Chapter 31 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Chapter 31 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

• The nurse notes black necrotic tissue on the client’s wound, and documents the presence of: 1)

1. A) B) Eschar. C) Alginate.                     D) Purulence.

Answer: B

Explanation: A)       Eschar is black necrotic tissue. Debridement is the process of removing dead tissue. Alginate is a fluid-absorbing substance that can be placed in highly exudative wounds to absorb the drainage. Purulence is the result of wound infection.

Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Eschar is black necrotic Debridement is the process of removing dead tissue. Alginate is a fluid-absorbing substance that can be placed in highly exudative wounds to absorb the drainage. Purulence is the result of wound infection.

Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Eschar is black necrotic Debridement is the process of removing dead tissue. Alginate is a fluid-absorbing substance that can be placed in highly exudative wounds to absorb the drainage. Purulence is the result of wound infection.

Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Eschar is black necrotic Debridement is the process of removing dead tissue. Alginate is a fluid-absorbing substance that can be placed in highly exudative wounds to absorb the drainage. Purulence is the result of wound infection.

Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Assessment

Objective: Learning Outcome 31-1: Define the key terms used in the skills of performing wound and pressure

ulcer care.

 

• The client experiences a burn on the arm that is confined to the The nurse documents: 2)

1. A) A clean B) A dirty or infected wound.
2. C) A partial-thickness D) A full-thickness wound.

Answer: C

Explanation: A)      The burn described is a partial-thickness burn if it is confined to the skin or dermis and epidermis. A full-thickness involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone. There is not enough information provided to know if it is a clean or dirty wound.

Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The burn described is a partial-thickness burn if it is confined to the skin or dermis and A full-thickness involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone. There is not enough information provided to know if it is a clean or dirty wound.

Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The burn described is a partial-thickness burn if it is confined to the skin or dermis and A full-thickness involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone. There is not enough information provided to know if it is a clean or dirty wound.

Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Implementation

1. The burn described is a partial-thickness burn if it is confined to the skin or dermis and A full-thickness involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone. There is not enough information provided to know if it is a clean or dirty wound.

Cognitive Level: Knowledge

Client Need: Physiological Integrity

Nursing Process: Implementation

Objective: Learning Outcome 31-1: Define the key terms used in the skills of performing wound and pressure

ulcer care.

• For which of the following would the nurse consider applying a transparent film for wound care? 3)

1. The client with a postoperative wound held together by sutures
2. A client with a stage I pressure ulcer
3. The client with a venous stasis ulcer
4. Highly exudative wounds

Answer: B

Explanation: A)      The client with a stage I pressure ulcer might benefit from a transparent film. The client with a postoperative wound would not be a candidate for a transparent film, due to the risk of removing or applying pressure to the sutures or staples, and would be better suited for an impregnated nonadherent dressing. A clear, absorbent acrylic dressing would be best for the client with a venous stasis ulcer, and polyurethane foams would be best for the wound with a large amount of

exudate.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Planning

1. The client with a stage I pressure ulcer might benefit from a transparent The client with a postoperative wound would not be a candidate for a transparent film, due to the risk of removing or applying pressure to the sutures or staples, and would be better suited for an impregnated nonadherent dressing. A clear, absorbent acrylic dressing would be best for the client with a venous stasis ulcer, and polyurethane foams would be best for the wound with a large amount of

exudate.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Planning

1. The client with a stage I pressure ulcer might benefit from a transparent The client with a postoperative wound would not be a candidate for a transparent film, due to the risk of removing or applying pressure to the sutures or staples, and would be better suited for an impregnated nonadherent dressing. A clear, absorbent acrylic dressing would be best for the client with a venous stasis ulcer, and polyurethane foams would be best for the wound with a large amount of

exudate.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Planning

1. The client with a stage I pressure ulcer might benefit from a transparent The client with a postoperative wound would not be a candidate for a transparent film, due to the risk of removing or applying pressure to the sutures or staples, and would be better suited for an impregnated nonadherent dressing. A clear, absorbent acrylic dressing would be best for the client with a venous stasis ulcer, and polyurethane foams would be best for the wound with a large amount of

exudate.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Planning

Objective: Learning Outcome 31-2: Identify indications and contraindications for various types of wound care

and dressings.

• The nurse is assessing the client for pressure ulcer The client has no sensory deficits, skin is 4) dry and not exposed to moisture, the client is confined to bed and is completely immobile, she has nutritional status that is adequate, and she requires moderate assistance in moving. The nurse scores the client’s risk as:

1. A) 14, indicating moderate B) 15, indicating high risk.
2. C) 12, indicating D) 14, indicating high risk.

Answer: A

Explanation: A) The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 for shear related to needing moderate assistance to move, totaling 14. A score of 15-18 indicates some risk, 13-14 indicates moderate risk, 10-12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate

risk.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

14. The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 for shear related to needing moderate assistance to move, totaling A score of 15-18 indicates some risk, 13-14 indicates moderate risk, 10-12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate

risk.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

14. The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 for shear related to needing moderate assistance to move, totaling A score of 15-18 indicates some risk, 13-14 indicates moderate risk, 10-12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate

risk.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

14. The client gets 4 points for lack of sensory deficits, 4 points for dry skin, 1 point for being bedridden, 1 point for immobility, 3 points for adequate nutrition, and 1 for shear related to needing moderate assistance to move, totaling A score of 15-18 indicates some risk, 13-14 indicates moderate risk, 10-12 indicates high risk, and 9 indicates very high risk. As a result, this client, with a score of 14, is at moderate

risk.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

Objective: Learning Outcome 31-3: Identify assessment data pertinent to skin integrity and wounds.

• The nurse is admitting a client with a pressure ulcer to the long-term care When assessing 5) the wound, the nurse finds partial-thickness skin loss free of eschar, and stages the ulcer as a:

1. A) Stage B) Stage II. C) Stage III.                      D) Stage IV.

Answer: B

Explanation: A)      A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure relief. A stage II ulcer has partial-thickness skin loss free of eschar. A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer. Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure A stage II ulcer has partial-thickness skin loss free of eschar. A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer. Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure A stage II ulcer has partial-thickness skin loss free of eschar. A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer. Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure A stage II ulcer has partial-thickness skin loss free of eschar. A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer. Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

Objective: Learning Outcome 31-3: Identify assessment data pertinent to skin integrity and wounds.