ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 64 : Introduction to the Integumentary System Questions
Question 1 of 5
The nurse is changing a brief for a client that has been incontinent of stool and observes an area over the left trochanter that is reddened and in the center of the area is a shallow skin tear. The nurse takes a picture of the wound for the chart. How will the nurse stage this wound?
Correct Answer: B
Rationale: A stage II pressure sore is red and is accompanied by blistering or a shallow break in the skin, sometimes described as a skin tear. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
Question 2 of 5
The nurse is caring for a client in the long-term care facility who had been living at home and being cared for by a family member. The family member states having had a difficult time getting the client to eat or drink and that the client developed a 'bed sore.' The nurse observes a serous drainage covering the dressing and a 2x2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure sore as?
Correct Answer: C
Rationale: Stage III pressure sores involve superficial skin impairment that progresses to a shallow crater extending to the subcutaneous tissue, often with serous drainage. Stage I is characterized by redness of intact skin. Stage II includes a blister or shallow break in the skin. Stage IV involves deep ulceration exposing muscle or bone.
Question 3 of 5
The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review?
Correct Answer: A
Rationale: Normal nails appear slightly convex with a 160?° angle between the nail base and the skin. Concave-shaped nails, referred to as 'spooning' because of their characteristic appearance, are a sign of iron-deficiency anemia. ABGs, BUN and creatinine, and glucose levels are not related to this shape of nail.
Question 4 of 5
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?
Correct Answer: D
Rationale: Clubbing of the nails is evidenced by an angle greater than 160?° and suggests long-standing cardiopulmonary disease and chronic hypoxic states. Concave or 'spooning' may indicate iron-deficiency anemia. Discolored or brittle nails may result from other disorders or smoking.
Question 5 of 5
A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination using ultraviolet light can be used to determine if the rash is a fungal rash?
Correct Answer: D
Rationale: A Wood light is also known as a black light and is a handheld device that can identify certain fungal infections that fluoresce under long-wave ultraviolet light. In a darkened room, when a physician or nurse aims the light at a lesion caused by a fungus that fluoresces, the lesion emits a blue-green color. It is the only test that uses a light; the others use skin scrapings.