Test 3 Nursing 155 Study Notes - Key Concepts & Wound Care Insights

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Activity/Immobility, SkinIntegrity, Oxygenation andCirc lation, Coping/Eth
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ics
Study online at https://quizlet.com/_ctjwkg Reversible state of confusion-usually caused by a medical condi- tt tt tt tt tt tt tt tt
Delirium tt tt tt

tion
Mood disorder; sense of hopelessness and persistent unhappi-
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Depression
ness
dementia a gradual and irreversible loss of intellectual function
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weakness on one side of the body tt tt tt tt tt tt



Hemiparesis
*damage from right side of the brain affects the left side of the bod tt tt tt tt tt tt tt tt tt tt tt tt tt

y and vis versa
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Tactile: touch; peripheral neuropathy Smell tt tt tt tt




: Olfactory; anosmia
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Taste: Gustatory; decreased gustatory cells tt tt tt tt




Hearing: Auditory; conductive hearing loss, sensorineural hearing lo t t t t t t tt

Types of sensory deficits and examples tt tt tt tt tt ss, and presbycusis (age related hearing loss)
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Equilibrium: motion sickness or Meniere's disease tt tt tt tt tt




Vision: Visual; m yopia, presbyopia (far sightedness- t t tt tt tt

age related), cataracts (lens of the eye affected), glaucoma (pressu
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re on optic nerve), diabetic retinopathy (blood vessels of eye are d
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amaged due to diabetes), and macular degeneration tt tt tt tt tt tt



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



2. Transparent dressing
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A stage 1 pressure injury is characterized by intact tt tt tt tt tt tt tt tt

skin with nonblanchable erythema. Dressings used to manage a s tt tt tt tt tt tt tt tt tt

tage 1 pressure injury include transparent dressings, hydrocol- tt tt tt tt tt tt tt

The nurse is preparing to provide wound care to a client with a st loid dressings, or no dressing and leaving the wound open to air. T
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age 1 pressure injury.W hich dressing would the nurse expect to b he wound should resolve without epidermal loss over a period of
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e prescribed in the treatment
tt 7 to 14 days. Hydrogel dressings are used to maintain a moist envi
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of this wound?
tt tt ronment for wound healing.Calcium alginate is absorbent and is use tt tt tt t tt tt tt tt tt tt

d in stage 4 wounds or those with deeper tissue injury. tt tt tt tt tt tt tt tt tt tt

1. Hydrogel dressing tt Antimicrobial dressings are used for pressure injuries that are infect tt tt tt tt tt tt tt tt tt

2. Transparent dressing ed. tt

3. Antimicrobial dressing tt

4. Calcium alginate dressing tt Test- tt

Taking Strategy: Focus on the subject, the wound dressing that is tt tt tt tt tt tt tt tt tt tt t

appropriate in the treatment of a stage 1 pressure injury. Remem t tt tt tt tt tt tt tt tt tt tt

ber that dressing use is conservative in this type of pres- tt tt tt tt tt tt tt tt tt tt

sure injury, and includes the use of transparent dressings or no d tt tt tt tt tt tt tt tt tt tt tt

ressing. The wound is expected to heal without epidermal loss ov t tt tt tt tt tt tt tt tt tt

er a period of 7 to 14 days. tt tt tt tt tt tt tt



4. The nursing student applies lotion to the dorsal and plantar surfa
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ces of the feet and in between the toes.
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The nurse in a long-
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term care facility is observing a nursing student provide foot care t Clients with diabetes mellitus are at an increased
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o a client with diabetes mellitus.W hich action by the nursing stude
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risk for impaired skin integrity related to peripheral neuropathy o tt tt tt tt tt tt tt tt tt
nt would indicate a need for further teaching?
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r vascular insufficiency. The feet are at an increased risk for the d tt tt t tt tt tt tt tt tt tt tt tt

evelopment of wounds and some clients may be unable to thorou tt tt tt tt tt tt tt tt tt tt
1. The nursing student tells the client to avoid soaking the feet.
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ghly inspect the feet regularly due to impaired mobility or other im tt tt tt tt tt tt tt tt tt tt tt
2. The nursing student dries the feet thoroughly, including in
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pairments. Meticulous foot care is necessary to prevent complicat t tt tt tt tt tt tt tt

ions. The client's feet would tt tt tt tt

not be soaked to prevent maceration, or skin softening, as this i tt tt tt tt tt tt tt tt tt tt tt

ncreases the risk of infection. Regarding nail trimming, a podi- tt tt tt tt tt tt tt tt tt




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,Nurs155Test3-
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Activity/Immobility, SkinIntegrity, Oxygenation andCirc lation, Coping/Eth
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ics
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Activity/Immobility, SkinIntegrity, Oxygenation andCirc lation, Coping/Eth
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ics
atrist or a physician's order may be necessary to trim the nails, as
Study online at https://quizlet.com/_ctjwkg
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a client with diabetes mellitus is at increased risk for infection if th tt tt tt tt tt tt tt tt tt tt tt tt

between the toes. tt tt e skin were to be accidentally cut. The feet need to be dried thorou tt tt tt tt tt tt t tt tt tt tt tt tt

3.The nursing student advises the client to consult the physician o ghly, with special attention given to the areas between the toes, a
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r a podiatrist regarding nail trimming.
tt tt tt s skin breakdown or ulcers can go undetected in this area. Lotion n
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4.The nursing student applies lotion to the dorsal and plantar surfa eeds to be applied to the dorsal and plantar surfaces of the foot.H
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ces of the feet and in between the toes.
tt tt tt owever, it would not be applied between the toes as this area needs t
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o be kept dry.Therefore, option 4 is the action by the nursing studen tt tt tt t tt tt tt tt tt tt tt tt tt

t that requires a need for further teaching. tt tt tt tt tt tt tt


As the nurse, you are providing care for a client and notice
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tiny, pinpoint red or purple spots. It would appropriate for you to do
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cument these spots as tt tt tt

A) mottling B tt B) Petechiae
)petechiae tt

C)cyanosis tt

D)jaundice.
As they nurse, you are performing a physical assessment of a cli
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ent and find an area of bluish marbling.You should document this a
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rea as tt

A) flushing C) Ecchymosis
B) mottling
C) ecchymosis
D) cyanosis.
connective tissue that deposits in injured area and becomes fram tt tt tt tt tt tt tt tt tt
Fibrin
ework for cell repair. tt tt tt



consists of clots and dead/dying tissue and serves to aid hemo-
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Scab
stasis and inhibit contamination of wound by microorganisms.
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collagen whitish protein substance that adds tensile strength to the wound.
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translucent red, fragile, bleeds easily. Has network of capillaries incr tt tt tt tt t tt tt tt tt
Granulation tissue tt
easing the blood supply tt tt tt



Eschar
dried plasma proteins and dead cells tt tt tt tt tt tt



Scar thick grey, fibrinous tissue tt tt tt



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


uninfected wound sin which there is minimal inflammation and tt tt tt tt tt tt tt tt

Clean wound tt the respiratory, GI, genital, and urinary tracts are not entered. P
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rimarily closed wounds. tt tt



surgical wounds in which the respiratory, GI, genital, or urinary trac
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Clean-contaminated wound tt
t has been entered. Show no signs of infection.
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areas of compromised tissue integrity as a result of sustained pre
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ssure on a particular area of the body
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* most common over bony prominences
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Pressure injuries tt




aging skin tt tt

immobility
moisture/incontinence obes tt

ity or lean body mass.
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poor or inadequate nutrition (low protein intake) Poor
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Activity/Immobility, SkinIntegrity, Oxygenation andCirc lation, Coping/Eth
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ics
Study online at https://quizlet.com/_ctjwkg
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