Review Questions
1
.
What term would the nurse document when describing the depth of a laceration through the second layer of skin?
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Langerhans
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keloid
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keratin
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dermis
2
.
Which layer of the epidermis is only present in the soles of the feet?
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stratum basale
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stratum granulosum
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stratum lucidum
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stratum spinosum
3
.
What is the primary function of the skin?
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protection
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store and release fat
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vitamin B production
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digestive enzyme production
4
.
The nurse is educating a patient on how their skin helps with temperature regulation. The nurse explains to the patient that when the body temperature decreases, the blood vessels do what?
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vasoconstrict to increase blood flow
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vasoconstrict to decrease blood flow
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vasodilate to increase blood flow
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vasodilate to decrease blood flow
5
.
The nurse caring for a dark-skinned patient knows that the patient is more susceptible to which of the following?
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freckles
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keloids
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skin cancer
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sunburns
6
.
The pediatric nurse is educating a new mother on risk factors that may contribute to her young infant’s risk for hypothermia. What statement from the mother would suggest that she understood the teaching?
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“My child is at risk for hypothermia because he has a lesser amount of subcutaneous tissue, meaning his blood vessels are farther away from the surface.”
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“My child is at risk for hypothermia because he has more subcutaneous tissue, meaning his blood vessels are farther away from the surface.”
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“My child is at risk for hypothermia because he has more subcutaneous tissue, meaning his blood vessels are closer to the surface.”
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“My child is at risk for hypothermia because he has a lesser amount of subcutaneous tissue, meaning his blood vessels are closer to the surface.”
7
.
What is an example of a lifestyle choice that is a behavioral risk factor for impaired skin integrity?
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diabetes
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illicit drug use
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medication use for congenital heart disease
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impaired mobility
8
.
A 67-year-old patient presents to the clinic with redness, edema, and fluid-filled vesicles on the right leg that is hot to the touch. The patient also complains of pain and tenderness. The patient’s heart rate is 110 and temperature is 100.8°F (38.2°C). The nurse should suspect what skin abnormality?
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folliculitis
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carbuncles
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impetigo
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cellulitis
9
.
The nurse is caring for an adult who has just been diagnosed with shingles. What statement from the patient would suggest that she understood the teaching?
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“Varicella lies dormant after having the vaccination or chickenpox. It can reactivate later in life and present as shingles.”
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“Shingles can only occur if you have had the varicella vaccine.”
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“I had chickenpox as a kid, so I should not be getting this virus.”
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“Shingles only affect women.”
10
.
You are educating a patient on preventing skin cancer. What statement from the patient would suggest that she understood the teaching?
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“I will only go to the tanning salon twice a week.”
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“I will avoid the sun from 9 a.m. to 1 p.m. when the ultraviolet rays are the strongest.”
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“I will wear protective clothing like long sleeves, hats, and sunglasses, and use sunscreen at the lake this weekend.”
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“I will use a sunscreen that has an SPF factor of five or greater.”
11
.
What is not a benign skin change found in older adults?
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cherry angiomas
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wrinkles
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carbuncle
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melasma
12
.
Identify an example of an intentional wound.
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bullet
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stab wound
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surgical incision
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fracture
13
.
The nurse recognizes that what factor does not put a patient at risk for pressure injury development?
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altered mental status
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loss of appetite
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advanced age
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weightlifting
14
.
Maceration can be defined as:
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loss of superficial layers of the skin
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tissue softened by prolonged wetting or soaking
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tissue hardened by pressure
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tissue that has development of slough
15
.
The nurse is assessing a patient with a deep red area of intact skin that does not blanche. At what stage of pressure injury is this classified?
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stage I injury
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deep-tissue injury
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unstageable injury
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stage II injury
16
.
The nurse is educating a new graduate nurse on pressure injuries. What statement from the student would suggest that she understood the teaching?
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“The difference in stage III and IV pressure injuries is the visibility of fascia, tendon, ligament, muscle, cartilage, and bone.”
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“Slough and eschar are present at every stage.”
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“If the area blanches, it is stage I.”
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“A diabetic ulcer is also called a deep-tissue pressure injury.”
17
.
During which phase of the healing process do leukocytes move into the interstitial space to ingest bacteria and cellular debris?
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hemostasis
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inflammatory phase
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proliferation phase
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maturation phase
18
.
The nurse is explaining complications associated with wound healing to a new patient at the clinic. How should the nurse describe maceration?
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occurs when hydration leads to cell death
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occurs when there is trauma the wound
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occurs when there is swelling that interrupts blood flow
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occurs where the cells are overhydrated, leading to skin softening and breakdown
19
.
What nursing intervention is appropriate when performing a dressing change?
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administering pain medication prior to wound care when the patient states that wound care is painful
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telling the patient that they just need to look at the wound
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explaining to the patient that the smell from the wound is not that bad
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encouraging the patient that they do not have to make any changes in their activities of daily living
20
.
What type of debridement promotes the body’s own defense mechanisms?
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enzymatic debridement
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mechanical debridement
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autolytic debridement
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wet-to-dry debridement