Nurs 155 Exam 3
Study online at https://quizlet.com/_hntifx
1. Delirium: Reversible state of confusion-usually caused by a medical condition
2. Depression: Mood disorder; sense of hopelessness and persistent unhappiness
3. dementia: a gradual and irreversible loss of intellectual function
4. 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
5. 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
6. If patient begins to complain of pair or if resistance to joint movement is met,
range of motion exercises should be_____: Range of motion exercises should be stopped; never
hyperextend or flex a joint beyond position of comfort
page 560 safety practice alert
7. The nurse is preparing to provide wound care to a client with a stage 1
pressure injury. Which dressing would the nurse expect to be prescribed in the
treatment
of this wound?
1. Hydrogel dressing
2. Transparent dressing
3. Antimicrobial dressing
4. Calcium alginate dressing: 2. Transparent dressing
, Nurs 155 Exam 3
Study online at https://quizlet.com/_hntifx
A stage 1 pressure injury is characterized by intact
skin with nonblanchable erythema. Dressings used to manage a stage 1 pressure injury include transparent dressings,
hydrocolloid dressings, or no dressing and leaving the wound open to air. The wound should resolve without epiderma
loss over a period of 7 to 14 days. Hydrogel dressings are used to maintain a moist environment for wound healing.
Calcium 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.
8. The nurse in a long-term care facility is observing a nursing student provide
foot care to a client with diabetes mellitus. Which action by the nursing student
would indicate a need for further teaching?
1. The nursing student tells the client to avoid soaking the feet.
2. The nursing student dries the feet thoroughly, including in between the
toes.
3. The nursing student advises the client to consult the physician or a podiatrist
regarding nail trimming.
4. The nursing student applies lotion to the dorsal and plantar surfaces of the
feet and in between the toes.: 4. The nursing student applies lotion to the dorsal and plantar surfaces
of the feet and in between the toes.
Clients with diabetes mellitus are at an increased
risk for impaired skin integrity related to peripheral neuropathy or vascular insufficiency. The feet are at an increased
risk for the development of wounds and some clients may be unable to thoroughly inspect the feet regularly due to
impaired mobility or other impairments. Meticulous foot care is necessary to prevent complications. The client's feet
would
not be soaked to prevent maceration, or skin softening, as this increases the risk of infection. Regarding nail trimming,
a podiatrist or a physician's order may be necessary to trim the nails, as a client with diabetes mellitus is at increased
risk for infection if the skin were to be accidentally cut. The feet need to be dried thoroughly, with special attention
, Nurs 155 Exam 3
Study online at https://quizlet.com/_hntifx
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.
9. As the nurse, you are providing care for a 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.: B) Petechiae
10. As they nurse, you are performing a physical 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.: C) Ecchymosis
11. Fibrin: connective tissue that deposits in injured area and becomes framework for cell repair.
12. Scab: consists of clots and dead/dying tissue and serves to aid hemostasis and inhibit contamination of wound
by microorganisms.
13. collagen: whitish protein substance that adds tensile strength to the wound.
14. Granulation tissue: translucent red, fragile, bleeds easily. Has network of capillaries increasing the blood
supply
15. Eschar: dried plasma proteins and dead cells
16. Scar: thick grey, fibrinous tissue
17. Keloid: in some dark-skinned individuals an abnormal amount of collagen is laid down, resulting in a hyper-
trophic scar.
18. Clean wound: uninfected wound sin which there is minimal inflammation and the respiratory, GI, genital,
and urinary tracts are not entered. Primarily closed wounds.
19. Clean-contaminated wound: surgical wounds in which the respiratory, GI, genital, or urinary tract has
been entered. Show no signs of infection.
20. Pressure injuries: areas of compromised tissue integrity as a result of sustained pressure on a particular
area of the body
, Nurs 155 Exam 3
Study online at https://quizlet.com/_hntifx
* most common over bony prominences
21. 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
22. Purple, dark red or brown discoloration on 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 com-
pared to surrounding skin.: Suspected Deep Tissue Injury
23. Slough or eschar covers the entire wound or part of the wound, and depth
cannot be assessed.: Unstageable pressure injury
24. Wound edges line up: approximated
25. Factors affecting wound healing: Oxygenation and tissue perfusion
Diabetes
Nutrition
Age
Infection
26. Position for relieving pressure from sacrum and greater trochanter: Side lying
at 30 degrees.
Study online at https://quizlet.com/_hntifx
1. Delirium: Reversible state of confusion-usually caused by a medical condition
2. Depression: Mood disorder; sense of hopelessness and persistent unhappiness
3. dementia: a gradual and irreversible loss of intellectual function
4. 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
5. 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
6. If patient begins to complain of pair or if resistance to joint movement is met,
range of motion exercises should be_____: Range of motion exercises should be stopped; never
hyperextend or flex a joint beyond position of comfort
page 560 safety practice alert
7. The nurse is preparing to provide wound care to a client with a stage 1
pressure injury. Which dressing would the nurse expect to be prescribed in the
treatment
of this wound?
1. Hydrogel dressing
2. Transparent dressing
3. Antimicrobial dressing
4. Calcium alginate dressing: 2. Transparent dressing
, Nurs 155 Exam 3
Study online at https://quizlet.com/_hntifx
A stage 1 pressure injury is characterized by intact
skin with nonblanchable erythema. Dressings used to manage a stage 1 pressure injury include transparent dressings,
hydrocolloid dressings, or no dressing and leaving the wound open to air. The wound should resolve without epiderma
loss over a period of 7 to 14 days. Hydrogel dressings are used to maintain a moist environment for wound healing.
Calcium 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.
8. The nurse in a long-term care facility is observing a nursing student provide
foot care to a client with diabetes mellitus. Which action by the nursing student
would indicate a need for further teaching?
1. The nursing student tells the client to avoid soaking the feet.
2. The nursing student dries the feet thoroughly, including in between the
toes.
3. The nursing student advises the client to consult the physician or a podiatrist
regarding nail trimming.
4. The nursing student applies lotion to the dorsal and plantar surfaces of the
feet and in between the toes.: 4. The nursing student applies lotion to the dorsal and plantar surfaces
of the feet and in between the toes.
Clients with diabetes mellitus are at an increased
risk for impaired skin integrity related to peripheral neuropathy or vascular insufficiency. The feet are at an increased
risk for the development of wounds and some clients may be unable to thoroughly inspect the feet regularly due to
impaired mobility or other impairments. Meticulous foot care is necessary to prevent complications. The client's feet
would
not be soaked to prevent maceration, or skin softening, as this increases the risk of infection. Regarding nail trimming,
a podiatrist or a physician's order may be necessary to trim the nails, as a client with diabetes mellitus is at increased
risk for infection if the skin were to be accidentally cut. The feet need to be dried thoroughly, with special attention
, Nurs 155 Exam 3
Study online at https://quizlet.com/_hntifx
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.
9. As the nurse, you are providing care for a 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.: B) Petechiae
10. As they nurse, you are performing a physical 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.: C) Ecchymosis
11. Fibrin: connective tissue that deposits in injured area and becomes framework for cell repair.
12. Scab: consists of clots and dead/dying tissue and serves to aid hemostasis and inhibit contamination of wound
by microorganisms.
13. collagen: whitish protein substance that adds tensile strength to the wound.
14. Granulation tissue: translucent red, fragile, bleeds easily. Has network of capillaries increasing the blood
supply
15. Eschar: dried plasma proteins and dead cells
16. Scar: thick grey, fibrinous tissue
17. Keloid: in some dark-skinned individuals an abnormal amount of collagen is laid down, resulting in a hyper-
trophic scar.
18. Clean wound: uninfected wound sin which there is minimal inflammation and the respiratory, GI, genital,
and urinary tracts are not entered. Primarily closed wounds.
19. Clean-contaminated wound: surgical wounds in which the respiratory, GI, genital, or urinary tract has
been entered. Show no signs of infection.
20. Pressure injuries: areas of compromised tissue integrity as a result of sustained pressure on a particular
area of the body
, Nurs 155 Exam 3
Study online at https://quizlet.com/_hntifx
* most common over bony prominences
21. 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
22. Purple, dark red or brown discoloration on 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 com-
pared to surrounding skin.: Suspected Deep Tissue Injury
23. Slough or eschar covers the entire wound or part of the wound, and depth
cannot be assessed.: Unstageable pressure injury
24. Wound edges line up: approximated
25. Factors affecting wound healing: Oxygenation and tissue perfusion
Diabetes
Nutrition
Age
Infection
26. Position for relieving pressure from sacrum and greater trochanter: Side lying
at 30 degrees.
