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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