General Tissue integrity Questions
What are the signs of cyanosis?
Blue tinge in conjunctivae, nail beds, earlobes, oral membranes, soles, & palms
Ashen grey lips & tongue in those with darker skin
What do you need to look for in a neoplastic skin disorder?
ABCDE
Asymmetry, Border, Color, Diameter, Evolving
Erosion
wearing away of epidermis causing a moist & shallow depression
The nurse is assessing a 78-year-old client and is determining the client’s risk for injury status. The nurse would concentrate a safety assessment on:
a) cognitive awareness
b) unsafe work environment
c) brand of car used
d) number of children in home
a) cognitive awareness
×Clients with impaired cognitive ability are at risk for injury. When caring for the older client, the nurse would want to determine the cognitive awareness of the client. Clients at age 78 are likely retired. The brand of car driven and number of children in the home are not relative to risk for injury.
Which of the following interventions would help prevent falls in older clients?
a) check vision every five years
b) exercise regularly
c) place socks on feet
d) turn the light on after getting out of bed
b) exercise regularly
×The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls. Vision can be a cause of falls, but it should be checked at least once a year; every five years is not often enough. Older clients should have something on their feet when walking, but not regular socks that will allow them to fall; a nonskid-type sock or shoe will help prevent falls.
When asked what the role of the skin is in maintaining homeostasis, the answer that reflects the greatest insight is:
a) "our body needs vitamin D, and without healthy skin we cannot utilize it into a form we can use"
b) "without skin we would not be able to enjoy the sense of touch that is so important to us as humans"
c) "the skin is a barrier that is really quite good at keeping disease-causing pathogens from getting into our body"
d) "it is the skin with pain receptors that alert us to danger so that we can take appropriate action in order to be safe"
c) "the skin is a barrier that is really quite good at keeping disease-causing pathogens from getting into our body"
×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.x
papule
elevated skin, small
Vesicle filled with pus
Pustule
a) An abdominal restraint should be placed on the client during sleeping hours.
b) The client should be checked frequently during the night.
c) A radio should be left playing at the bedside to assist in reality orientation.
d) The client should be placed in a room that is away from the activity of the nurses’ station.
b) The client should be checked frequently during the night.
×Alternatives to restraints should be attempted first. (A physician’s order is required for restraints to be applied.) The most appropriate intervention is to check on the client frequently. Alternatives to restraints should be attempted first before an abdominal restraint while sleeping. A radio may help orientate a client to reality. However, the most appropriate intervention for the client who wanders is to check on the client frequently. Clients who wander should be assigned to rooms near the nurses’ station and checked on frequently.
The nurse has investigated safety hazards and recognizes which one of the following statements is accurate regarding safety needs?
a) Bacterial contamination of foods is uncontrollable.
b) Fire is the greatest cause of unintentional death.
c) Carbon dioxide levels should be monitored in home settings.
d) Temperature extremes seldom affect the safety of clients in acute care facilities.
c) Carbon dioxide levels should be monitored in home settings.
×Annual inspections of heating systems, chimneys, and appliances should be done in private homes. Carbon monoxide detectors are available but should not be used as a replacement for proper use and maintenance of fuel-burning appliances. Bacterial contamination of foods is controllable. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances. Motor vehicle accidents are the leading cause of unintentional death, not fire. Temperature extremes can affect the safety of clients in acute care facilities, especially the elderly.x
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:
a) reduced skin elasticity is common in the older adult
b) the attachment between the epidermis and dermis is weaker
c) the older client has less subcutaneous padding on the elbows
d)older adults have a poor diet that increases risk for pressure ulcers
c) the older client has less subcutaneous padding on the elbows
×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.x
Linear crack with sharp edges
Fissure
Nodule or Tumor
elevated hard mass, deep
The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the client's skin integrity?
a) having the client sit up in a chair for 4-hour intervals
b) keeping the head of bed in a high-Fowler's position to increase circulation
c) keeping a written schedule of turning and positioning
d) encouraging the client to perform pelvic muscle training exercises several times a day
c) keeping a written schedule of turning and positioning.
×The frequency of repositioning should be individualized for the client; however, clients should be repositioned at least every 2 hours. The Agency for Healthcare Research and Policy (AHRQ) guidelines recommend that a written turning and positioning schedule be used. Clients able to sit in a chair should be limited to sitting for 2 hours or less. Elevating the head of the bed to 30 degrees or less will decrease the chance of pressure ulcer development from shearing forces. Pelvic muscle training may help prevent incontinence, but it is not the best intervention for maintaining the client’s skin integrity. x
Which of the following statements made by an older adult client alerts the nurse to the possibility of medication errors?
a) “My husband is on the same medication, so we always take our medications together in the morning.”
b) “I prepare all my medication for the week and place the pills in a container labeled for each day.”
c) “When I don’t sleep well at night, I take two thyroid pills the next day instead of just one.”
d) “I take my Coumadin every day when the noon news comes on the television.”
c) “When I don’t sleep well at night, I take two thyroid pills the next day instead of just one.”
×Changing the dose of medication without correct understanding of the drug’s use and appropriate schedule can cause serious problems.
Which of the following interventions is most likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose?
a) turn and position the client at least every 2 hours
b) use a lift sheet when moving the client up in the bed
c) change wet, soiled clothing as promptly as it is detected
d) keep the head of the client's bed elevated to less than 30 degrees
a) turn and position the client at least every 2 hours
×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.x
atrophy
paper-like, dry
Flat, unelevated change in color
Macule or Patch
The presence of arterial insufficiency is suspected during an inspection of the lower extremities when the nurse observes:
a) increased hair growth
b) cooler skin temperatures
c) marked edema
d) brown pigmentation
b) cooler skin temperatures
×In the presence of arterial insufficiency, the client has signs resulting from an absence of blood flow, such as pain, pallor, and decreased or absent pulses in the lower extremities. The lower extremities become dusky red when the extremity is lowered. They feel cool to touch because blood flow is blocked to the extremity. Decreased hair growth or the absence of hair growth over the legs may indicate arterial insufficiency. Marked edema is seen in venous insufficiency, not arterial insufficiency. Brown pigmentation around the ankles is seen in venous insufficiency. Skin changes in arterial insufficiency include thin, shiny skin, decreased hair growth, and thickened nails.
An 85-year-old client with diabetes, heart disease, and renal insufficiency is admitted. What action should the nurse take to prevent falls by this particular client?
a) Provide assistance to the client in getting out of the bed or chair.
b) Place the client in restraints to prevent movement without assistance.
c) Maintain the client on complete bedrest with the siderails up at all times.
d) Request that a family member remain with the client at all times to assist in ambulation.
a) Provide assistance to the client in getting out of the bed or chair.
×Advanced age, multiple illnesses, particularly those that result in alterations in sensation, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to prevent falls. The client should not be restrained or maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point.
Which of the following statements best reflects the nurse’s role in the health and maintenance of a client’s skin? (Select all that apply.)
a) “I’ll note on the client’s care plan to apply lotion to her dry elbows.”
b) “I’m on my way in to turn the client. Will you be able to help me?”
c) “The ancillary staff tells me that her skin is generally very dry.”
d) “The pressure ulcer on her hip has really gotten smaller.”
e) “Can you bring in some scented lotion for your mom?”
f) “A 1.5-cm reddened area noted on client’s left heel.”
a) “I’ll note on the client’s care plan to apply lotion to her dry elbows.”, b) “I’m on my way in to turn the client. Will you be able to help me?”, d) “The pressure ulcer on her hip has really gotten smaller.”, f) “A 1.5-cm reddened area noted on client’s left heel.”
×One of the nurse’s most important responsibilities is to monitor skin integrity and to plan, implement, and assess interventions to maintain skin integrity. The remaining options do not reflect nursing interventions—one reflects ancillary staff, and the other does not really mention the therapeutic role of the request.x
Vessivle/Bulla
What is the difference between a full-thickness and partial-thickness wound
A partial-thickness wound is confined to the dermis & epidermis. Full-thickness wounds also involve the subcutaneous tissue (maybe muscle and bone) and require connective tissue repair.
The nurse is planning a program on wound healing and includes information that smoking influences healing by:
a) suppressing protein synthesis
b) creating increased tissue fragility
c) depressing bone marrow function
d) reducing functional hemoglobin in the blood
d) reducing functional hemoglobin in the blood
×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.x
The nurse caring for clients in an acute care facility recognizes that attending to the safety of each client is most likely to result in: (Select all that apply.)
a) freedom from illness
b) a shorter hospital stay
c) attention to the basic human needs
d) a well-founded sense of well-being
e) preservation of the optimal functioning level
f) minimal exposure to bacterial cross-contamination
b) a shorter hospital stay, c) attention to the basic human needs, d) a well-founded sense of well-being, e) preservation of the optimal functioning level, f) minimal exposure to bacterial cross-contamination
×Safety in health care settings reduces the incidence of illness and injury, prevents extended length of treatment and/or hospitalization, improves or maintains a client’s functional status, and increases the client’s sense of well-being. A safe environment gives protection to the staff as well, allowing them to function at an optimal level. A safe environment includes meeting basic needs, reducing physical hazards, reducing the transmission of pathogens, maintaining sanitation, and controlling pollution. While a reduction of illness is an expectation, there is no assurance of the freedom from illness.