accepted Answer

The arch of the jaw changes to compensate for the absence of teeth.

Question 11

A patient's toenails are brittle and thick. What other assessment should the nurse be sure to include?

Accepted Answer

The nail changes are the result of decreased peripheral circulation. Checking for the strength of pedal pulses can add extra information related to circulation.

Question 12

The 80-year-old woman newly admitted to a long-term care facility complains of intense itching in her axillae and antecubital fossa. There are small red lesions in linear patterns. What condition does the nurse suspect?

Accepted Answer

Scabies is common in older adults,causing intense itching and small red lesions in a linear pattern. The condition is communicable and,unless treated,can spread to the entire facility.

Question 13

What is the cause of progressively graying hair?

Accepted Answer

Decreased production of melanin causes the hair to lose color and turn gray.

Question 14

The older adult complains of multiple bruises on his extremities. What are the marks the result of?

Accepted Answer

Age-related fragility of the capillary walls allows bruises to develop with the mildest injury.

Question 15

When performing a skin assessment for pressure ulcers on an older man who is bedridden and prefers to lie on his right side, the nurse will pay special attention to the __________. (Select all that apply.)

Accepted Answer

For this right side-lying patient,the right ear,lateral edge of the right foot,and medial edge of the left foot are probable areas for pressure ulcers.

Question 16

What preventative action can be taken to prevent skin trauma from shearing force?

Accepted Answer

Lifting patients up clear of the bed linens to move or change position will reduce the risk of shear force injury.

Question 17

What position would be most appropriate to reduce pressure ulcers in a bedridden patient?

Accepted Answer

The 30-degree lateral position places weight on the gluteus muscle,avoiding weight-bearing on bony prominences such as the trochanter,sacrum,and ischium.

Question 18

What factors make the older adult more susceptible to pressure ulcers? (Select all that apply.)

Accepted Answer

Lack of subcutaneous fat to pad the bony prominences and reduced sensitivity to touch and pressure put older adults at risk for pressure ulcers.

Question 19

What are causes of pruritus in the older adult? (Select all that apply.)

Accepted Answer

Emollients keep the skin moist and reduce dryness. All other options listed contribute to pruritus.

Question 20

The long-term care facility nurse requests a dental consult to treat gingivitis in a resident. If left untreated, what can gingivitis ultimately cause?

Accepted Answer

The bleeding,swelling,and receding gums of gingivitis ultimately lead to tooth loss.

Quiz 17: Care of Aging Skin and Mucous Membranes