Integumentary/Infection Flashcards
A patient with impaired blood flow to their lower extremities would face which barrier to healing of a foot ulcer?
A. Hemorrhage
B. Malnutrition
C. Lack of Oxygen
D. Infection
C. Lack of Oxygen
Rationale: Hemoglobin on RBCs carries oxygen to the tissues. Impairment of blood flow leads to a lack of oxygenation (ischemia) to the tissues. This lack of oxygen would delay wound healing
Which of the following would heal by primary intention? SATA
A. Surgical Incision
B. Second degree burn
C. Pressure Ulcer on the Coccyx
D. Paper Cut
Answer: A and D
Rationale: A wound that heals by primary intention will have approximated edges and a clean cut
A patient finished a dose of antibiotics and reports abnormal vaginal discharge/itching. What do you suspect is the cause?
A. Vaginal candidiasis
B. Oropharyngeal candidiasis
C. Herpes Zoster
D. Tinea cruris
Answer: A
Rationale: Antibiotics kill the normal flora of the vagina which puts a patient at risk for fungal infections. Vaginal discharge and itching are common CM of a vaginal yeast infection
Your patient is positive for C diff. What clinical manifestations will they likely experience? SATA
A. Watery diarrhea
B. Fever
C. Abdominal pain
D. Hives
Answer: A,B,C
Rationale: C diff is a bacteria that infects the GI tract. It causes watery diarrhea, fever, abdominal pain, cramping, and nausea.
Your patient reports severe pain followed by the presence of a rash that presented unilaterally. What disease do you suspect?
A. Chicken pox
B. AIDs
C. Herpes Zoster
D. Candida Albicans
Answer: C
Rationale: The CM of herpes zoster (shingles) include pain and itching as well as grouped vesicles that present unilaterally
Which burn is the most painful? Which has no pain at all?
A. First Degree
B. Second Degree
C. Third Degree
Answer: Second degree is most painful, Third degree has no pain
Rationale: The nerves are all exposed with a second degree burn. However, with a third degree burn the nerve endings are all destroyed so there is no pain at all.
You are assigned four patients on your nursing unit. Which patient is at most risk for pressure ulcers?
A. A 72 year old female weighing 82lbs with stress incontinence and dementia.
B. A 90 year old male with Congestive Heart Failure who has 3+ pitting edema in lower extremities.
C. A 9 month old admitted with RSV
D. An ambulatory 88 year old with dementia who is admitted with shingles.
Answer: A
Rationale: This patient has the MOST risk factors for developing pressure ulcers (more risk factors = greater risk)
Risk Factors: Pressure, Tissue Tolerance, Friction, Shear Force
The home health registered nurse is reinforcing instructions to the family about how to prevent pressure ulcers for their family member who is bedridden. Which measure should the RN enforce?
A. Massage directly over reddened sites
B. Lift the client when turning to prevent sliding
C. Change client’s position every 4 hours
D. Place pillows under both knees
Answer: B
Rationale: Lifting the client reduces the shear force exerted on the client.
Bonus: Why is A incorrect? C?
During your admission assessment you notice a reddened area on your patient’s hip. Which finding would concern you?
A. Area blanches and erythema returns
B.Areadoes not blanch but doesblanch upon reassessment in 1 hour
C. Area does not blanch and remains non-blanchable upon reassessment in 1 hour
Answer: C
Rationale: This is a stage 1 pressure ulcer
A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur?
A. tertiary intention
B. secondary intention
C. primary intention
Answer: B
Rationale: a pressure ulcer does not have a clean cut or approximated edges and requires more time to heal. This is secondary intention healing.
During the second phase of wound healing, you will see? SATA
A.Scar formation
B.Collagen Formation
C.Wound Contraction
D. Granulation Tissue
E.Inflammation
F. Re-epithelialization
Answer: B,D,F
Rationale: The other options would be seen during the first and third phase of wound healing.
Define the following
- Vector:
- Vehicle:
Vector: a LIVING organism carries an infectious disease
Vehicle: A NON LIVING substance harbors an infectious disease
Give some examples of both
What are the three types of contact transmission?
A. Airborne
B. Direct
C. Indirect
D. Droplet
Answer: B,C,D
Rationale: Airborne is a separate mode of transmission
Direct = direct human to human contact
Indirect = no direct contact.
Droplet = Sneeze, cough, spit
Airborne = It aerosolizes and lives in the air
Tip: Remember that MODES OF TRANSMISSION are not the same as what we will see in the hospital for isolation precautions! They have similar names
Don’t get them confused if you work in the hospital
During the incubation period of infection what symptoms would you expect to see?
A. Flu like symptoms - non-specific
B. Symptoms specific to that disease
C. A decrease in symptoms as the patient recovers
D. A symptomatic
Answer: D
During the incubation period you would be asymptomatic. This is the stage of infection when an organism invades the host and proliferates.
During which stage of infection would you expect to see non-specific flu-like symptoms?
A. Incubation
B. Prodromal
C. Acute
D. Convalescence
Answer: B
Rationale: During the prodromal stage you would see non specific symptoms, during the acute you would see specific symptoms, and during convalescence you would see recovery from the illness
