Chapter 36 Skin Integrity and Wound Care

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Chapter 36  Skin Integrity and Wound Care

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

MULTIPLE CHOICE

1. Mrs. Jenkins is a 78-year-old patient who was admitted to the hospital for a bowel obstruction. She is immobile and the nurse has noticed that she has a reddened area on her right heel. When the nurse presses on the area it does not turn lighter in color. She knows that the skin injury is reversible if the pressure is relieved and she uses measures to protect the tissue. How should the nurse document the tissue condition?
A.
Reactive hyperemia
B.
Blanchable hyperemia
C.
Nonblanchable hyperemia
D.
Cachexia

ANS: C
Nonblanchable hyperemia is redness that persists after palpation and indicates tissue damage. When you press a finger against the red or purple area, it does not turn lighter in color. Deep tissue damage is present and is commonly the first stage of pressure ulcer development.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 1059
OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) classification of pressure ulcer staging TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity

2. Jeannie is a nurse who works in a nursing home. One of the patients, 83-year-old Mrs. Stoll, is bedridden. Jeannie needs to pull her up in bed and instructs Fiona, the student nurse who is with her, that they need to make sure that they use the draw sheet to pull her up to avoid which of the following factors that would contribute to pressure ulcer formation?
A.
Hyperemia
B.
Shear
C.
Tissue ischemia
D.
Cachexia

ANS: B
Shear is the force exerted against the skin while the skin remains stationary and the bony structures move. For example, when the head of the bed is elevated, gravity causes the bony skeleton to pull toward the foot of the bed, while the skin remains against the sheets.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 1059
OBJ: Describe risk factors for pressure ulcer development
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment

3. Mrs. Griffin is a frail, elderly patient who has been admitted to the hospital for pneumonia. Which of the following factors is puts her at an increased risk for a pressure ulcer?
A.
She has had a diet low in protein.
B.
She has been on a low sodium diet.
C.
She has an IV of lactated Ringers running at 120 mL/hr.
D.
She is being repositioned every 2 hours.

ANS: A
Poor nutrition, specifically severe protein deficiency, causes soft tissue to become susceptible to breakdown. Low protein levels cause edema or swelling, which contributes to problems with oxygen transport and the transport of nutrients.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1060
OBJ: Describe risk factors for pressure ulcer development
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

4. Dottie is a 67-year-old patient who was admitted to the hospital when a community health nurse discovered that her family was having difficulty caring for her at home. She has a pressure ulcer on her sacrum. The wound is open with exposed bone. The nurse admitting her should document this as what stage of a pressure ulcer?
A.
Stage I
B.
Stage II
C.
Stage III
D.
Stage IV

ANS: D
Stage I:
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II:
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III:
Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV:
Full-thickness tissue loss with exposed bone, tendon, or muscle

PTS: 1 DIF: Cognitive Level: Application REF: 1061
OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) classification of pressure ulcer staging TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity

5. Frank is a 4-year-old paraplegic patient with cerebral palsy who was admitted to the hospital with complications from the H1N1 virus. The nurse who was admitting him noted that he had an area of redness on his right malleolus that was nonblanchable. The nurse correctly identified this area as what stage of a pressure ulcer?
A.
Stage I
B.
Stage II
C.
Stage III
D.
Stage IV

ANS: A
Stage I:
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II:
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III:
Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV:
Full-thickness tissue loss with exposed bone, tendon, or muscle

PTS: 1 DIF: Cognitive Level: Application REF: 1061
OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) classification of pressure ulcer staging TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity

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