Nurs 155 Test 3- Skin Integrity,
Oxygenation and Circulation
Questions And Correct Answers
Delirium Answers Reversible state of confusion-usually caused by a
medical condition
Depression Answers Mood disorder; sense of hopelessness and persistent
unhappiness
dementia Answers a gradual and irreversible loss of intellectual function
Hemiparesis Answers 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 Answers 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
If patient begins to complain of pair or if resistance to joint movement is met,
range of motion exercises should be_____ Answers Range of motion
exercises should be stopped; never hyperextend or flex a joint beyond
position of comfort
page 560 safety practice alert
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 Answers 2. Transparent dressing
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 epidermal 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.
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. Answers 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 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.
, 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. Answers B) Petechiae
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. Answers C) Ecchymosis
Fibrin Answers connective tissue that deposits in injured area and
becomes framework for cell repair.
Scab Answers consists of clots and dead/dying tissue and serves to aid
hemostasis and inhibit contamination of wound by microorganisms.
collagen Answers whitish protein substance that adds tensile strength to
the wound.
Granulation tissue Answers translucent red, fragile, bleeds easily. Has
network of capillaries increasing the blood supply
Eschar Answers dried plasma proteins and dead cells
Scar Answers thick grey, fibrinous tissue
Keloid Answers in some dark-skinned individuals an abnormal amount of
collagen is laid down, resulting in a hypertrophic scar.
Clean wound Answers 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 Answers surgical wounds in which the
respiratory, GI, genital, or urinary tract has been entered. Show no signs of
infection.
Oxygenation and Circulation
Questions And Correct Answers
Delirium Answers Reversible state of confusion-usually caused by a
medical condition
Depression Answers Mood disorder; sense of hopelessness and persistent
unhappiness
dementia Answers a gradual and irreversible loss of intellectual function
Hemiparesis Answers 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 Answers 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
If patient begins to complain of pair or if resistance to joint movement is met,
range of motion exercises should be_____ Answers Range of motion
exercises should be stopped; never hyperextend or flex a joint beyond
position of comfort
page 560 safety practice alert
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 Answers 2. Transparent dressing
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 epidermal 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.
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. Answers 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 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.
, 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. Answers B) Petechiae
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. Answers C) Ecchymosis
Fibrin Answers connective tissue that deposits in injured area and
becomes framework for cell repair.
Scab Answers consists of clots and dead/dying tissue and serves to aid
hemostasis and inhibit contamination of wound by microorganisms.
collagen Answers whitish protein substance that adds tensile strength to
the wound.
Granulation tissue Answers translucent red, fragile, bleeds easily. Has
network of capillaries increasing the blood supply
Eschar Answers dried plasma proteins and dead cells
Scar Answers thick grey, fibrinous tissue
Keloid Answers in some dark-skinned individuals an abnormal amount of
collagen is laid down, resulting in a hypertrophic scar.
Clean wound Answers 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 Answers surgical wounds in which the
respiratory, GI, genital, or urinary tract has been entered. Show no signs of
infection.
