Fundamentals of Nursing

Nursing

Quiz 36 :

Skin Integrity and Wound Care

Quiz 36 :

Skin Integrity and Wound Care

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You have been assigned to care for Mr. Johns, a 74-year-old client being treated for a urinary tract disorder. Mr. Johns suffered a cere-brovascular accident (stroke) 6 months ago and has had difficulty ambulating and attending to his own needs because of right-sided weakness. While assessing Mr. Johns you note that he is thin for his height, is incontinent of foul-smelling urine, and has deeply reddened areas on his right hip, coccyx, and entire peritoneal area. Mr. Johns is alert and oriented to person, place, and time, but he has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a chair due to his difficulty with ambulation. What independent measures can you take to protect Mr. Johns' skin from further breakdown?
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Skin integrity is defined as the presence of a normal skin that is devoid of any wounding and tissue damage. Intact skin integrity is essential for the body as the skin provides mechanical and physical protection to the body from the external pathogens and chemical compounds.
As given in the question, the patient Mr. Johns, is 74-years-old, and is currently being treated with a urinary tract disorder. He has recently encountered with a CVA (cerebrovascular accident), which has rendered his entire right side weakened. He is potentially inactive and dependent for ambulation.
The client is at a risk for developing pressure ulcers as indicated by the chronic immobility, reduced activity, reduced sensation in the right side of the body, and reddened patches on the skin of the right hip, coccyx and peritoneal area. Certain preventive measures that the nurse is required to take can be mentioned as follows:
1. The nurse can turn the patient on the opposite side in every 2 hours, so as to transfer the constant pressure on both sides of the body.
2. The nurse can provide the patient with daily skin care with lukewarm water treatment and application of moisturizer, when the skin is wet.
3. The nurse can place foaming pads under the patient's bony prominences, which are at the highest risk for developing pressure ulcers.
4. The nurse can routinely assess the patient's skin for reddened patches, which do not blanch.

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Your client has a Braden scale score of 17. Which is the appropriate nursing action? 1) Assess the client again in 24 hours; the score is within normal limits. 2) Implement a turning schedule; the client is at increased risk of skin breakdown. 3) Apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown. 4) Request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown.
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Braden scale was invented by Barbara Braden and Nancy Bergstrom in 1987. It is a scoring tool for assessing risk for the pressure ulcers. Braden scale uses six parameters to assess the risk for the pressure ulcers like sensory perception, friction, mobility, activity, nutrition as well as shear.
According to the Braden scale, the client should be assessed for 24 hours when the score is above 18 and indicates normal conditions. The client is considered to be at a moderate risk for skin breakdown when he/she has a Braden score of 13 or 14.
The client should be considered to be at a very high risk of skin breakdown only when the Braden score is below 9.
Hence, the options 1, 3 and 4 are incorrect.
Since, the client has a Braden score of 17, he/she should be subjected to routine positional changes in order to prevent skin breakdown.
Hence, the correct answer is option
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A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1) Alginate 2) Dry gauze 3) Hydrocolloid 4) No dressing is indicated
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Pressure ulcer is defined as localized inflammation, tissue necrosis and cell death at certain regions of the body due to constant pressure, which prevents normal blood circulation in the affected regions thereby blocking adequate oxygen and nutrient supply.
Alginate is an organic polymer that is used for a wound, which has a great amount of drainage. Alginate is not an appropriate dressing material for pressure ulcers. Dry gauze should not be used to dress the wound of the pressure ulcers because the gauze wound stick to the newly formed granulation tissue thereby leading to more tissue and skin damage.
Hence, the options 1, 2 and 4 are incorrect.
The nurse should use hydrocolloid dressing for the pressure ulcer wounds because these are appropriate for shallow wounds and also provide ideal healing environment.
Hence, the correct answer is option
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You have been assigned to care for Mr. Johns, a 74-year-old client being treated for a urinary tract disorder. Mr. Johns suffered a cere-brovascular accident (stroke) 6 months ago and has had difficulty ambulating and attending to his own needs because of right-sided weakness. While assessing Mr. Johns you note that he is thin for his height, is incontinent of foul-smelling urine, and has deeply reddened areas on his right hip, coccyx, and entire peritoneal area. Mr. Johns is alert and oriented to person, place, and time, but he has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a chair due to his difficulty with ambulation. What data suggest that Mr. Johns is particularly vulnerable to pressure ulcer development?
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Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains the following to the client: 1) Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation). 2) It will be acceptable to leave the pad in place if the temperature is reduced. 3) It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed. 4) It will be acceptable to leave the pad in place as long as it is moist heat.
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Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1) Low-protein diet 2) Insomnia 3) Lengthy surgical procedures 4) Fever 5) Sleeping on a waterbed
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An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is 1) Risk for Impaired Skin Integrity. 2) Impaired Skin Integrity. 3) Impaired Tissue Integrity. 4) Risk for Infection.
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Proper technique for performing a wound culture includes which of the following? 1) Cleansing the wound prior to obtaining the specimen 2) Swabbing for the specimen in the area with the largest collection of drainage 3) Removing crusts or scabs with sterile forceps and then culturing the site beneath 4) Waiting 8 hours following a dose of antibiotic to obtain the specimen
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Your client is only comfortable lying on the right or left side (not on the back or stomach). List four potential sites of pressure ulcers you must assess. 1) 2) 3) 4)
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You have been assigned to care for Mr. Johns, a 74-year-old client being treated for a urinary tract disorder. Mr. Johns suffered a cere-brovascular accident (stroke) 6 months ago and has had difficulty ambulating and attending to his own needs because of right-sided weakness. While assessing Mr. Johns you note that he is thin for his height, is incontinent of foul-smelling urine, and has deeply reddened areas on his right hip, coccyx, and entire peritoneal area. Mr. Johns is alert and oriented to person, place, and time, but he has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a chair due to his difficulty with ambulation. Considering that Mr. Johns does not have any areas of skin breakdown, why is it important to institute treatment for pressure ulcers at this time?
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Which statement, if made by the client or family member, would indicate the need for further teaching? 1) "If a skin area gets red but then the red goes away after turning, I should report it to the nurse." 2) "Putting foam pads under my heels or other bony areas can help decrease pressure." 3) "If my father cannot turn himself in bed, I should help him change position every 4 hours." 4) "The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet."
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You have been assigned to care for Mr. Johns, a 74-year-old client being treated for a urinary tract disorder. Mr. Johns suffered a cere-brovascular accident (stroke) 6 months ago and has had difficulty ambulating and attending to his own needs because of right-sided weakness. While assessing Mr. Johns you note that he is thin for his height, is incontinent of foul-smelling urine, and has deeply reddened areas on his right hip, coccyx, and entire peritoneal area. Mr. Johns is alert and oriented to person, place, and time, but he has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a chair due to his difficulty with ambulation. What additional information do you need in order to use the Braden scale to determine Mr. Johns' potential for pressure ulcer development?
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Which of the following indicates proper use of a triangle arm sling? 1) The elbow is kept flexed at 90° or more. 2) The knot is placed on either side of the vertebrae of the neck. 3) The sling extends to just proximal of the hand. 4) The sling is removed every 2 hours to check for circulation and skin integrity.
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Which of the following items are used to perform wound irrigation? Select all that apply. 1) Clean gloves 2) Sterile gloves 3) Refrigerated irrigating solution 4) 60-mL syringe 5) Forceps
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