Chapter 12 My Nursing Test Banks

Tabloski Gerontological Nursing, 3/e
Chapter 12

Question 1

Type: MCSA

An older patient is diagnosed with an infection but has a subnormal body temperature. What should the nurse explain to the patients family as the reason for this discrepancy?

1. The temperature regulating mechanism changes with aging.

2. The patient is on medication that drops the body temperature.

3. The diagnosis of an infection is inaccurate and will be checked.

4. The temperature was measured incorrectly and will be repeated.

Correct Answer: 1

Rationale 1: An elevated temperature is a common sign of infection but may not be present in the frail older adult.
Reference: Page 297

Rationale 2: There is no information to support that the patient is receiving antipyretics that would alter the patients body temperature.
Reference: Page 297

Rationale 3: The nurse should not state that the patient received an inaccurate diagnosis. This would have the family question the quality of care the patient is receiving.
Reference: Page 297

Rationale 4: There is no evidence to suggest that the patients temperature was measured incorrectly.
Reference: Page 297

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe normal skin changes associated with aging.

Question 2

Type: MCSA

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

1. The healing time is increased.

2. The healing time is decreased.

3. There is a need to keep the wound edges taped.

4. Skin near the wound needs to be massaged to increase blood flow.

Correct Answer: 1

Rationale 1: Epidermal mitosis slows 30% after the age of 50, resulting in longer healing time for older persons.
Reference: Page 286

Rationale 2: The healing time in older persons is increased because of the slowing of epidermal mitosis.
Reference: Page 286

Rationale 3: Taping the wound edges would cause damage to the skin.
Reference: Page 286

Rationale 4: Massaging the skin would cause further damage to the skin.
Reference: Page 286

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Describe normal skin changes associated with aging.

Question 3

Type: MCSA

The home care nurse notes that an older patient who lives alone has a large red mark on the arm. When asked about the mark the patient states unawareness of the injury and believes it occurred from hot water when cooking. How should the nurse interpret this finding?

1. The patient is at risk for further injury.

2. The patient is losing short-term memory.

3. The patient is experiencing friction tears of the skin.

4. The patient is demonstrating senile purpura of the skin.

Correct Answer: 1

Rationale 1: With normal aging there is a gradual decline in both touch and pressure sensations, causing the older adult to be at risk for injury such as burns and pressure sores.
Reference: Page 288

Rationale 2: There is no indication that the patient has memory loss.
Reference: Page 288

Rationale 3: A skin tear is a dramatic separation of the dermis.
Reference: Page 288

Rationale 4: Bruised or discolored skin would be seen in senile purpura.
Reference: Page 288

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe normal skin changes associated with aging.

Question 4

Type: MCMA

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?

Standard Text: Select all that apply.

1. Avoid sitting unless for meals.

2. Use pillows to protect the skin.

3. Reposition the patient every 2 hours.

4. Keep the skin dry with frequent bathing.

5. Encourage independent position changes.

Correct Answer: 1,2,3,5

Rationale 1: Interventions to prevent pressure ulcer formation include avoiding the sitting position unless it is for meals.
Reference: Pages 302, 305

Rationale 2: Interventions to prevent pressure ulcer formation include using pillows to protect the skin.
Reference: Pages 302, 305

Rationale 3: Interventions to prevent pressure ulcer formation include repositioning the patient every 2 hours.
Reference: Pages 302, 305

Rationale 4: Frequent bathing could dry out the skin and encourage the formation of ulcers, wounds, and skin tears.
Reference: Pages 302, 305

Rationale 5: Interventions to prevent pressure ulcer formation include encouraging the patient to make independent position changes. Even small shifts redistribute the body weight and improve perfusion of the tissue.
Reference: Pages 302, 305

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.

Question 5

Type: MCSA

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

1. Apply a dry dressing to the site.

2. Apply a donut under the right heal.

3. Cleanse the area with tepid water without soap.

4. Keep the head of the bed elevated to a 45-degree angle.

Correct Answer: 3

Rationale 1: A dry dressing is not indicated for this type of pressure ulcer.
Reference: Page 305

Rationale 2: Mechanical devices can exacerbate pressure ulcers and should not be used.
Reference: Page 305

Rationale 3: The area at risk for pressure sore development should be washed gently with tepid water, with or without minimal soap. Soap removes natural oils from the skin, and cleaning the soap off may cause additional friction damage.
Reference: Page 305

Rationale 4: Elevating the head of the bed at a 45-degree angle increases pressure on the sacrum and lower extremities which could cause the pressure ulcer to become worse.
Reference: Page 305

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 6

Type: MCSA

While assessing an older patients stage III pressure ulcer the nurse notes that the wound is beefy red and grainy, and the depth has decreased by 2 mm but the width has not changed. How should the nurse interpret this assessment finding?

1. Not healing properly

2. About to slough off tissue

3. No longer at risk for infection

4. Progressing positively toward healing

Correct Answer: 4

Rationale 1: The wound color, texture, and decreasing depth all indicate that the wound is healing properly.
Reference: Page 296

Rationale 2: The wounds color, texture, and depth do not indicate that tissue is going to be sloughed off.
Reference: Page 296

Rationale 3: Any open wound is at risk for infection.
Reference: Page 296

Rationale 4: Healing of a decubitus fills from the wound bottom so the depth decreases before the wound width decreases. The beefy red and grainy appearance is evidence of granulation tissue as the capillary bed builds. These are all indicators of good wound healing.
Reference: Page 296

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 7

Type: MCSA

The nurse is caring for an older patient who previously had a sacral pressure ulcer that has completely healed. What does the nurse recognize as a characteristic of the previously healed pressure ulcer?

1. Heal faster if reinjured

2. Break down faster if reinjured

3. Have no sensation in the injured area

4. Be at risk for infection even with intact skin

Correct Answer: 2

Rationale 1: This site will not heal faster if reinjured. The wound will never reach the pre-wound strength.
Reference: Page 296

Rationale 2: Scarred wounds never reach the prewound strength and are more prone to reinjury than normal tissue.
Reference: Page 296

Rationale 3: Sensation does return to the skin of a pressure ulcer.
Reference: Page 296

Rationale 4: Intact skin does not increase the risk for infection.
Reference: Page 296

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 8

Type: MCMA

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?

Standard Text: Select all that apply.

1. Diagnosis of dehydration

2. Hemoglobin level 9 mg/dL

3. Treatment for chronic renal failure

4. Serum albumin level below normal

5. Loss of 20 pounds over the last 3 months

Correct Answer: 1,2,4,5

Rationale 1: Nutritional factors associated with pressure ulcer development include dehydration.
Reference: Page 295

Rationale 2: A hemoglobin level of 9 mg/dL indicates anemia, which is a nutritional factor associated with pressure ulcer development.
Reference: Page 295

Rationale 3: Chronic renal failure is not specifically associated with the development of pressure ulcer formation.
Reference: Page 295

Rationale 4: Nutritional factors associated with pressure ulcer development include a decreased serum albumin level.
Reference: Page 295

Rationale 5: Nutritional factors associated with pressure ulcer development include decreased body weight.
Reference: Page 295

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.

Question 9

Type: MCMA

Which over-the-counter skin preparations should the nurse instruct an older patient to use with caution?

Standard Text: Select all that apply.

1. Sunblock

2. Super-fatted soaps

3. Emollients that keep the skin moist

4. Steroid-based ointments and creams

5. Topical lotion with an antihistamine

Correct Answer: 4,5

Rationale 1: Sunblock is appropriate to protect for UV exposure to the sun.
Reference: Page 300

Rationale 2: Super-fatted soaps are appropriate treatments for dry skin.
Reference: Page 300

Rationale 3: Emollients are an appropriate treatment for dry skin.
Reference: Page 300

Rationale 4: Older adults have a high rate of adverse reactions to corticosteroids, which are frequently prescribed for skin problems. Older adults should be reminded not to buy over-the-counter preparations of this drug without specific instructions from the primary care provider. If this medication is prescribed, directions should be strictly followed and any unusual symptoms reported promptly.
Reference: Page 300

Rationale 5: Older adults have a high rate of adverse reactions to antihistamines, which are frequently prescribed for skin problems. Older adults should be reminded not to buy over-the-counter preparations of this drug without specific instructions from the primary care provider. If this medication is prescribed, directions should be strictly followed and any unusual symptoms reported promptly.
Reference: Page 300

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Discuss the nursing responsibilities related to pharmacological and nonpharmacological treatment of common skin problems.

Question 10

Type: MCMA

The nurse is preparing to cleanse an older patients abdominal wound. Which techniques should the nurse use to perform this action?

Standard Text: Select all that apply.

1. Pour saline over the wound.

2. Apply saline-soaked gauze over the wound.

3. Squeeze a saline-filled syringe over the wound.

4. Place gauze pads soaked with hydrogen peroxide on the wound.

5. Apply dry gauze pads over the wound and saturate with sterile water.

Correct Answer: 1,2,3

Rationale 1: Wound cleansing can be done by pouring saline over the wound.
Reference: Page 307

Rationale 2: Wound cleansing can be done by applying saline-soaked gauzes over the wound to clean the debris from the wound bed.
Reference: Page 307

Rationale 3: Wound cleansing can be done by squeezing a saline-filled bulb syringe over the wound.
Reference: Page 307

Rationale 4: Placing gauze pads soaked with hydrogen peroxide on the wound is not a recommended approach to cleanse a wound.
Reference: Page 307

Rationale 5: Applying dry gauze pads over the wound and saturating with sterile water is not a recommended approach to cleanse a wound.
Reference: Page 307

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 11

Type: MCSA

The nurse provides a seminar on the impact of the sun on the skin with a group of older community members. Which statement indicates that additional teaching is necessary?

1. Sunscreen is important to wear during all daytime hours.

2. The sun should be avoided between the peak hours of 10 a.m. and 4 p.m.

3. African Americans can experience sun damage despite the dark skin tones.

4. The melanocytes in the subcutaneous tissue protect the skin from sun damage.

Correct Answer: 4

Rationale 1: Sunscreen is important to wear during all daytime hours. This statement does not indicate that additional teaching is necessary.
Reference: Page 284

Rationale 2: The sun should be avoided between the peak hours of 10 a.m. and 4 p.m. This statement does not indicate that additional teaching is necessary.
Reference: Page 284

Rationale 3: African Americans can experience sun damage despite the dark skin tones. This statement does not indicate that additional teaching is necessary.
Reference: Page 284

Rationale 4: Melanocytes are located in the epidermal skin layers and not the subcutaneous tissue. This statement indicates that additional teaching is necessary.
Reference: Page 284

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.

Question 12

Type: MCMA

While performing a physical assessment, the nurse notes that an older patient has multiple brown and black bands on the finger nails of the thumbs and index fingers. What does this assessment finding indicate to the nurse?

Standard Text: Select all that apply.

1. A fungal infection

2. Damage to the nail matrix

3. Possible melanoma of the nail

4. Benign finding often seen in African Americans

5. Finger nails split in response to recent trauma

Correct Answer: 3,4

Rationale 1: This finding is a longitudinal pigmented band and is not associated with a fungal infection.
Reference: Page 289

Rationale 2: This finding is a longitudinal pigmented band and is not associated with damage to the nail matrix.
Reference: Page 289

Rationale 3: This finding is a longitudinal pigmented band and may indicate possible melanoma of the nail.
Reference: Page 289

Rationale 4: This finding is a longitudinal pigmented band, is common in dark-skinned races, and is more visible in the older adult.
Reference: Page 289

Rationale 5: This finding is a longitudinal pigmented band and does not mean the finger nails are going to split in response to trauma.
Reference: Page 289

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.

Question 13

Type: MCMA

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

Standard Text: Select all that apply.

1. There is a reduction in sebum production as the body ages.

2. There is a decrease in the number of sweat glands in the body with aging.

3. There is a change in the keratinization and lipid content in the stratum corneum.

4. There is an increase in body core temperature with aging, resulting in skin drying.

5. There is a change in the structure of the skin cell because of years of using alcohol-based soaps.

Correct Answer: 1,3

Rationale 1: Sebum is an oily substance that keeps hair supple and lubricates the skin. Sebum protects the skin from water loss and provides protection against infection. Sebaceous glands increase in size with age, but the amount of sebum produced is decreased. This would explain why the older patient is experiencing increasingly dry skin.
Reference: Page 289

Rationale 2: The number of sweat glands does decrease with aging but does not have a role in the reduction of the production of sebum.
Reference: Page 289

Rationale 3: Changes in the keratinization process and lipid content in the stratum corneum cause the flaking appearance and dry sensation of the skin.
Reference: Page 289

Rationale 4: Changes in body temperature do not impact the dryness of the older patients skin.
Reference: Page 289

Rationale 5: The older patients complaint of increasingly dry skin is not because of years of using alcohol-based soaps.
Reference: Page 289

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe normal skin changes associated with aging.

Question 14

Type: MCSA

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?

1. Can you tell me more about your feelings?

2. Sun exposure can happen from driving a car.

3. We frequently never find out why cancer strikes.

4. This is unusual, as skin cancer normally only occurs in sunbathers.

Correct Answer: 2

Rationale 1: Asking the patient to explain feelings does not answer the patients question. This is an inappropriate response for the nurse to make.
Reference: Page 289

Rationale 2: Sun exposure can occur from routine activities such as driving or riding in a car.
Reference: Page 289

Rationale 3: Stating that we frequently never find out why cancer strikes does not answer the patients question. This is an inappropriate response for the nurse to make.
Reference: Page 289

Rationale 4: Stating that skin cancer normally only occurs in sunbathers is an inaccurate response. Skin cancer can occur after sun exposure, regardless how the sun exposure occurs.
Reference: Page 289

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Delineate skin changes associated with benign and malignant skin changes.

Question 15

Type: MCMA

The nurse is preparing discharge instructions for an older patient. For which medications should the nurse teach the patient to avoid extended sun exposure?

Standard Text: Select all that apply.

1. Aspirin

2. Ibuprofen

3. Amiodarone

4. Promethazine

5. Acetaminophen

Correct Answer: 2,3,4

Rationale 1: Aspirin is not a medication that causes skin sensitivity.
Reference: Page 290

Rationale 2: Ibuprofen is a medication that causes skin sensitivity.
Reference: Page 290

Rationale 3: Amiodarone is a medication that causes skin sensitivity.
Reference: Page 290

Rationale 4: Promethazine is a medication that causes skin sensitivity.
Reference: Page 290

Rationale 5: Acetaminophen is not a medication that causes skin sensitivity.
Reference: Page 290

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.

Question 16

Type: MCSA

The nurse notes a small, indurated, scaled spot on the upper chest of an older patient. Which type of skin condition did the nurse assess in this patient?

1. Actinic keratosis

2. Basal cell carcinoma

3. Malignant melanoma

4. Squamous cell carcinoma

Correct Answer: 4

Rationale 1: Actinic keratosis is a precancerous condition. The lesion appears as a sore, rough, scaly plaque.
Reference: Page 291

Rationale 2: Basal cell carcinoma presents as a small fleshy bump.
Reference: Page 291

Rationale 3: Malignant melanoma manifests as black, brown, or multicolored nodules or plaques.
Reference: Page 291

Rationale 4: Squamous cell carcinoma most often appears as a flesh-colored, erythematous, indurated scaly plaque.
Reference: Page 291

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Delineate skin changes associated with benign and malignant skin changes.

Question 17

Type: MCSA

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

1. I will obtain the device for you.

2. Using the donut can cause skin breakdown.

3. I will need to get an order from the physician.

4. You will need to wait until discharge and use this at home.

Correct Answer: 2

Rationale 1: The use of the device should be avoided because it applies pressure and results in tissue hypoxia.
Reference: Page 302

Rationale 2: The use of a donut applies pressure and results in tissue anoxia. The patient may indeed feel that pressure is lessened, but this is due to the loss of sensation. The use of the devices should be avoided.
Reference: Page 302

Rationale 3: The use of the device should be avoided because it applies pressure and results in tissue hypoxia.
Reference: Page 302

Rationale 4: The nurse should instruct the patient that the use of the device should be avoided because it applies pressure and results in tissue hypoxia. The patient should not use the device at home.
Reference: Page 302

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.

Question 18

Type: MCSA

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

1. I will record these findings in the medical record.

2. I will need to obtain an order from the physician to perform a massage.

3. Massaging the area may actually cause more harm to a potentially compromised area of skin.

4. Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care.

Correct Answer: 3

Rationale 1: The nurse needs to do more than state that these finding will be recorded in the patients medical record.
Reference: Page 305

Rationale 2: A massage does not require a physicians order.
Reference: Page 305

Rationale 3: The presence of redness may indicate the presence of a stage I pressure ulcer. Massage can cause a friction-like response to compromised skin and should be restricted when problems are noted.
Reference: Page 305

Rationale 4: Massaging the area twice a day may encourage the area to breakdown and should not be done.
Reference: Page 305

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 19

Type: MCMA

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

Standard Text: Select all that apply.

1. Bluish gums

2. Many small, dark papules on the face

3. Purple, hard ,smooth area on the upper arm

4. Multiple skin tears with clear fluid drainage

5. Freckle-like pigmentation of the tongue borders

Correct Answer: 1,2,5

Rationale 1: Some dark-skinned people have bluish gums.
Reference: Page 301

Rationale 2: Many small dark papules on the face are dermatosis papulosa nigra, a type of Seborrheic keratoses that only occurs in African Americans.
Reference: Page 301

Rationale 3: A purple, hard, smooth area on the upper arm is erythema in the dark-skinned patient and is not a normal skin finding.
Reference: Page 301

Rationale 4: Multiple skin tears with clear fluid drainage is not a normal skin finding for the African American patient.
Reference: Page 301

Rationale 5: Dark-skinned people may have freckle-like pigmentations of the tongue borders which is a normal finding.
Reference: Page 301

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe normal skin changes associated with aging.

Question 20

Type: MCSA

An older patient has a Braden Scale pressure ulcer risk score of 18. What does this score mean to the nurse?

1. The patient is at a low risk for the development of a pressure ulcer.

2. This patient is at a high risk for the development of a pressure ulcer.

3. The score is inconclusive and the assessment repeated within 3 days.

4. This score is inconclusive and shows no significant risk pressure ulcer development.

Correct Answer: 2

Rationale 1: The Braden Scale is used to evaluate a patients risk for the development of pressure ulcers. A score of 16 or less indicates a pressure sore risk and the need for a prevention plan.
Reference: Page 303

Rationale 2: The Braden Scale is used to evaluate a patients risk for the development of pressure ulcers. A score of 16 or less indicates a pressure sore risk and the need for a prevention plan.
Reference: Page 303

Rationale 3: The score is not inconclusive and does not need to be repeated within 3 days.
Reference: Page 303

Rationale 4: The score is not inconclusive and it does show a risk for pressure ulcer development.
Reference: Page 303

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 21

Type: MCSA

The nurse is caring for an older patient with a stage II pressure ulcer. Which product will the nurse use to clean the wound at the next dressing change?

1. Saline

2. Dakins solution

3. Povidone-iodine

4. Hydrogen peroxide

Correct Answer: 1

Rationale 1: The safest, most cost effective and most common cleansing agent for wounds is isotonic saline.
Reference: Pages 306307

Rationale 2: Topical antiseptics such as Dakins solution should not be used on a wound because it has been found to be toxic to the wound fibroblasts and macrophages.
Reference: Pages 306307

Rationale 3: Topical antiseptics such as povidone-iodine should not be used on a wound because it has been found to be toxic to the wound fibroblasts and macrophages.
Reference: Pages 306307

Rationale 4: Topical antiseptics such as hydrogen peroxide should not be used on a wound because it has been found to be toxic to the wound fibroblasts and macrophages.
Reference: Pages 306307

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 22

Type: MCSA

The nurse is treating a skin tear on an older patients lower leg. Which dietary selection contains ingredients that will be most favorable to wound healing for this patient?

1. Cereal, milk, and toast

2. Bacon, toast, and coffee

3. Eggs, toast, and orange juice

4. Ham slices, milk, and applesauce

Correct Answer: 3

Rationale 1: Protein and vitamin C are needed for tissue healing. Cereal, milk, and toast do not contain the most amounts of healing foods for the patient.
Reference: Pages 296, 305

Rationale 2: Protein and vitamin C are needed for tissue healing. Bacon, toast, and coffee do not contain the most amounts of healing foods for the patient.
Reference: Pages 296, 305

Rationale 3: Protein and vitamin C are needed for tissue healing. Eggs and orange juice contain the most amounts of healing foods for the patient.
Reference: Pages 296, 305

Rationale 4: Protein and vitamin C are needed for tissue healing. Ham slices, milk, and applesauce do not contain the most amounts of healing foods for the patient.
Reference: Pages 296, 305

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 23

Type: MCSA

The nurse is planning care for an older patient with pneumonia and a stage II pressure ulcer. Which nursing diagnosis would have the greatest priority for this patients care?

1. Acute Pain related to destruction of tissue

2. Knowledge Deficit related to care of skin disorder

3. Risk for Infection related to impaired skin integrity

4. Potential for Infection related to impaired skin integrity

Correct Answer: 1

Rationale 1: Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned.
Reference: Page 297

Rationale 2: All of the diagnoses are appropriate and have importance. Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned.
Reference: Page 297

Rationale 3: All of the diagnoses are appropriate and have importance. Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned.
Reference: Page 297

Rationale 4: All of the diagnoses are appropriate and have importance. Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned.
Reference: Page 297

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 24

Type: MCSA

An older patient has a nonhealing stage III pressure ulcer. Which treatment would be indicated for this patients wound?

1. Cadexomer

2. Silver sulfadiazine

3. Nanocrystalline silver

4. Topical antibiotic cream

Correct Answer: 2

Rationale 1: Cadexomer iodine dressings provide a slow-release form of iodine. These dressings have effective antibacterial action and do not harm granulation tissue. The patients wound is not healing and would not have granulation tissue.
Reference: Page 299

Rationale 2: Silver sulfadiazine is the topical antimicrobial of choice for the nonhealing ulcer.
Reference: Page 299

Rationale 3: Nanocrystalline silver dressings have been found to be effective against gram-negative, gram-positive, and anaerobic organisms.
Reference: Page 299

Rationale 4: Topical antibiotics are not recommended for pressure ulcers. Reasons include inadequate penetration if the wound is deep, development of antibiotic resistance, hypersensitivity reactions, and local irritation.
Reference: Page 299

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

Question 25

Type: MCMA

Which actions would the nurse take to prevent skin tears on an older patient with friable skin?

Standard Text: Select all that apply.

1. Avoid harsh soaps.

2. Apply silk tape over dressings.

3. Ensure an adequate fluid intake.

4. Use a lift sheet to reposition in bed.

5. Apply skin-moisturizing cream to arms and legs twice a day.

Correct Answer: 1,3,4,5

Rationale 1: An intervention to prevent skin tears is to avoid harsh soaps.
Reference: Page 301

Rationale 2: An intervention to prevent skin tears is to use paper tape and not silk tape to affix dressings.
Reference: Page 301

Rationale 3: An intervention to prevent skin tears is to ensure an adequate fluid intake.
Reference: Page 301

Rationale 4: An intervention to prevent skin tears is to use a lift sheet to reposition the patient in bed.
Reference: Page 301

Rationale 5: An intervention to prevent skin tears is to apply skin-moisturizing cream to the arms and legs twice a day.
Reference: Page 301

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Explain the nursing management principles related to the care of pressure ulcers.

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