Chapter 29. Skin Integrity and Wound Care: Assess and Recognize Cues Awesome Guide With 100% Correct And Verified Answers.

Which question would the nurse ask to determine the patient's health history about skin integrity? Does your skin pain feel sharp, achy, or dull? When did you notice the lesion on your skin? Has anyone in your family had a skin disorder? Can a family member help you care for the lesion? - correct answer Has anyone in your family had a skin disorder? Which finding is expected in a physical skin assessment? Elastic skin turgor Nonintact skin Stage 1 pressure injury Cool, dry skin - correct answer Elastic skin turgor Which primary parameters are measured when using the Norton Scale? Select all that apply. Activity Mobility Mental state Friction and shear Sensory perception - correct answer Activity Mobility Mental state Which parameters would the nurse assess when performing a focused wound assessment? Select all that apply. Location Drainage Wound bed Level of pain tolerance Presence of tunneling - correct answer Location Drainage Wound bed Presence of tunneling Which steps are involved in measuring wound undermining? Select all that apply. Administer pain medication. Laterally insert the cotton-tipped applicator into the widest section. Measure any changes in the surrounding skin that may indicate infection. Mark the area on the stick end of the applicator that is even with the edges of the skin. Measure the distance from the top of the applicator to the marked area. - correct answer Administer pain medication. Laterally insert the cotton-tipped applicator into the widest section. Mark the area on the stick end of the applicator that is even with the edges of the skin. Measure the distance from the top of the applicator to the marked area Which cue is relevant for a patient who has a wound? Living in a northern state Having a high creatinine level Being male Having a low prealbumin level - correct answer Having a low prealbumin level Which factors can make a patient prone to pressure injuries? Select all that apply. Inactivity Immobility Young age Incontinence Malnourishment - correct answer Inactivity Immobility Incontinence Malnourishment Which cue about a wound is an immediate concern? Excessive bleeding Staples in place Packing in a wound Infected wound - correct answer Excessive bleeding Which cues are relevant for an infected wound? Select all that apply. Decreased white blood cell count Positive culture growth Purulent drainage Induration around edges Granulated wound bed - correct answer Positive culture growth Purulent drainage Induration around edges Which obesity factors contribute to a nonhealing wound? Select all that apply. Excess of needed nutrients Lack of blood vessels in adipose tissue Undue pressure on wound edges Presence of a pale wound bed Decreased oxygen and nutrients to the wound - correct answer Lack of blood vessels in adipose tissue Undue pressure on wound edges Decreased oxygen and nutrients to the wound Which reasoning explains why a nurse measures wound size during an initial wound assessment? To determine the proper medication amount for the wound To help assess progression of wound healing To provide evidence for the presence of infection To reassure patients they are receiving proper care - correct answer To help assess progression of wound healing Which cues related to skin integrity may reflect an overall health problem? Select all that apply. Cracking Tenting Warm skin temperature Pathogens identified in a wound culture Immunocompetence - correct answer Cracking Tenting Pathogens identified in a wound culture Which term would the nurse use to describe excessive moisture on the patient's skin? Diaphoresis Ashen Purpura Icterus - correct answer Diaphoresis Match the type of wound drainage to the color of fluid the nurse would observe on a patient's dressing. Clear and watery - Pink to pale red - Bright red - Greenish, yellow - Purulent Serosanguineous Serous Sanguineous - correct answer Clear and watery - Serous Pink to pale red - Serosanguineous Bright red - Sanguineous Greenish, yellow - Purulent Which factors may impact the development of pressure injuries or nonhealing wounds? Select all that apply. Smoking Diabetes Specific gender Urinary incontinence Skin tone - correct answer Smoking Diabetes Urinary incontinence Which statements by the nurse caring for a postoperative patient who suffered a spinal cord injury indicate correct understanding about assessment tools? Select all that apply. "I can use the Braden Scale to assess for the risk for infection." "The Norton Scale is used to assess for pressure injury risk." "I can use the Braden Scale to assess my patient's surgical incision." "When assessing for open wounds, I can use the Wound Characteristic Instrument." "The Pressure Ulcer S - correct answer "The Norton Scale is used to assess for pressure injury risk." "When assessing for open wounds, I can use the Wound Characteristic Instrument." Which type of fluid would the nurse likely observe if the patient was hemorrhaging? Serous Serosanguineous Sanguineous Purulent - correct answer Sanguineous Which interpretation would the nurse make about a patient's wound culture that is positive? It is infected. It is hemorrhaging. It is eviscerated. It is nonhealing. - correct answer It is infected. Match the unexpected skin assessment finding to its description. Blue skin - Pinpoint, flat, red spots - Red skin - Bruise - Ecchymosis Jaundice Purpura Erythema Petechiae Cyanosis - correct answer Blue skin - Cyanosis Pinpoint, flat, red spots - Petechiae Red skin - Erythema Bruise - Ecchymosis Which factors can place a patient at risk for a pale, dry wound? Select all that apply. Anemia Diabetes Wound infection Vascular disease Nutritional deficiencies - correct answer Anemia Diabetes Vascular disease Nutritional deficiencies Which cues would the nurse observe for a patient with an infected lateral malleolus wound? Select all that apply. Erythema noted on the superior portion of the wound Purulent, malodorous drainage 1.5-cm wound with serous drainage and tissue epithelialization Temperature of 102°F (38.9°C) Pain level of 2/10 - correct answer Erythema noted on the superior portion of the wound Purulent, malodorous drainage Temperature of 102°F (38.9°C) Which Braden Scale score range would alert the nurse that a patient is at moderate risk for pressure injury development? __13-14_______ Record your answer as whole numbers separated by a hyphen - correct answer 13-14 Which patient is likely at risk for developing a pressure injury? Patient with unrelieved pressure who has a fractured hip Patient with a history of sports-related injuries and concussions Left-handed patient with a broken left wrist Paralyzed patient who is being turned and repositioned every 2 hours - correct answer Patient with unrelieved pressure who has a fractured hip Which steps would the nurse take to measure the dimensions of a sacral pressure injury? Select all that apply. Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound. Measure the width laterally from left to right at the widest portion of the wound. Measure the depth of the unde