Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
113 Cards in this Set
- Front
- Back
|
Prevention of the loss of body fluids, protection of deeper tissues from pathogenic organisms, noxious chemicals, and protection from short-wavelength ultraviolet radiation, are functions of what body system?
a. Immune Sytem b. Integumentary System c. Physioneurological System d. Adrenal System |
Integumentary System
|
|
|
The Integumentary System ...?
a. Provides locations for sensory reception of touch, pressure, temperature, pain, wetness, tickle, etc. b. Assists in vitamin D synthesis c. Plays a minor excretory role d. Skin, nails, hair e. all of the above |
all of the above
|
|
|
The Integumentary System ...?
a. Helps regulate body temperature b. Provides locations for sensory reception of touch, pressure, temperature, pain, wetness, tickle, etc. c. all of the above |
all of the above
|
|
|
Why is integument assessment important?
a. Provides a clear sense of the patient’s overall health b. Changes in the skin, hair, and nails may be the first indicator that a person’s health is declining c. Watch for subtle changes in color, texture, moisture, or temperature as well as for unusual markings or areas of injury |
all of the above
|
|
|
When assessing the integumentary ayatem it is important to?
a. inspect all exposed areas of the patient’s skin b. Pay particular attention to areas associated with the patient’s chief complaint and other clinical findings c. Look for skin pigmentation, complexion, note areas of skin breakdown, lesions, bruising d. Inspect any area that may be excoriated or infected from incontinence, heavy perspiration, lack of exposure to air (obesity) e. Beneath the breast, in the axillae, between the thighs, in the gluteal fold f. Look for lesions rashes, wounds, bruising |
all of the above
|
|
|
When assessing the integument by palpatation it is important to?
a. Palpate temperature with the palm of the hand b. Palpate temperature with the back of the hand c. Palpate temperature with the back of the hand d. Palpate temperature with the back of the hand |
Palpate temperature with the back of the hand
|
|
|
When palpating the patients temperature with the back of the hand you can?
a. warm your hands b. compare bilaterally c. use yuor own temperature for comparison if necessary |
all of the above
|
|
|
Skin Turgor should be checked on what areas of the body?
a. back of the hand b. axillary regions c. on the sternum d. under the clavicle |
on the sternum & under the clavicle
|
|
|
Skin turgor is normal when?
a. when it returns to shape when released b. elasticity is decreased c. Returns to normal slowly d. Patient is dehydrated |
when it returns to shape when released
|
|
|
When a lesion is present,gently palpate the borders to determine?
a. if there is a discharge b. if it is raised or flat c. if patient feels pain d. if there are signs of dehydration |
if it is raised or flat
|
|
|
Ecchymosis is characterized by?
a. grayish blue skin tones b. dry patchy scales c. yellowish color d. Bruise |
Bruise
|
|
|
Cyanosis is characterized by?
a. inflammation b. raised edges or borders on a leison c. tenting d. Grayish –blue tone |
Grayish –blue tone
|
|
|
Erythema is indicative of?
a. hypoxemia b. jaundice c. localized infection d. Hepatic disease |
localized infection
|
|
|
The thinning of hair can be attributed to?
a. Deficiency of vitamin D b. Hypoxia c. Adrenal d. Thyroid |
Thyroid
|
|
|
Loss of hair on lower extremities vcan be indicative of/
a. Ecchymosis b. Arterial insufficiency c. Hepatic Disease d. Erythema |
Arterial insufficiency
|
|
|
Decreased hair growth may be indicative of?
a. Hepatic disease b. Decreased circulation c. Polycythemia d. Hirsutism |
Decreased circulation
|
|
|
Diaphoresis is?
a. a result of dehydration b. abnormal skin color c. jaundice d. sweat |
sweat
|
|
|
Normal findings in integumentary assessments are?
a. even skin tone b. warm c. Turgor is elastic d. no unexplaned leisons |
All of the above
|
|
|
Trichotillomania is characterized by?
a. excessive use of hair care products b. fear of going bald c. habitual pulling of hair d. hormonal imbalances |
habitual pulling of hair
|
|
|
Alopecia areata is?
a. caused by poneytails b. caused by low estrogen c. excessive hair growth d. patchy balness |
patchy balness
|
|
|
Traction alopecia is?
a. hair loss from pulling hair b. hair loss from seborrheic dermatitis c. hair loss from tight hair do's d. hair loss from hormonal changes |
hair loss from tight hair do's
|
|
|
Patchy baldness with breakage of hair shaft at surface?
a. trichotillomania b. alopecia areata c. traction alopecia |
traction alopecia
|
|
|
Hair loss from wearing tightly bond hairstyles?
a. trichotillomania b. alopecia areata c. traction alopecia |
traction alopecia
|
|
|
Silky hair can be an affect of?
a. hypothyroidism b. Hypotension c. Hypertension d. hyperthyroidism |
hyperthyroidism
|
|
|
Scalp eruptions may indicate?
a. hirsutism b. alopecia c. hepatism d. psoriasis e. sebborrheic dermatitis |
psoriasis & sebborrheic dermatitis
|
|
|
Long term effects of stress on the skin on the skin include?
a. Cool, clammy, sweaty skin b. Hives, itching c. Tightening of scalp Psoriasis d. Acne e. Eczema |
All of the above !!!
|
|
|
Why is integument assessment important?
|
Provides a clear sense of the patient’s overall health
Changes in the skin, hair, and nails may be the first indicator that a person’s health is declining |
|
|
Dry brittle hair may indicate?
a. malnutrition b. hypothyroidism |
malnutrition &/or hypothyroidism
|
|
|
When assessing the nails the Nurse should observe for ?
a. shape, color, opacity b. determine smoothness/uneveness c. ridges, white spots, splinter hemmorrhages d. clubbing or spooning e. capillary refill |
All of the above !!!
|
|
|
Splinter hemmorrhages in the nail bed are indicative of?
a. Jaundice b. echymosis c. endocarditis d. malnutrition |
endocarditis
|
|
|
Nutritional deficiencies can be detected in the nails by ?
a. splinter hemmorrhages b. yellowing c. clubbing d. ridges |
ridges
|
|
|
Normal findings in assessing the nails are all of the following EXCEPT?
a. Smooth, round, fairly translucent nail plate b. Curvature is convex with 160 degree angle between the nails & skin at the nail base c. smooth surface, even & hard with smooth, rounded edges d. Nail beds pink & firm e. Cap refill < 3 sec f. Cuticles smooth, flat and unbroken |
All of the above are normal findings !!!
|
|
|
Abnormal findings when assessing the nails are?
a. Brittle, thinning, peeling nail plates b. Cracks or fissures in nails c. Thickened nails d. Trauma, decreased circulation, fungal infection e. White nail plates f. Pale nail plates g. Greenish-black nail plates h. Yellow nail plates |
All of the above !!!
|
|
|
Brittle, thinning, peeling nail plates are indicative of?
a. nutritional deficiencies b. circulatory deficiencies c. trauma d. hypoalbuminemia |
nutritional & circulatory deficiencies
|
|
|
Cracks or fissures observed in nail during assessment are indicative of?
a. malnutrition b. circulatory deficiencies c. trauma d. hypoalbuminemia |
malnutrition
|
|
|
White nail plates observed during an assessment may indicate?
a. nutritional deficiencies b. circulatory deficiencies c. trauma d. hypoalbuminemia |
hypoalbuminemia
|
|
|
Pale nail plates observed in a patients assessment are indicative of?
a. malnutrition b. circulatory deficiencies c. anemia d. hypoalbuminemia |
anemia
|
|
|
Greenish-black nail plates are indicative of?
a. fungal/bacterial infection b. circulatory deficiencies c. trauma d. hypoalbuminemia |
fungal/bacterial infection
|
|
|
Yellow nail plates are indicative of?
a. Psoriasis b. respiratory disease c. cigarette smoking d. staining from nail polish |
All of the above !!!
|
|
|
Spoon shaped nails are indicative of?
a. Iron deficiency b. poor circulation c. endocarditis d. cardiopulmonary disease |
Iron deficiency
|
|
|
Poor adhesion of nails to nail bed or pitting nail plate is indicative of?
a. Iron deficiency b. respiratory disease c. Psoriasis d. anemia |
Psoriasis
|
|
|
Rough, jagged, or bitten nails are indicative of?
a. Poor hygiene b. nail biting habit c. nervousness d. stress |
All of the above !!!
|
|
|
Clubbing of the nails is indicative of?
a. cardiopulmonary disease b. iron deficiency C. trauma D. endocarditis |
cardiopulmonary disease
|
|
|
Splinter hemorrhages of nail bed is indicative of all EXCEPT?
a. endocarditis b. psoriasis c. trauma d. hypoalbuminemia |
hypoalbuminemia
|
|
|
Capillary refill greater than 5 seconds indicates?
a. iron deficiency b. trauma c. endocarditisa. d. compromised circulation |
compromised circulation
|
|
|
An angioma is?
a. tricuspid dysfunction b. tumor of blood or lymph vessel c. tumor of the integument |
tumor of blood or lymph vessel
|
|
|
An angioma is detected in the integument by?
a. Splinter hemmorrhages b. Clusters of "red cherries" c. Capillary refill > 5 sec d. Clubbing |
Clusters of "red cherries"
|
|
|
White depigmented skin is called?
a. angioma b. iron deficiency c. anemia d. vitilago |
vitilago
|
|
|
Visible dilated superficial cutaneous blood vessels that spider out are indicative of?
a. endocarditis b. alcoholics c. anemia d. chronic steriod use |
alcoholics & chronic steriod use
|
|
|
Visible dilated superficial cutaneous blood vessels that spider out are called?
a. erythemia b. Angioma's c. Telangiectasia d. Splinter hemorrhages |
Telangiectasia
|
|
|
An increased prominence of superficial veins visable in the integument is called?
a. Erythema b. Angioma c. Variscosity d. inflammation |
Variscosity
|
|
|
Cyanosis can be detected in dark-skinned patients having?
a. red lips & tongue b. pink palms, soles c. bluish tinge in nail beds, lips & conjuctivae |
bluish tinge in nail beds, lips & conjuctivae
|
|
|
To assess inflammation in dark skinned patients?
a. palpate for warmth b. observe darker than normal skin tone |
All of the above !!!
|
|
|
A Punch biopsy is a procedure that?
a. a small circular instrument or punch ranges from 2-6 mm b. requires local anesthesia c. removes a plug of tissue d. May require 1 -2 stitches |
All of the above !!!
|
|
|
A Shave biopsy?
a. Is the removal only of the portion of the skin that is raised b. Requires local anesthesia c. Uses a scalpel that is moved parallel to the skin d. Does not require suturing |
All of the above !!!
|
|
|
An excisional biopsy?
a. involves the removal of an entire lesion b. remove large or deeper specimens c. are sutured |
All of the above !!!
|
|
|
A diagnostic test involving a biopsy that uses a small circular instrument or punch ranges from 2-6 mm is a ?
a. Excisional biopsy b. Punch biopsy c. Plug biopsy |
Punch biopsy
|
|
|
A localized area of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues is called?
a. hematoma b. erythemia c. pressure Ulcer d. fissure |
pressure ulcer
|
|
|
Necrosis is?
a. infection of the dermis b. infection of the epidermis c. death of tissue d. dry scaley patches |
death of tissue
|
|
|
Pressure ulcers are caused by?
a. friction b. shearing force c. excessive moisture d. pressure |
All of the above !!!
|
|
|
Factors that put an individual at risk for pressure ulcers?
a. immobility b. impaired circulation c. age related changes to the skin d. incontinence e. chronic illnesses such as diabetes mellitus |
All of the above !!!
|
|
|
Risk assessment tools that are available for predicting the need for intervention of pressure ulcers are all of the following EXCEPT?
a. Braden Scale b. Norton c. Gosnell d. Morse |
All
EXCEPT for MORSE |
|
|
An observational method of risk assessment that over time can indicate potential for development of pressure ulcer long before development occurs is called?
a. Mapping b. Trending c. Assessing |
Trending
|
|
|
FHP assessment of risk for pressure ulcers should include which of the following?
a. Health maintenance b. Nutritional-metabolic c. Elimination d. Activity-exercise e. Cognitive-perceptual |
All of the above !!!
|
|
|
Staging of pressure ulcers is based on?
a. the depth of the ulcer b. the amount of tissue layers involved in the ulcer c. the rate of healing of an ulcer d. how long an ulcer has been manifested |
Staging is based upon the DEPTH and the AMOUNT of tissue layers involved in a pressure ulcer.
|
|
|
A condition in which a “red spot” appears on the skin from pressure is called?
a. Vitilago b. Reactive Hyperemia c. Hypererythemia d. Hypoerythemia |
Reactive Hyperemia
|
|
|
When a red spot on the skin blanches out when thumb pressure is applied is called?
a. Erythemia b. Blanchable erythema c. Reactive Hyperemia d. ecchymosis |
Blanchable erythema
|
|
|
In stage I of a pressure ulcer, an indication that the tissue will recover if pressure is removed is?
a. erythemia b. turgor c. tenting d. blanchable erythema |
blanchable erythema
|
|
|
Persistent redness in light skinned individuals, persistent red, blue or purple hues in darker skinned individuals is an indication of what stage of a pressure ulcer?
a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage I
|
|
|
A pressure ulcer that ivolves damage of SQ tissue that may extend down to, but not through the underlying fascia is in what stage of a pressure ulcer?
a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage III
|
|
|
Asuperficial abrasion, blister, or shallow crater that may look like a skin tear is in what stage of a pressure
ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage II
|
|
|
A pressure ulcer that may include tendons or joint capsule is in what stage?
a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage IV
|
|
|
Long extensions of a pressure ulcer under the surrounding skin and tissues
that may extend some distance from the visible wound is called ? a. Stage I pressure ulcer b. Tunneling c. Sinus Tracts d. Funnels |
Sinus Tracts
|
|
|
Partial thickness skin loss involving epidermis and/or dermis is in what stage of a pressure ulcer?
a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage II
|
|
|
Full-thickness skin loss of a pressure ulcer is in what stage?
a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage III
|
|
|
A thick, dark scab like material is called?
a. necrotic tissue b. debrided tissue c. eschar d. blanchable erythema |
eschar
|
|
|
An observable pressure related alteration of intact skin is in what stage of a pressure ulcer?
a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage I
|
|
|
An observable pressure related alteration of intact skin that may be warmer or cooler than adjacent skin is in what stage of a pressure ulcer?
a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage I
|
|
|
Non-blanchable erythema differs from blanchable erythema in that?
a. non-blanchable erythema occurs in Stage I of a pressure ulcer & does not blanch out when pressure is applied b. Blanchable erythema blanches out with additional pressure which indicates the tissue can recover if pressure is removed |
Stage I = non-blanchable erythema
Blanchable erythema is tissue that recovers when pressure is removed |
|
|
When diagnosing a pressure ulcer the nurse should?
a. measure the ulcer b. document the size |
Measure & Document
|
|
|
Risk assessment for pressure ulcers on any patient with a mobility or activity deficit should be subject to a risk assessment & the skin of an “at risk” patient should be inspected?
a. Immediatly, & as soon as the patient complains of itching, pain, or redness b. on admit & at least 3 times a week c. On admit & at least once a week d. on admit and at least once daily |
on admit and at least once daily
|
|
|
Use of pressure reduction apparatus includes?
a. Alternating pressure mattresses b. Foam cushions c. Lift sheets d. Heel protector boots e. Elbow protector pads |
All of the above !!!
|
|
|
Documentation of Pressure Ulcers include?
a. Stage b. Size of wound using measuring card or tape measure c. Depth by inserting cotton tipped applicator into deepest portion of wound, remove and measure the applicator |
All of the above !!!
|
|
|
Acute Interventions for patients with pressure ulcers are:
a. Positioning is essential b. Support of body parts c. Avoid positions that place patient directly on an area of existing ulceration d. Use a posted turning schedule e. Assess the other “good” side frequently as it will now have increased pressure because of inability to position on the “bad” side f. Avoid massage over boney prominences g. Avoid hot water and/or strong cleansers in the bath h. Minimize environmental factors such as low humidity and cold air i.Use moisturizers to re-hydrate dry skin j. Cleanse the patient often and thoroughly if incontinent |
All of the above !!!
|
|
|
The best cleanser for a pressure ulcer is?
a. drying agents b. cytotoxic cleaners c. betadine d. normal saline |
normal saline
|
|
|
Cleaning the ulcer with these solutions will kill new cells EXCEPT?
a. Normal saline b. Drying agents c. Alcohol d. Cytotoxic cleaners e. Dakin’s solution f. Betadine |
Normal saline
|
|
|
To remove slough of a pressure ulcer using the irrigation method without killing new cells, a psi no higher than ____ should be used?
a. 1-5 psi b. 3-10 psi c. 4-15 psi d. 15-30 psi |
4-15 psi
|
|
|
To irrigate & remove slough of a pressure ulcer the nurse should use pressure no higher than 4-15 psi & a ______mL syringe with a_____ gauge angiocath?
a. 10 ml syringe w/5 gauge agiocath b. 15 ml syringe w/15 gauge angiocath c. 25 ml syringe w/25 gauge angiocath d. 35 ml syringe w/19 gauge angiocath |
35 ml syringe w/19 gauge angiocath
|
|
|
A necessary procedure used in the treatment of a pressure ulcer with necrotic tissue or eschar present is called?
a. irrigation b. debridement c. excision |
debridement
|
|
|
Methods of debridement of a pressure ulcer can be?
a. surgical procedure b. mechanical debridement c. enzymatic debridement d. autolytic debridement e. hydrocolloids f. calcium alginates g. surgical reconstruction |
All of the above !!!
|
|
|
A debridemnet done with application of wet-to-dry dressings is called?
a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. mechanical debridement |
mechanical debridement
|
|
|
In treating a pressure ulcer using a dressing applied in contact with the necrotic tissue, so that it dries into that tissue, and then pulls bits of the tissue away as it is removed from the wound is a procedure called?
a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. mechanical debridement |
mechanical debridement
|
|
|
The key to mechnical debridement is to ?
a. get the dressing material wet enough to get “into” the necrotic tissue, but not so wet that it will not dry between dressing changes a. get the dressing material wet enough to get “into” the necrotic tissue, so it will dry between dressing changes |
get the dressing material wet enough to get “into” the necrotic tissue, but not so wet that it will not dry
between dressing changes |
|
|
A form of debridement using materials such as Accuzyme, Panafil, Ziox, Liberase,& Elastasethen are used to “eat into” the necrotic tissue and dissolve it away it is called?
a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. mechanical debridement |
enzymatic debridement
|
|
|
This approach to treating a pressure ulcer should not be used if the wound is infected?
a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. mechanical debridement |
autolytic debridement
|
|
|
Debrididement of a pressure ulcer using Hydrocolloids, hydrogels, Calcium alginates, or materials that hold body fluids close to the wound bed and keep it moist is called?
a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. mechanical debridement – |
autolytic debridement
|
|
|
A form of debridement where the body has the capacity to remove necrotic tissue through autolysis & can be be supported through the application of occlusive dressings is called?
a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. mechanical debridement |
autolytic debridement
|
|
|
A form of debridement using materials such as Duoderm or Tegasorb placed over the wound and then allowed to remain in place for a period of time is called?
a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. mechanical debridement |
hydrocolloidal debridement
|
|
|
Problems with this form of debridement include rolling up of edges of dressing, causing additional pressure areas?
a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. mechanical debridement |
hydrocolloidal debridement
|
|
|
A form of debridement using products made from seaweed
having a “fishy” odor when the dressing is removed is called? a. autolytic debridement b. enzymatic debridement c. hydrocolloidal debridement d. calcium alginate debridement |
calcium alginate debridement
|
|
|
A form of debridement that dissolves and “fills in” the area under an occlusive dressing and helps to keep the good body fluids close to the bed of the wound using a product that turns into a jelly that may be yellowish in color is?
a. calcium alginate debridement b. enzymatic debridement c. hydrocolloidal debridement d. autolytic debridement |
calcium alginate debridement
|
|
|
AlgiDerm, AlgiSite, Sorbsan are all products that are used in what type of debridement of pressure ulcers?
a. calcium alginate debridement b. enzymatic debridement c. hydrocolloidal debridement d. autolytic debridement |
calcium alginate debridement
|
|
|
Once debridement has been accomplished the goal is?
a. to keep the wound covered so that the wound bed is kept moist b. there is no containment of any drainage that might be present c. the wound is protected from contamination from outside sources |
All of the above !!!
|
|
|
All Stage II through Stage IV pressure ulcers are assumed to be?
a. infected b. infectious c. colonized with bacteria |
colonized with bacteria
|
|
|
All pressure ulcers are assumed to be colonized with bacteria that are in?
a. Stage I b. Stage II c. Stage III d. Stage IV |
Stage II, III, IV
|
|
|
Expect that your patient with a pressure ulcer will be treated with ______?
a. mechanical debridement b. Hydrocolloids c. Autolytic Debridement d. antibiotics |
antibiotics
|
|
|
Often the patient who is at risk for development of pressure ulcer is also at risk for?
a. fatigue b. nutritional deficiency c. renal failure d. hypothyroidism |
nutritional deficiency
|
|
|
A patient who has decreased skin turgor is most likely?
a. weak b. incontinent c. dehydrated d. using corticosteroids |
dehydrated
|
|
|
The use of corticosteroids can result in?
a. incontinence b. inability to feel pain c. thinning of skin d. suppress immune responses e. edema |
thinning of skin
suppress immune responses edema |
|
|
Stage I pressure ulcers present observable related alteration of _____ skin?
a. necrotic b. intact c. yellowish d. hardened |
intact
|
|
|
Stage I pressure ulcers the skin may feel?
a. May be warmer or cooler than adjacent skin b. May have a firm or boggy feel c. Patient may report pain or itching in the area |
All of the above !!!
|
|
|
Evaluating a patient for pressure ulcers would involve?
a. Observing the surrounding skin for redness b. Observing the skin for tenderness c. Observing the skin for inflammation d. Observing existing ulcer for drainage e. Observing the skin for odor f. monitor WBC g. monitor the patient for fever |
All of the above !!!
|
|
|
When speaking in terms of pressure ulcers, the term "granulation" refers to?
a. necrotic tissue b. signs of infected tissue c. new tissue d. red spots |
new tissue
|
