Question 1

The nurse notes a small, indurated, scaled spot on the upper chest of an older patient. The nurse would suspect the physician to diagnose this condition as:

Accepted Answer

D

Question 2

An older patient has a subnormal body temperature and an infection. How does the nurse best describe this phenomenon?

Accepted Answer

The temperature regulating mechanism can deteriorate with aging, leading to less typical responses to infection such as not developing a fever. This is why an older patient might have a subnormal body temperature even when they have an infection.

Question 3

An older patient is recovering from surgery to repair a fractured hip. What interventions will the nurse use to prevent the development of a pressure ulcer in this patient? Select all that apply.

Accepted Answer

A,B,C,E

Question 4

An older patient has a Braden Scale pressure ulcer risk score of 18. What interventions would be indicated by the nurse?

Accepted Answer

A Braden Scale score of 18 indicates a mild risk for pressure ulcers. Inspecting the skin during repositioning, toileting, and assisting with activities of daily living (ADLs) is a proactive measure to identify potential issues early and prevent pressure ulcers.

Question 5

An older patient is recovering from abdominal surgery. Which interventions will the nurse consider when planning care for this patient?

Accepted Answer

Antimicrobial dressings help prevent infection, which is crucial for wound healing, especially in older patients who may have compromised immune systems.

Question 6

The nurse is preparing to cleanse an older patient's pressure injury. Which techniques should the nurse use to perform this action? Select all that apply.

Accepted Answer

The answer of The nurse is preparing to cleanse an...

Question 7

An older patient complains about increasing dry skin. What should the nurse explain to the patient about this skin problem? Select all that apply.

Accepted Answer

As the body ages, there is a reduction in sebum production and a change in the keratinization and lipid content in the stratum corneum.

Question 8

The nurse is assessing an older patient's stage III pressure ulcer. What would be indicative of proper wound healing?

Accepted Answer

Beefy red and moist, grainy appearance of a wound indicates granulation tissue, which is a sign of proper wound healing. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process.

Question 9

The nurse is caring for an older patient diagnosed with melanoma of the nail. What might the nurse find during the physical assessment? Select correct answer.

Accepted Answer

A longitudinal pigmented band is a common sign of melanoma of the nail, often appearing as a streak extending from the nail bed to the tip of the nail.

Question 10

After an assessment the nurse is concerned that an older patient is at risk for pressure ulcer development because of the current nutritional status. What nutritional factors did the nurse assess in the patient? Select all that apply.

Accepted Answer

Dehydration, low hemoglobin, low serum albumin, and significant weight loss are all indicators of poor nutritional status, which can increase the risk of pressure ulcer development. Chronic renal failure is not directly a nutritional factor.

Question 11

The nurse is teaching assisted living center residents about over-the-counter skin preparations. Which should be used with caution in an older patient? Select all that apply.

Accepted Answer

Steroid-based ointments and creams (D) can cause skin thinning and other side effects, especially in older adults whose skin is already more fragile. Topical lotions with antihistamines (E) can cause increased sensitivity, dryness, or other adverse reactions in older patients, making them also a cautious choice.

Question 12

What instruction should the nurse provide to a nursing assistant who is assigned to care for an older patient with a stage I pressure injury on the right heel?

Accepted Answer

For a stage I pressure injury, it's important to maintain skin cleanliness to prevent infection and promote healing. Cleansing the area with tepid water is gentle and effective for this purpose. Applying a dry dressing or a donut under the heel are not recommended for stage I pressure injuries, as they require minimal intervention focused on reducing pressure and maintaining cleanliness. Keeping the head of the bed elevated is unrelated to the care of a pressure injury on the heel.

Question 13

An older patient recently diagnosed with skin cancer does not understand why the disease developed since sunbathing has always been avoided. How should the nurse respond to this patient?

Accepted Answer

Sun exposure can occur indirectly, such as through the windows of a car, contributing to skin cancer risk even in individuals who do not intentionally sunbathe.

Question 14

The nurse is caring for an older patient who has a healed, sacral pressure ulcer. What would the nurse include in teaching about this new tissue growth?

Accepted Answer

The new tissue that grows in after a pressure ulcer has healed is more fragile than the original skin, making it more susceptible to breakdown if the area is subjected to pressure or injury again.

Question 15

The nurse is performing a skin assessment on an older African American patient. Which findings would be considered normal for this patient? Select all that apply.

Accepted Answer

Xerosis (dry skin) is common in older adults. Small, dark papules, known as dermatosis papulosa nigra, are common in African American individuals. Freckle-like pigmentation on the tongue is also a normal variation in darker-skinned individuals.

Question 16

The nurse provides a seminar on the impact of the sun on the skin with a group of older community members. Which statement indicates the older clients understood the education?

Accepted Answer

Sunscreen protects the skin from harmful UV rays, reducing the risk of sun damage and skin cancer, which is why wearing it is important.

Question 17

The home-care nurse determines that their patient is at risk for further injury due to normal aging sensation loss when they state the following:

Accepted Answer

The statement in choice A indicates a loss of sensation, as the patient did not feel the injury when it occurred, which is a risk factor for further injury.

Question 18

The nurse is preparing discharge instructions for an older patient. If the patient is prescribed Ibuprofen, what should the nurse specifically educate the patient about? Select correct answer.

Accepted Answer

Ibuprofen can make the skin more sensitive to sunlight, increasing the risk of sunburn or skin damage. Therefore, patients should be advised to avoid extended sun exposure and to use protective measures such as sunscreen or protective clothing when outdoors.

Question 19

An older patient requests a small, inflated donut to sit on to relieve pressure. What response by the nurse is appropriate?

Accepted Answer

Using a donut-shaped cushion can actually increase the risk of pressure sores or skin breakdown by concentrating pressure around the ring. Proper pressure relief involves redistributing pressure, not concentrating it.

Question 20

The daughter of an older patient sees a reddened area on the patient's coccyx and wants to massage the area to improve circulation. What response by the nurse is indicated?

Accepted Answer

The answer of The daughter of an older patient sees...

Quiz 12: The Integument