Question 1

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

Accepted Answer

Many factors predispose an individual to have pressure injuries; factors can be physical (local infections, malnutrition), functional (impaired mobility, incontinence), and psychosocial (poor adherence to treatment, impaired cognition).

Question 2

The thin, outermost layer of the skin is continuously shed in a process called:

Accepted Answer

The thin, outermost layer of the epidermis, the stratum corneum or horny layer, is continuously shed in a process called desquamation.

Question 3

The cells in the epidermis that provide protection from microorganisms are:

Accepted Answer

The cells that provide protection are the Langerhans cells and keratinocytes in the epidermis and the macrophages and mast cells beneath the epidermis' basal layer.

Question 4

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

Accepted Answer

Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.

Question 5

A mother is asking the nurse about care of her toddler's skin. The nurse should instruct the mother:

Accepted Answer

Sunscreen is necessary to protect against damage caused by ultraviolet rays.

Question 6

The nurse is instructing mothers of toddlers on the care of skin and the prevention of injury. The nurse should include which educational intervention?

Accepted Answer

Toddlers and preschoolers are susceptible to burns. Instructions should include keeping hot liquids out of their reach and capping electrical outlets with protective covers.

Question 7

A nursing student visits a nursing instructor's office and the instructor states, "Gina, are you tanning in a tanning booth?" The nursing student says yes. The nursing instructor's best response would be to instruct her on:

Accepted Answer

Because excessive sun exposure has been linked to skin cancer, teach adolescents and young adults to protect their skin by using effective sunscreen products.

Question 8

In the older adult client, wrinkling is related to:

Accepted Answer

Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue.

Question 9

Which nutrient will prevent abnormal pigmentation?

Accepted Answer

Adequate intake of iron, copper, and zinc is important to prevent abnormal pigmentation and changes in nails and hair.

Question 10

A nurse is providing a complete bed bath to a 60-year-old client with diabetes. The nurse is conducting an assessment during the bath and observes a red, raised rash under the client's breasts. This manifestation is most consistent with:

Accepted Answer

Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.

Question 11

A child is brought to the clinic by his mother. The mother states he has been at Boy Scout camp. The child has a rash on his face, arms, and legs. The child states it itches severely. The child has probably come in contact with:

Accepted Answer

The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy.

Question 12

A skin infection caused by beta-hemolytic streptococci common in children is:

Accepted Answer

Impetigo, which usually is caused by beta-hemolytic streptococci, is the most common bacterial skin infection.

Question 13

A full-thickness burn develops a leathery covering called a(an):

Accepted Answer

The full-thickness burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.

Question 14

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Accepted Answer

Shearing force occurs when tissue layers move on each other, causing vessels to stretch as they pass through the subcutaneous tissue. If a client slides in bed, shearing force can occur.

Question 15

A client has a fissure on her finger due to chafing. The client asks "How long will it be painful?" The nurse explains that the inflammation phase will last:

Accepted Answer

The inflammation phase of a partial thickness wound lasts approximately 3 days.

Question 16

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for:

Accepted Answer

Dehiscence is a total or partial disruption in wound edges. Clients often report feeling the incision has given way. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

Question 17

A woman fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. The client has a(an):

Accepted Answer

A fistula is an abnormal tubelike passageway that forms from one organ to outside the body.

Question 18

A client has developed blisters around the tape that secures the dressing. The nurse should:

Accepted Answer

Bandages, binders, and stretch nets also can be used to hold gauze dressings in place.

Question 19

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?

Accepted Answer

Heat promotes vasodilation, allowing for the consolidation of pus in infected areas. Scented products may contain chemicals that promote irritation to the infected area and have no curative benefits to this particular client. Cold application will result in vasoconstriction and will not promote healing.

Question 20

The nurse is caring for a client who has recently noted abnormal pigmentation in the skin. What is most likely deficient in the client's diet?

Accepted Answer