Nursing Exam: Skin Integrity and Wound Care Questions with Solutions, Exams of Nursing

Download Nursing Exam: Skin Integrity and Wound Care Questions with Solutions and more Exams Nursing in PDF only on Docsity! NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers. DIF: Remember REF: 1177-1178 OBJ: Discuss the risk factors that contribute to pressure ulcer formation. TOP: Assessment MSC: Physiological Integrity: Reduction of Risk Potential  Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? a. The patient ate two thirds of breakfast. b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient’s capillary refill is less than 2 seconds. ANS: B The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits. DIF: Understand REF: 1177-1178 OBJ: Discuss the risk factors that contribute to pressure ulcer formation. TOP: Implementation MSC: Physiological Integrity: Reduction of Risk Potential NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023  The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? a. Stage I pressure ulcer b. Healing stage II pressure ulcer c. Healing stage III pressure ulcer d. Stage III pressure ulcer ANS: C When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words “healing stage.” Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III. DIF: Remember REF: 1178-1179 OBJ: Describe the pressure ulcer staging system. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage a. I. b. II. c. III. d. IV. ANS: B This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle. DIF: Remember REF: 1178-1179 OBJ: Describe the pressure ulcer staging system. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal. DIF: Understand REF: 1182-1183 OBJ: Discuss the normal process of wound healing. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention. ANS: D A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. DIF: Remember REF: 1181-1183 OBJ: Describe the differences in wound healing by primary and secondary intention. TOP: Planning MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention. NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 ANS: B A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial- thickness repair are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. DIF: Remember REF: 1181-1183 OBJ: Describe the differences in wounds healing by primary and secondary intention. TOP: Planning MSC: Physiological Integrity: Physiological Adaptation  Which nursing observation would indicate that a wound healed by secondary intention? a. Minimal scar tissue b. Minimal loss of tissue function c. Permanent dark redness at site d. Scarring can be severe. ANS: D A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin. DIF: Understand REF: 1181-1183 OBJ: Describe the differences in wounds healing by primary and secondary intention. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 a. The incision site has started to itch. b. The incision site is approximated. c. The patient has pain at the incision site. d. The incision has a mass, bluish in color. ANS: D A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain. DIF: Understand REF: 1183-1184 OBJ: Describe complications of wound healing. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? a. Complaint by patient that something has given way b. Protrusion of visceral organs through a wound opening c. Chronic drainage of fluid through the incision site d. Drainage that is odorous and purulent ANS: A occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent. DIF: Understand REF: 1183-1184 OBJ: Describe complications of wound healing. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023  The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E. ANS: C Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing. DIF: Apply REF: 1184-1186 OBJ: Explain factors that impede or promote wound healing. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? a. “I think I will be ready to go home early next week.” b. “I am so weak and tired, I want to feel better.” c. “I am ready for my bath and linen change as soon as possible.” d. “I am hoping there will be something good for dinner tonight.” ANS: C The patient’s psychological response to any wound is part of the nurse’s assessment. Body image changes can influence self-concept. Factors that affect the patient’s perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens gives you a clue that he or she may be concerned about the smell in the room. The patient stating that he or she NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey. DIF: Analyze REF: 1186 OBJ: Explain factors that impede or promote wound healing. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to a. Inspect the wound for bleeding. b. Inspect the wound for foreign bodies. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection. ANS: A After determining that a patient’s condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination. DIF: Apply REF: 1190 OBJ: Describe the differences between nursing care for acute and chronic wounds. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a. Don sterile gloves. b. Provide analgesic medications as ordered. c. Avoid accidentally removing the drain. d. Gather supplies. NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 ANS: B Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure. DIF: Apply REF: 1189-1191 OBJ: Describe the differences between nursing care for acute and chronic wounds. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse’s next best step? a. Remove the drain; a drain is no longer needed. b. Call the physician; a blockage is present in the tubing. c. Call the charge nurse to look at the drain. d. As long as the evacuator is compressed, do nothing. ANS: B Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present. DIF: Apply REF: 1190-1191 OBJ: Describe the differences between nursing care for acute and chronic wounds. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? a. Standard mattress b. Nonpowered redistribution air mattress c. Low-air-loss therapy unit NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023  The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient’s Braden scale total score? a. 15 b. 17 c. 20 d. 23 ANS: C With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20. DIF: Apply REF: 1185 OBJ: Complete an assessment for a patient with impaired skin integrity. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient’s willingness and ability to increase mobility, which intervention is most important for the nurse to complete? a. Encourage the patient to sit up in the chair. b. Provide analgesic medication as ordered. c. Explain the risks of immobility to the patient. d. Turn the patient every 3 hours while in bed. ANS: B Maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient’s willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient’s ability to increase mobility. DIF: Apply REF: 1188| 1196-1197 NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 OBJ: Complete an assessment for a patient with impaired skin integrity. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain ANS: C After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity. DIF: Understand REF: 1191 OBJ: List nursing diagnoses associated with impaired skin integrity. TOP: Planning MSC: Physiological Integrity: Physiological Adaptation  The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a. Ineffective tissue perfusion b. Risk for infection c. Imbalanced nutrition: less than body requirements d. Acute pain ANS: A The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient’s nursing diagnosis, but the data provided do not support this nursing diagnosis. NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 DIF: Understand REF: 1177| 1191 OBJ: List nursing diagnoses associated with impaired skin integrity. TOP: Planning MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? a. Teach the family how to manage the odor associated with the wound. b. Discuss with the family how to prepare for care of the patient in the home. c. Encourage thorough handwashing of all individuals caring for the patient. d. Encourage increased quantities of carbohydrates and fats. ANS: C The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does not relate to the risk of infection. If the patient will be discharged before the wound is healed, the family will certainly need education on how to care for the patient. Teaching the family how to manage the odor associated with a wound is certainly important, but these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process. DIF: Apply REF: 1183| 1191 OBJ: List nursing diagnoses associated with impaired skin integrity. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a a. Respiratory therapist. b. Registered dietitian. c. Chaplain. d. Case manager. ANS: B NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 DIF: Apply REF: 1196 OBJ: Develop a nursing care plan for a patient with impaired skin integrity. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? a. Gentle cleaners and thorough drying of the skin b. Absorbent pads and garments c. Positioning with use of pillows d. Therapeutic beds and mattresses ANS: A Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown. DIF: Apply REF: 1195-1196 OBJ: Develop a nursing care plan for a patient with impaired skin integrity. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a. At least 3 hours b. Not longer than 30 minutes c. Less than 2 hours d. As long as the patient remains comfortable NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 ANS: C When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia. DIF: Apply REF: 1197 OBJ: Develop a nursing care plan for a patient with impaired skin integrity. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? a. Obtain assistance and use the drawsheet to place the patient into the new position. b. Place the patient in a 30-degree supine position. c. Utilize a transfer sliding board and assistance to slide the patient into the new position. d. Elevate the head of the bed 45 degrees. ANS: C When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient’s body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30- degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces. DIF: Apply REF: 1196-1197 OBJ: Develop a nursing care plan for a patient with impaired skin integrity. TOP: Implementation MSC: Physiological Integrity: Physiological Adaptation  The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage a. I. b. II. NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 c. III. d. IV. ANS: A Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer. DIF: Understand REF: 1203 OBJ: List appropriate nursing interventions for a patient with impaired skin integrity. TOP: Diagnosis MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient’s anxiety? a. Tell the patient to close his eyes. b. Explain the procedure. c. Turn on the television. d. Ask the family to leave the room. ANS: B Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient’s anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient’s anxiety. DIF: Understand REF: 1216 OBJ: List appropriate nursing interventions for a patient with impaired skin integrity. NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23. DIF: Evaluate REF: 1185 OBJ: List appropriate nursing interventions for a patient with impaired skin integrity. TOP: Evaluation MSC: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE  The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel e. Chaplain f. Pharmacist ANS: A, B, C, D A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special need arises. DIF: Evaluate REF: 1212-1213 OBJ: List appropriate nursing interventions for a patient with impaired skin integrity. NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 TOP: Evaluation MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) a. Nutrition b. Evisceration c. Tissue perfusion d. Infection e. Hemorrhage f. Age ANS: A, C, D, F Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and decreases the production of proinflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing. DIF: Remember REF: 1184-1186 OBJ: Explain factors that impede or promote wound healing. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. “Can you easily change your position?” b. “Do you have sensitivity to heat or cold?” c. “How often do you need to use the toilet?” d. “Is movement painful?” e. “What medications do you take?” f. “Have you ever fallen?” ANS: A, B, C, D NURS EXAM|SKIN INTEGRITY AND WOULD CARE QUESTIONS WITH COMPLETE SOLUTIONS 2022/2023 Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, he can protect himself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with mobility such as pain will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions. DIF: Understand REF: 1187 OBJ: Complete an assessment for a patient with impaired skin integrity. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.) a. Mobility b. Hyperemia c. Induration d. Blanching e. Temperature of skin f. Nutritional status ANS: B, C, D, E Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and abnormal reactive hyperemia (when the skin turns red after an obstruction of blood flow returns and vasodilatation causes the tissue to turn red). Assess for indurated (hardened) areas on the skin and palpate reddened areas for blanching. Changes in temperature can indicate changes in blood flow to that area of the skin. Mobility and nutritional status are certainly part of the overall assessment for pressure ulcer risk but are not part of the actual skin assessment. DIF: Apply REF: 1777| 1188 OBJ: Complete an assessment for a patient with impaired skin integrity. TOP: Assessment MSC: Physiological Integrity: Physiological Adaptation  The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse’s responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.)