Question 1

The buildup of tough necrotic tissue found with a pressure ulcer is called _________.

Accepted Answer

The answer of The buildup of tough necrotic tissue found...

Question 2

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

Accepted Answer

Understanding the functions of the skin is imperative for providing proper care for patients and for identifying risk factors for skin integrity.

Question 3

The culturally sensitive nurse caring for a Muslim woman who has noticeable body odor as well as abundant underarm hair should:

Accepted Answer

Washing the area with soap and water will reduce odor. Several cultures do not consider the use of deodorant or shaving underarms essential. These personal preferences should be respected.

Question 4

Skin that is frequently wet leads to __________, the softening of tissue that increases the chance of trauma or infection.

Accepted Answer

The answer of Skin that is frequently wet leads to...

Question 5

The nurse shampooing the hair of an African American takes into consideration that the hair:

Accepted Answer

The hair of African Americans should be washed only every 7 to 10 days because the hair is much drier and less oily. Heat and the use of a fine-toothed comb cause the hair to break.

Question 6

During the provision of oral care to an unconscious patient, the nurse uses suction primarily to:

Accepted Answer

An unconscious patient may not have a gag or swallowing reflex, and thus fluids introduced during mouth care need to be suctioned out (and the patient is positioned to facilitate drainage with the head lowered and turned to the side).

Question 7

A stage III pressure ulcer is indicated by: (Select all that apply.)

Accepted Answer

Stage III includes full-thickness skin loss, drainage, and damage to the subcutaneous tissue. Stage I may have an induration. Stage II may be indicated by warmth of the surrounding tissue. Stage IV may be indicated by widespread infection.

Question 8

A nurse is caring for a patient who is wearing contact lenses. If the patient cannot care for the lenses himself, and the nurse has difficulty removing a hard lens by hand, it is correct for the nurse to:

Accepted Answer

A lens suction cup is usually available in health care facilities to remove contact lenses.

Question 9

A nurse is instructing a nursing student regarding prevention of pressure ulcers. The nurse would recognize further instruction is warranted when the nursing student states, "I will:

Accepted Answer

Prevention of pressure ulcers includes not positioning the patient directly on the trochanter.

Question 10

A patient with insulin-dependent diabetes has a below-the-knee amputation on the right leg. What modification of his personal care is noted as most important?

Accepted Answer

A diabetic with a below-the-knee amputation is likely to have circulatory problems in the remaining foot. Therefore, good foot care is essential, but toenail cutting should be performed by a podiatrist.

Question 11

A usual routine for providing nail care to a patient includes:

Accepted Answer

Soaking nails softens them and makes it easier to remove dirt or to cut them. A metal file should not be used under the nails.

Question 12

One of the facility's unlicensed assistive personnel (UAPs) is being instructed on foot care for a 74-year-old patient with severely overgrown ragged toenails. The UAP should be reminded to:

Accepted Answer

Cutting the nails straight will prevent ingrown toenails.

Question 13

A nurse notes that her patient has an area of red skin that does not blanch with fingertip pressure. The nurse documents this finding as a stage _____ pressure ulcer.

Accepted Answer

A stage I pressure ulcer is characterized by an area of red, deep pink, or mottled skin that does not blanch with fingertip pressure.

Question 14

The nurse stages a pressure ulcer as a stage II based on the knowledge that such lesions have:

Accepted Answer

A stage II pressure ulcer is characterized by an area of partial-thickness skin loss involving the epidermis and/or dermis. It may look like an abrasion, blister, or shallow crater. The area surrounding the damaged skin may feel warmer.

Question 15

When the nurse is assisting a male patient to shave his face, it is most important for her to:

Accepted Answer

A patient who is on anticoagulants or who has a bleeding tendency should use an electric razor.

Question 16

A nurse admitting a 76-year-old patient to the unit carefully documents the appearance of a stage III pressure ulcer and informs the charge nurse because:

Accepted Answer

Medicare will reimburse the facility at a higher rate if stages III and IV ulcers are documented within 2 days of admission.

Question 17

The changes in the integumentary system that are part of the normal aging process are: (Select all that apply.)

Accepted Answer

Noting normal aging processes helps the nurse detect abnormal changes earlier. Sebaceous gland activity is decreased and nail growth decreases.

Quiz 19: Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers