Chapter 23: Concepts of Care for Patients With Skin Problems
Ignataviciu Medical-Surgical Nursing, 10th Edition
1. A nurse teaches a client who has pruritus. Which statement by the
client shows a need to
review the information?
a. "I will shower daily using a super-fatted soap."
b. "I can try taking a bath with colloidal oatmeal."
c. "I will pat my skin dry instead of rubbing it with a towel."
d. "I will be careful to keep my nails filed smoothly.": ANS: D
The client with pruritus should shower only every other day, although
super-fatted soap is an
appropriate choice. Colloidal oatmeal baths are very soothing. Patting
the skin dry avoids
trauma and injury. Keeping nails filed smoothly also prevents injury.
2. A nurse assesses clients on a medical-surgical unit. Which client is
at greatest risk for pressure
injury development?
a. A 44 year old prescribed IV antibiotics for pneumonia
b. A 26 year old who is bedridden with a fractured leg
c. A 65 year old with hemiparesis and incontinence
d. A 78 year old requiring assistance to ambulate with a walker: ANS: C
Risk factors for development of a pressure injury include lack of
mobility, exposure of skin to
excessive moisture (e.g., urinary or fecal incontinence),
malnourishment, and aging skin. The
client with hemiparesis and incontinence has two risk factors. The client
with pneu- monia has
, Chapter 23: Concepts of Care for Patients With Skin Problems
Ignataviciu Medical-Surgical Nursing, 10th Edition
no identified risk factors. The other two are at lower risk if they are not
very mobile, but
having two risk factors is a higher risk.
3. A nurse is caring for a client with an electrical burn. The client has
entrance wounds on the
hands and exit wounds on the feet. What information is most important to
include when
planning care?
a. The client may have memory and cognitive issues postburn.
b. Everything between the entry and exit wounds can be damaged.
c. The respiratory system requires close monitoring for signs of swelling.
d. Electrical burns increase the risk of developing future cancers.: ANS:
B As the electricity enters the body, travels through various tissues,
and exits, it damages all the
tissue it flows through. There may be severe internal injury that is not
yet apparent.
The client
may have cognitive issues postburn but this is not as important as
vigilant monitoring for
complications. Respiratory system swelling is associated with thermal
burns and smoke
inhalation. Exposure to radiation increases cancer risk.
4. A nurse cares for a client who has a stage 3 pressure injury with
copious exudate. What type
of dressing does the nurse use on this wound?
, Chapter 23: Concepts of Care for Patients With Skin Problems
Ignataviciu Medical-Surgical Nursing, 10th Edition
a. Wet-to-damp saline moistened gauze
b. None, the wound is left open to the air
c. A transparent film
d. Multi-fiber superabsorbent dressing: ANS: D
This pressure injury requires a superabsorbent dressing that will collect
the exudate but not
stick to the wound itself. A wet-to-damp gauze dressing provides
mechanical re- moval of
necrotic tissue. A draining wound would not be left open. A transparent
film is a good choice
for a noninfected stage 2 pressure injury.
5. A nurse is caring for a client who has a nonhealing pressure injury on
the right ankle. Which
action would the nurse take first?
a. Draw blood for albumin, prealbumin, and total protein.
b. Prepare for and assist with obtaining a wound culture.
c. Instruct the client to elevate the foot.
d. Assess the right leg for pulses, skin color, and temperature.: ANS: D
A client with an ulcer on the foot would be assessed for interruption in
arterial flow to the
area. This begins with the assessment of pulses and color and
temperature of the skin. The
nurse can also assess for pulses noninvasively with a Doppler
flowmeter if unable to palpate
with his or her fingers. Tests to determine nutritional status and risk
Ignataviciu Medical-Surgical Nursing, 10th Edition
1. A nurse teaches a client who has pruritus. Which statement by the
client shows a need to
review the information?
a. "I will shower daily using a super-fatted soap."
b. "I can try taking a bath with colloidal oatmeal."
c. "I will pat my skin dry instead of rubbing it with a towel."
d. "I will be careful to keep my nails filed smoothly.": ANS: D
The client with pruritus should shower only every other day, although
super-fatted soap is an
appropriate choice. Colloidal oatmeal baths are very soothing. Patting
the skin dry avoids
trauma and injury. Keeping nails filed smoothly also prevents injury.
2. A nurse assesses clients on a medical-surgical unit. Which client is
at greatest risk for pressure
injury development?
a. A 44 year old prescribed IV antibiotics for pneumonia
b. A 26 year old who is bedridden with a fractured leg
c. A 65 year old with hemiparesis and incontinence
d. A 78 year old requiring assistance to ambulate with a walker: ANS: C
Risk factors for development of a pressure injury include lack of
mobility, exposure of skin to
excessive moisture (e.g., urinary or fecal incontinence),
malnourishment, and aging skin. The
client with hemiparesis and incontinence has two risk factors. The client
with pneu- monia has
, Chapter 23: Concepts of Care for Patients With Skin Problems
Ignataviciu Medical-Surgical Nursing, 10th Edition
no identified risk factors. The other two are at lower risk if they are not
very mobile, but
having two risk factors is a higher risk.
3. A nurse is caring for a client with an electrical burn. The client has
entrance wounds on the
hands and exit wounds on the feet. What information is most important to
include when
planning care?
a. The client may have memory and cognitive issues postburn.
b. Everything between the entry and exit wounds can be damaged.
c. The respiratory system requires close monitoring for signs of swelling.
d. Electrical burns increase the risk of developing future cancers.: ANS:
B As the electricity enters the body, travels through various tissues,
and exits, it damages all the
tissue it flows through. There may be severe internal injury that is not
yet apparent.
The client
may have cognitive issues postburn but this is not as important as
vigilant monitoring for
complications. Respiratory system swelling is associated with thermal
burns and smoke
inhalation. Exposure to radiation increases cancer risk.
4. A nurse cares for a client who has a stage 3 pressure injury with
copious exudate. What type
of dressing does the nurse use on this wound?
, Chapter 23: Concepts of Care for Patients With Skin Problems
Ignataviciu Medical-Surgical Nursing, 10th Edition
a. Wet-to-damp saline moistened gauze
b. None, the wound is left open to the air
c. A transparent film
d. Multi-fiber superabsorbent dressing: ANS: D
This pressure injury requires a superabsorbent dressing that will collect
the exudate but not
stick to the wound itself. A wet-to-damp gauze dressing provides
mechanical re- moval of
necrotic tissue. A draining wound would not be left open. A transparent
film is a good choice
for a noninfected stage 2 pressure injury.
5. A nurse is caring for a client who has a nonhealing pressure injury on
the right ankle. Which
action would the nurse take first?
a. Draw blood for albumin, prealbumin, and total protein.
b. Prepare for and assist with obtaining a wound culture.
c. Instruct the client to elevate the foot.
d. Assess the right leg for pulses, skin color, and temperature.: ANS: D
A client with an ulcer on the foot would be assessed for interruption in
arterial flow to the
area. This begins with the assessment of pulses and color and
temperature of the skin. The
nurse can also assess for pulses noninvasively with a Doppler
flowmeter if unable to palpate
with his or her fingers. Tests to determine nutritional status and risk
