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 performing a skin assessment on a client that is admitted to the hospital and observes an area over the left heel that is reddened but intact. How would the nurse stage this pressure sore?
Correct Answer: A
Rationale: 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 II is the same as stage I but has a blister or shallow break in the skin. 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 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 3 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 4 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 5 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.