Question 1

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

Accepted Answer

The skin is the largest organ of the body, covering an average of 22 square feet in adults. While the heart, lungs, and intestines are essential organs, they do not have the same surface area as the skin.

Question 2

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

Accepted Answer

The skin serves many important functions, including protection from injury and infection (A), regulation of body temperature (B), sensation of touch, pressure, pain, and temperature (C), and immunity through the presence of immune cells and cytokines (E). Vitamin C production (D) and lipid reduction (F) are not primary functions of the skin.

Question 3

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

Accepted Answer

An infant's skin and mucous membranes are thinner and easily injured compared to an adult's skin. They are also subject to infection due to immature immune systems. It is important to carefully assess and protect a newborn's skin during routine care and in the presence of medical issues.

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.

Accepted Answer

Obesity can lead to skin folds and increased risk of infections; excessive perspiration can cause skin breakdown; low BMI can result in less cushioning and increased risk of pressure sores; jaundice can cause itching and skin changes.

Question 5

What is the most accurate definition of a wound?

Accepted Answer

A wound is defined as a disruption in normal skin and tissue integrity, which can be caused by a variety of factors such as trauma, surgical incisions, or chronic conditions. This can lead to a variety of symptoms, such as pain, bleeding, and inflammation. Option B, C, and D do not accurately define a wound.

Question 6

Which of the following best describes an unintentional wound?

Accepted Answer

An unintentional wound is typically caused by an accidental trauma, and can have jagged edges and uncontrolled bleeding.

Question 7

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

Accepted Answer

Ecchymosis is a type of closed wound that occurs when there is bleeding under the skin, but the skin itself is not broken. Abrasion, incision, and puncture wounds are all examples of open wounds.

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?

Accepted Answer

Shearing force occurs when the skin is pulled in one direction while the tissues underneath are pulled in another direction. This can cause injury to the tissues and increase the risk of a decubitus ulcer. Lifting, rather than pulling, patients helps to minimize this risk. Friction, necrosis of tissue, and ischemia can also contribute to the development of decubitus ulcers, but are not specifically related to pulling patients up in bed.

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?

Accepted Answer

The nurse should recognize the change from pale white skin to red and warm as a sign of ischemia followed by reactive hyperemia, indicating that the skin is responding to pressure being relieved and blood flow returning, rather than immediately identifying it as a pressure ulcer.

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?

Accepted Answer

The nurse should check under the patient for any drainage that may have seeped through the dressing and onto the bed linens.

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?

Accepted Answer

The increased drainage and pain, red and swollen wound, and purulent wound drainage are all signs of infection. The increased body temperature is also a possible sign of infection. Evisceration refers to the partial or complete protrusion of organs through a wound, dehiscence is the separation of wound edges, and a fistula is an abnormal connection between two body parts or organs.

Question 12

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

Accepted Answer

Heat applications accelerate the inflammatory response by increasing blood flow to the affected area, which can promote healing by delivering more oxygen and nutrients to the tissues.

Question 13

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

Accepted Answer

The answer of Which of the following considerations should be...

Quiz 32: Stress and Adaptation