Chapters 19/37/4/5/6

Question 1

Stages of Pressure injuries:

Answer 1

Stage 1: area of reddened skin that does not blanch when touched (sunburn)
Stage 2: partial-thickness skin loss (blister)
Stage 3: full-thickness skin loss (deep crater, subcutaneous tissue damaged)
Stage 4: full-thickness skin skin loss with extensive tissue necrosis or damage to muscle or muscle supporting structures (black and dry)

Question 2

Preventing pressure injuries:

Answer 2

Assessment begins on admission to the nursing unit

Question 3

What to avoid doing with pressure injuries:

Answer 3

DO NOT MASSAGE

Question 4

Which of the following is not a function of the integumentary system?
1) Protection
2) Provides color
3) Temperature regulation
4) Excretion and secretion

Answer 4

2: Provides color

Question 5

Four purposes of bathing:

Answer 5

-Cleanse skin
-Promote comfort
-Stimulate circulation
-Remove waste products

Question 6

Types of baths:

Answer 6

-Cleansing
-Theraputic bath:
*Whirlpool bath
*Sitz bath
*Sponge bath

Question 7

Cleansing bath:

Answer 7

Done in bed, tub or shower.

Question 8

Different types of therapeutic bath:

Answer 8

*Whirlpool
*Sitz
*Sponge

Question 9

Whirlpool bath:

Answer 9

used to cleanse and stimulate peripheral circulation

Question 10

sitz bath:

Answer 10

applies moist heat and cleansing to perineal area

Question 11

sponge bath:

Answer 11

may be used to bring down fever

Question 12

Variation of the bed bath:

Answer 12

Bag bath- a variation of the bed bath

Question 13

Bathing the older adult:

Answer 13

full bath is not required everyday

Question 14

What are pathogens?

Answer 14

agents that live in a host, such as a human, and are responsible for causing infections or diseases in
that host.

Question 15

Important reminder for dentures:

Answer 15

check for dentures if appropriate fitting and check meal tray for any dentures, or linens, bedsheet

Question 16

Ingrown toenail:

Answer 16

An ingrown toenail (Onychocryptosis) is a common discomfort that involves the nail curving
down, into the surrounding skin as it grows.

Question 17

A toe with an abnormal bend or
deformity in the middle joint.

Answer 17

It usually
affects the second or third toe.
Treatment- surgery, orthotic shoes

Question 18

Perineal care is usually called:

Answer 18

“peri care” - meaning washing the genitals and anal areas

Question 19

How to “peri care”:

Answer 19

wipe from front to back (vagina toward rectum) on female patients to avoid contaminating the vagina or urethral meatus.

Question 20

1. . A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take?
   A. Turn the client’s head to the side.
   B. Place two fingers in the client’s mouth to open it.
   C. Brush the client’s teeth once per day.
   D. Inject a mouth rinse into the center of the client’s mouth.