Questions 26

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Integumentary NCLEX RN Questions Questions

Extract:

The wound care nurse is caring for a client at the outpatient clinic
Item 1 of 1
Nurses' Notes
Medical History
1300 - Client presents to the clinic on a referral from the primary healthcare provider for a wound to the right ankle area. The injury developed three months ago and has worsened despite topical treatment. On assessment, the wound is 5 cm x 4 cm and is shallow. The wound bed is pink with some granulation tissue; scant sanguineous drainage. Wound edges are uneven. Client reports pain only when dressing changes are performed, and the pain is rated as 5 on a scale of 0 (no pain) to 10 (severe pain). The surrounding skin on the affected foot is dry, darkened, and flaky. Capillary refill < 3 seconds. Peripheral pedal pulse 2+ on the affected foot. 3+ Ankle edema was noted in both lower extremities. The client denies leg pain during ambulation but endorses ankle swelling during the day while walking, and the only relieving factor is the application of a compression hose to both legs. The client reports applying a hot compress to the extremity but states after 2-3 applications, it worsened and became painful.


Question 1 of 5

For each assessment finding below, click to specify if the finding is consistent with an arterial, venous, or diabetic ulcer. Each finding may support more than one (1) disease process.

Assessment findings Arterial ulcer Venous ulcer Diabetic ulcer
swelling in affected extremity
pedal peripheral pulse 2+
swelling relieved with compression hose
denies leg pain during ambulation
shallow wound bed
medical history of hypertension and diabetes mellitus
worsened with hot compress

Correct Answer: A: B, D, E, F; V: A, C, E; D: E, F, G

Rationale: Arterial ulcers: normal pulse, no leg pain, shallow wounds, and hypertension/diabetes history. Venous ulcers: swelling, compression relief, shallow wounds. Diabetic ulcers: shallow wounds, diabetes history, worsened with heat.

Extract:


Question 2 of 5

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Question 3 of 5

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Question 5 of 5

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