Question 1

The client is brought into the emergency department with a knife wound.The nurse correctly documents the client's wound as a(n):

Accepted Answer

A client with a knife wound is an example of an acute wound.An acute wound is caused by trauma from a sharp object.A contusion is a closed wound caused by a blow to the body by a blunt object,resulting in a bruise.A clean wound is a wound that contains no pathogenic organisms,such as a closed surgical wound that does not enter the gastrointestinal,respiratory,or genitourinary system.An intentional wound is a wound resulting from therapy,such as a surgical incision.

Question 2

In reviewing the client's nutritional intake,the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity.The nurse suggests that the client eat:

Accepted Answer

Citrus fruits contain vitamin C,which is important in collagen synthesis,capillary wall integrity,and fibroblast function.Fish and eggs contain protein and vitamin E.Protein plays a role in neogenesis,collagen formation,and wound remodeling.Liver contains vitamin A,which is important in epithelialization and wound closure.

Question 3

The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is:

Accepted Answer

Although all the options are related to causes of skin injury in older adults,the hypodermis decreases in size with age,and so the older client has little subcutaneous padding over bony prominences;thus they are more prone to skin breakdown.

Question 4

To reduce pressure points that may lead to pressure ulcers,the nurse should:

Accepted Answer

Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces.The client should not be positioned directly on the trochanter because this can create pressure over the bony prominence.Donut-shaped cushions are contraindicated because they reduce blood supply to the area,resulting in wider areas of ischemia.Bony prominences should not be massaged.Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk for injury to underlying tissue and pressure ulcer formation.

Question 5

Although all of the following represent poor transfer techniques,which is most likely to result in a shearing injury to the skin of an older adult client?

Accepted Answer

Shear is the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction)between the client and a surface.The remaining options result in friction damage to the client's skin.

Question 6

Which of the following statements made by the nurse shows the greatest insight into the need to manage the risk factors that contribute to the formation of a pressure ulcer?

Accepted Answer

Pressure is the major cause in pressure ulcer formation.Three pressure-related factors contribute to pressure ulcer development: (1)pressure intensity, (2)pressure duration,and (3)tissue tolerance.The remaining options,although related to contributing factors,do not address the primary factor,pressure.

Question 7

The client has a stage IV pressure ulcer.In accordance with the Agency for Healthcare Research and Quality (AHRQ),the nurse recommends that the client should have a(n):

Accepted Answer

Air-fluidized beds are recommended for clients with burns or multiple stage III or stage IV pressure ulcers.A foam mattress is recommended for pressure reduction in clients at high risk for developing a pressure ulcer.A Rotokinetic bed is recommended for clients who are at risk for or have developed atelectasis and/or pneumonia.A static support surface is not recommended for a client with a stage IV ulcer.It is used for clients at high risk for developing a pressure ulcer.

Question 8

When changing the soiled linen on the bed of a client who is comatose,the nurse notices a reddened,blanchable area approximately 2 cm in diameter on her left buttock.The nurse's initial skin breakdown intervention is to:

Accepted Answer

Pressure is the major cause in pressure ulcer formation,and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pressure.The remaining options are appropriate,but none has priority over proper positioning of the client.

Question 9

Which of the following assessment findings is most representative of a stage II pressure ulcer?

Accepted Answer

Stage II ulcers have partial-thickness skin loss involving the epidermis,dermis,or both.The ulcer is superficial and presents clinically as an abrasion,blister,or shallow crater.The remaining options describe elements of stage I and stage III ulcers.

Question 10

A cognitively impaired client spends hours a day involuntarily wringing her hands.Which of the following interventions is the most therapeutic as a means of minimizing this client's risk for friction damage to her hands?

Accepted Answer

A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion.The remaining options are not as likely to be effective with a cognitively impaired client.

Question 11

The client is experiencing low back pain and is to have an aquathermia pad applied.The nurse recognizes that safe application of heat to a client's injury includes:

Accepted Answer

An application should last only 20 to 30 minutes.Providing a timer for the client will help prevent injury to the tissue.The temperature setting is fixed by inserting a plastic key into the temperature regulator.In many institutions the central supply room sets the regulators to the recommended temperature.The nurse does not place the pad directly on the client's skin.To prevent injury,it should be covered with a thin towel or pillow case.The recommended temperature is 105° to 110° F.The pad should not be used at the highest temperature that is tolerated by the client.

Question 12

The nurse is planning a program on wound healing and includes information that smoking influences healing by:

Accepted Answer

Smoking reduces the amount of functional hemoglobin in the blood,thus decreasing tissue oxygenation.Antiinflammatory drugs suppress protein synthesis.Radiation creates tissue fragility.Chemotherapeutic drugs can depress bone marrow function.

Question 13

A client on the medical unit is taking steroids and also has a wound from a minor injury.To promote wound healing for this client,the nurse recommends that which of the following be specifically added?

Accepted Answer

Vitamin A can reverse steroid effects on skin and delayed healing.Iron does not reverse the effects of steroids.It is important in the transport of oxygen.Folic acid does not reverse the effects of steroids.It is a B complex vitamin needed for DNA synthesis.The B complex vitamins do not reverse the effects of steroids.The B vitamins affect growth and stimulate appetite,lactation,and the gastrointestinal,neurological,and endocrine systems.

Question 14

The client requires support,and an abdominal binder is ordered.The nurse correctly implements the use of a binder by:

Accepted Answer

After applying the binder,the nurse should assess the client's ability to ventilate properly,including deep breathing and coughing.Wounds should be entirely covered with dressings;the binder is applied over the dressing.The binder should not be loose,or it will be ineffective in providing support.The client should be lying supine with head slightly elevated and knees slightly flexed for application of the abdominal binder.

Question 15

Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client?

Accepted Answer

In dark-skinned individuals areas of pressure appear darker than surrounding skin and have a purplish/bluish hue;the temperature of the area may be warm or cool to the touch.The remaining options use descriptives not applicable to the dark-skinned individual or less definite indicators.

Question 16

The nurse uses the Norton scale in the extended care facility to determine the client's risk for pressure ulcer development.Which one of the following scores,based on this scale,places the client at the highest level of risk?

Accepted Answer

According to the Norton scale,a lower score indicates a higher risk for pressure ulcer development.The total score ranges from 5 to 20.The client at highest risk would be the client with a score of 6.

Question 17

Which of the following interventions is mostly likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose?

Accepted Answer

Pressure is the major cause in pressure ulcer formation,and changing the client's position to minimize the time spent in a particular position will be the best intervention to relieve the pressure.

Question 18

Which of the following statements made by the nurse shows the most thorough understanding of the therapeutic value of testing a reddened area on the heel of a mobility-impaired client for blanching?

Accepted Answer

If the area blanches (turns lighter in color)and the erythema returns when you remove your finger,the hyperemia is transient and is an attempt to overcome the ischemic episode,thus called blanching hyperemia.If,however,the erythemic area does not blanch (nonblanching erythema)when you apply pressure,deep tissue damage is probable.

Question 19

Which of the following clients has the greatest risk for friction-induced skin breakdown?

Accepted Answer

A friction injury occurs in clients who are restless or in those who have uncontrollable movements or any repetitive skin-against-skin motion.The other options represent friction or moisture factors that contribute to skin breakdown.

Question 20

When asked what the role of the skin is in maintaining homeostasis,the answer that reflects the greatest insight is:

Accepted Answer

Although it is a sensory organ for pain,temperature,and touch and synthesizes vitamin D,its primary role is that of a protective barrier against disease-causing organisms.

Quiz 48: Skin Integrity and Wound Care

The client is brought into the emergency department with a knife wound.The nurse correctly documents the client's wound as a(n) :