CHAPTER 12 The Integument

CHAPTER 12 The Integument

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

12.1•A nurse aide reports to the nurse that a 94-year-old client’s rectal temperature is 35.8C. The nurse interprets this value as

1. a sign of infection.
2. a normal value for older clients.
3. an inaccurate reading by the nurse aide.
4. a sign of anemia.

Answer: 2

Rationale: Body temperature in the elderly is usually lower than the baseline of 37C. Therefore, this is a normal value for this client. Signs of infection result in an elevated temperature and anemia would not be reflected by a low temperature. The inaccurate reading could be questioned but the rectal temperature is the most accurate method for measuring the temperature.

Assessment

Physiological Integrity

Analysis

12.2•A 75-year-old client is recovering from surgery to remove a tumor in the abdomen. When planning care for this client, the nurse would consider that the skin of an older person would require

1. increased healing time.
2. decreased healing time.
3. a need to keep the wound edges taped.
4. skin near the wound to be massaged to increase blood flow.

Answer: 1

Rationale: Epidermal mitosis slows 30% after the age of 50, resulting in longer healing time for older persons. Additional changes place the client at risk for infection and skin tears. Taping the wound edges and massaging the skin would cause further damage to skin.

Planning

Physiological Integrity

Analysis

12.3•The nurse is completing a home care visit of an 86-year-old client. The client lives alone and is independent in activities of daily living. During your visit, you notice a red mark on the arm of the client. The client states she was unaware of the injury and it may have occurred from hot water when cooking. Your interpretation of this finding is that the client is

1. losing short-term memory.
2. experiencing friction tears of the skin.
3. at risk for further injury.
4. experiencing senile purpura in the skin.

Answer: 3

Rationale: Normal changes in the skin result in a decline of both touch and pressure sensations placing them at risk for burns and pressure sores. Clients are to be cautioned to prevent this type of injury. There is no indication the client has memory loss. A skin tear is a dramatic separation of the dermis, and a bruised or discolored appearance is seen in senile purpura.

Assessment

Physiological Integrity

Analysis

12.4•An 82-year-old client is admitted for a hip fracture. During the postoperative recovery, the nurse notices a stage I pressure ulcer forming on the client’s sacrum. To reduce the progression of this stage of ulcer, the nurse would

1. maintain the head of the bed at 45.
2. apply a dry dressing to pressure ulcer.
3. maintain the head of the bed at 30 positioned on the right or left side.
4. apply a heat lamp to the area to increase circulation.

Answer: 3

Rationale: Keeping the head of the bed at 30 or less decreases pressure on the sacrum. Dry dressings are not indicated with this stage pressure wound. Heat lamp is a method no longer used, as it does not provide therapeutic benefit.

Implementation

Physiological Integrity

Analysis