Question 1

Which of the following are functions of the skin? Select all that apply.

Accepted Answer

The skin serves many functions including protection against physical, chemical, and microbial damage (A), regulation of body temperature through sweating and blood vessel dilation/constriction (B), sensation through nerve endings for touch, pressure, pain, and temperature (C), and immunological defense through the presence of immune cells and keratinocytes (E). Vitamin C production (D) is not a primary function of the skin.

Question 2

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply.

Accepted Answer

Cold therapy causes vasoconstriction, which reduces blood flow to the area, thereby reducing inflammation and edema. It also helps in reducing muscle spasms and can decrease the perception of pain. Cold does not increase blood flow or the release of pain-producing substances; it has the opposite effect.

Question 3

An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what?

Accepted Answer

Edema, redness, and clear drainage in the lower extremities are common signs of venous insufficiency. Age may contribute to the development of venous insufficiency, but it is not the primary cause. Beta-hemolytic streptococcus is a bacterial infection that can cause swelling and redness, but it is less likely in this scenario. Hemangiomas are usually benign tumors and are not typically associated with edema or drainage.

Question 4

Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound?

Accepted Answer

The answer of Which of the following is an accurate...

Question 5

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound?

Accepted Answer

Based on the description given, the wound is a Stage II pressure ulcer. Stage II pressure ulcers involve partial thickness loss of dermis and present as shallow open ulcers with a red-pink wound bed. Stage I pressure ulcers involve intact skin with non-blanchable redness, while Stage III and IV pressure ulcers involve full-thickness tissue loss and may involve muscle or bone.

Question 6

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?

Accepted Answer

According to the National Pressure Ulcer Advisory Panel, stage III pressure ulcers involve full-thickness tissue loss with visible subcutaneous fat. Tendons, muscles, and bones are not visible or directly palpable. Therefore, this pressure ulcer is categorized as stage III.

Question 7

Which of the following is an indication for the use of negative pressure wound therapy?

Accepted Answer

Negative pressure wound therapy is indicated for various types of wounds, including pressure ulcers, diabetic ulcers, venous ulcers, and traumatic wounds, among others. It helps by promoting wound healing through the application of negative pressure to draw the edges of the wound together, remove exudate and infectious materials, and promote granulation tissue formation.

Question 8

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record?

Accepted Answer

A laceration is a tear or rip in the skin and/or tissue. Option B describes a laceration with torn and irregular edges, which is typical of childbirth-related cervical lacerations.

Question 9

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client?

Accepted Answer

Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or cooler as compared with adjacent tissue.

Question 10

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following?

Accepted Answer

Serosanguineous drainage is a mixture of blood and serous fluid, which is typically pale pink-yellow in color, indicating a normal healing process. This type of drainage is common in surgical wounds.

Question 11

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client?

Accepted Answer

Placing a heating pad underneath a body part can cause burns. It is recommended to place it anteriorly or laterally to the body part. Option A is incorrect because safety pins can cause injury or discomfort to the client. Option B is incorrect because too much insulation can lead to overheating and burns. Option C is incorrect as the client may accidentally turn the heating pad too high and sustain burns.

Question 12

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do?

Accepted Answer

Partial care involves assisting the client with aspects of personal hygiene they are unable to manage themselves, such as reaching difficult areas, while allowing them to perform tasks they are capable of independently.

Question 13

Which of the following clients would be considered at risk for skin alterations? Select all that apply.

Accepted Answer

A teenager with multiple body piercings is at risk for skin alterations due to possible infections and scarring.
A client receiving radiation therapy is at risk for skin alterations such as dryness, redness, and irritation.
A client with diabetes is at risk for skin alterations such as dryness, cracking, and ulcerations due to poor circulation and neuropathy.

Question 14

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound?

Accepted Answer

Hydrocolloid dressings are ideal for shallow wounds with minimal drainage because they maintain a moist environment that promotes healing, can absorb small amounts of exudate, and protect the wound from external contamination.

Quiz 31: Skin Integrity and Wound Care