Chapter 54. Nursing Care of Patients With Skin Disorders

Chapter 54. Nursing Care of Patients With Skin Disorders

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____     1.   A patient admitted to the hospital from a nursing home has a stage 3 pressure ulcer. What is the best way for the nurse to initially document the appearance of the wound?

____     2.   The nurse is monitoring a patient’s stage 3 pressure ulcer for healing during treatment. Which finding indicates that the nursing interventions have been effective?

____     3.   A patient has a pressure ulcer that has purulent drainage, areas if black material, foul smelling, and painful. What should the nurse do first for healing to occur?

____     4.   A patient’s pressure ulcer is 3 cm in diameter and 1 cm deep and has tunneling on the left side. The ulcer holds 17 mL of normal saline and has no visible fascia or bone in the ulcer. What pressure ulcer stage should the nurse document?

____     5.   The nurse is caring for a patient who has a stage 4 pressure ulcer that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which patient assessment finding should be communicated to the registered nurse (RN) immediately?

MULTIPLE CHOICE

1. ANS:  B

Be sure to document with photographs all pressure ulcers present on admission to the hospital. A photograph is objective and easy to use as a baseline to monitor wound healing progress. A. C. D. Using a ruler, clock analogy, and objective terminology are all important but are not as clear a communication tool as a photograph for documenting appearance.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

2. ANS:  D

Granulation tissue is a sign of healing and has a budding appearance, from the development of tiny new capillaries. If the granulations are healthy, they have a slightly spongy texture. A. A hard crust indicates eschar, which must be removed for healing to occur. C. Serosanguinous drainage indicates absence of infection, not healing. B. Minimal pain is a good outcome but is not a measure of healing.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Evaluation

3. ANS:  B

Débridement of nonviable tissue is necessary if there is an open wound. Débridement removes drainage and wound debris and permits granulation of tissue. A. C. D. After the wound is debrided the need for culture and additional treatment may be determined.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

4. ANS:  C

A stage 3 ulcer has full-thickness skin loss, which extends to the subcutaneous tissue but not fascia. The ulcer looks like a deep crater and may have undermining of adjacent tissue. A. Skin is still intact in stage 1. B. Stage 2 is shallow. D. Stage 4 has damage to muscle and bone.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

5. ANS:  C

A reddened area adjacent to the ulcer can indicate extension of the ulcer or infection and should be reported. B. Yellow drainage may indicate colonization and not true wound infection. A. Pain is not unexpected and can be treated by the LPN. D. Pink grainy appearance is a sign of healing.

PTS:   1                    DIF:    Moderate

KEY:  Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis