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Nurs 155 Test 3- Activity/Immobility, Skin Integrity, Oxygenation and Circulation, Coping/Ethics exam with question and answer 100% correct

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Nurs 155 Test 3- Activity/Immobility, Skin Integrity, Oxygenation and Circulation, Coping/Ethics exam with question and answer 100% correct

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12/27/25, 4:44 PM Nurs 155 Test 3- Activity/Immobility, Skin Integrity, Oxygenation and Circulation, Coping/Ethics Flashcards | Quizlet

Science Medicine Nursing


Nurs 155 Test 3- Activity/Immobility, Skin Integrity,
Oxygenation and Circulation, Coping/Ethics exam with
question and answer 100% correct


C




Terms in this set (236)



Delirium Reversible state of confusion-usually caused by a medical
condition


Depression Mood disorder; sense of hopelessness and persistent
unhappiness


dementia a gradual and irreversible loss of intellectual function


Hemiparesis weakness on one side of the body


*damage from right side of the brain affects the left side of the
body and vis versa


Types of sensory deficits and examples Tactile: touch; peripheral neuropathy


Smell: Olfactory; anosmia


Taste: Gustatory; decreased gustatory cells


Hearing: Auditory; conductive hearing loss, sensorineural
hearing loss, and presbycusis (age related hearing loss)


Equilibrium: motion sickness or Meniere's disease


Vision: Visual; myopia, presbyopia (far sightedness-age
related), cataracts (lens of the eye affected), glaucoma
(pressure on optic nerve), diabetic retinopathy (blood vessels
of eye are damaged due to diabetes), and macular
degeneration




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,12/27/25, 4:44 PM Nurs 155 Test 3- Activity/Immobility, Skin Integrity, Oxygenation and Circulation, Coping/Ethics Flashcards | Quizlet


If patient begins to complain of pair or if Range of motion exercises should be stopped; never
resistance to joint movement is met, range hyperextend or flex a joint beyond position of comfort
of motion exercises should be_____
page 560 safety practice alert


The nurse is preparing to provide wound 2. Transparent dressing
care to a client with a stage 1 pressure injury.
Which dressing would the nurse expect to A stage 1 pressure injury is characterized by intact
be prescribed in the treatment skin with nonblanchable erythema. Dressings used to manage
of this wound? a stage 1 pressure injury include transparent dressings,
hydrocolloid dressings, or no dressing and leaving the wound
1. Hydrogel dressing open to air. The wound should resolve without epidermal loss
2. Transparent dressing over a period of 7 to 14 days. Hydrogel dressings are used to
3. Antimicrobial dressing maintain a moist environment for wound healing. Calcium
4. Calcium alginate dressing alginate is absorbent and is used in stage 4 wounds or those
with deeper tissue injury. Antimicrobial dressings are used for
pressure injuries that are infected.


Test-Taking Strategy: Focus on the subject, the wound
dressing that is appropriate in the treatment of a stage 1
pressure injury. Remember that dressing use is conservative in
this type of pressure injury, and includes the use of transparent
dressings or no dressing. The wound is expected to heal
without epidermal loss over a period of 7 to 14 days.


The nurse in a long-term care facility is 4. The nursing student applies lotion to the dorsal and plantar
observing a nursing student provide foot surfaces of the feet and in between the toes.
care to a client with diabetes mellitus. Which
action by the nursing student would indicate Clients with diabetes mellitus are at an increased
a need for further teaching? risk for impaired skin integrity related to peripheral
neuropathy or vascular insufficiency. The feet are at an
1. The nursing student tells the client to increased risk for the development of wounds and some
avoid soaking the feet. clients may be unable to thoroughly inspect the feet regularly
2. The nursing student dries the feet due to impaired mobility or other impairments. Meticulous
thoroughly, including in between the toes. foot care is necessary to prevent complications. The client's
3. The nursing student advises the client to feet would
consult the physician or a podiatrist not be soaked to prevent maceration, or skin softening, as this
regarding nail trimming. increases the risk of infection. Regarding nail trimming, a
4. The nursing student applies lotion to the podiatrist or a physician's order may be necessary to trim the
dorsal and plantar surfaces of the feet and nails, as a client with diabetes mellitus is at increased risk for
in between the toes. infection if the skin were to be accidentally cut. The feet need
to be dried thoroughly, with special attention given to the
areas between the toes, as skin breakdown or ulcers can go
undetected in this area. Lotion needs to be applied to the
dorsal and plantar surfaces of the foot. However, it would not
be applied between the toes as this area needs to be kept dry.
Therefore, option 4 is the action by the nursing student that
requires a need for further teaching.




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,12/27/25, 4:44 PM Nurs 155 Test 3- Activity/Immobility, Skin Integrity, Oxygenation and Circulation, Coping/Ethics Flashcards | Quizlet


As the nurse, you are providing care for a B) Petechiae
client and notice tiny, pinpoint red or purple
spots. It would appropriate for you to
document these spots as
A) mottling
B)petechiae
C)cyanosis
D)jaundice.


As they nurse, you are performing a physical C) Ecchymosis
assessment of a client and find an area of
bluish marbling. You should document this
area as
A) flushing
B) mottling
C) ecchymosis
D) cyanosis.


Fibrin connective tissue that deposits in injured area and becomes
framework for cell repair.


Scab consists of clots and dead/dying tissue and serves to aid
hemostasis and inhibit contamination of wound by
microorganisms.


collagen whitish protein substance that adds tensile strength to the
wound.


Granulation tissue translucent red, fragile, bleeds easily. Has network of
capillaries increasing the blood supply


Eschar dried plasma proteins and dead cells


Scar thick grey, fibrinous tissue


Keloid in some dark-skinned individuals an abnormal amount of
collagen is laid down, resulting in a hypertrophic scar.


Clean wound uninfected wound sin which there is minimal inflammation and
the respiratory, GI, genital, and urinary tracts are not entered.
Primarily closed wounds.


Clean-contaminated wound surgical wounds in which the respiratory, GI, genital, or urinary
tract has been entered. Show no signs of infection.




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, 12/27/25, 4:44 PM Nurs 155 Test 3- Activity/Immobility, Skin Integrity, Oxygenation and Circulation, Coping/Ethics Flashcards | Quizlet


Pressure injuries areas of compromised tissue integrity as a result of sustained
pressure on a particular area of the body


* most common over bony prominences




Risk factors for pressure ulcers aging skin
immobility
moisture/incontinence
obesity or lean body mass.
poor or inadequate nutrition (low protein intake)
Poor or inadequate hydration
Illness-fever and dehydration
anemia
impaired circulation/Vascular disorders
edema
sensory deficits
decreased loss of consciousness or under sedation
skin friction/shearing


Purple, dark red or brown discoloration on Suspected Deep Tissue Injury
the skin but the skin is intact. Injury occurs
under the skin and depth cannot be
determined. Pain complaint prior to
discoloration appears. Skin feels mushy,
warm, firm, and cool compared to
surrounding skin.


Slough or eschar covers the entire wound or Unstageable pressure injury
part of the wound, and depth cannot be
assessed.


Wound edges line up approximated


Factors affecting wound healing Oxygenation and tissue perfusion
Diabetes
Nutrition
Age
Infection


Position for relieving pressure from sacrum Side lying at 30 degrees.
and greater trochanter


Scales that measure a person's risk factor for Norton Scale and Braden Scale
pressure injuries




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