Tissue Integrity Flashcards
The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.
- Sclerae
- Tongue
- Nail beds
- Elbows and heels
- Mucous membranes
- Tongue
- Nail beds
- Mucous membranes
Rationale:
Skin color may be more difficult to assess in the client with dark skin. The best areas to use to detect pallor and cyanosis include the tongue, nail beds, and mucous membranes. The sclerae are most useful in evaluating jaundice. Elbows and heels are not appropriate areas to assess for skin color changes.
The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for?
- A yellow tinge to the skin
- Bluish discoloration of the skin
- Loss of normal red tones in the skin
- An ashen-gray appearance to the skin
- Loss of normal red tones in the skin
Rationale:
In dark-skinned clients, pallor results in the loss of normal red tones in the skin. The brown-skinned client may have yellow-tinged skin when pallor is present. Bluish discoloration of the skin most often is associated with cyanosis. In the black-skinned client, pallor produces an ashen-gray color.
The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area?
- Sclerae
- Oral mucosa
- Sole of the foot
- Palm of the hand
- Oral mucosa
Rationale:
In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best noted in the palms of the hands and soles of the feet.
The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema?
- Assess for drainage from the wound.
- Assess for redness around the wound edges.
- Palpate for swelling around the wound edges.
- Palpate for increased skin temperature around the wound edges.
- Palpate for increased skin temperature around the wound edges.
Rationale:
Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema.
The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?
- Skin turgor
- Level of edema at burn site
- Adequacy of capillary filling
- Amount of fluid tolerated in 24 hours
- Adequacy of capillary filling
Rationale:
Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation. Although options 1, 2, and 4 may provide some information related to fluid volume, in a burn injury, and from the options provided, adequacy of capillary filling is most accurate.
The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child’s skin?
- Fine grayish red lines
- Purple-colored lesions
- Thick, honey-colored crusts
- Clusters of fluid-filled vesicles
- Fine grayish red lines
Rationale:
Scabies is a parasitic skin disorder caused by an infestation of Sarcoptes scabiei (itch mite). Scabies appears as burrows or fine, grayish red, thread-like lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid-filled vesicles are seen in herpesvirus infection.
The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a “positive” head check for lice?
- Maculopapular lesions behind the ears
- Lesions in the scalp that extend to the hairline or neck
- White flaky particles throughout the entire scalp region
- White sacs attached to the hair shafts in the occipital area
- White sacs attached to the hair shafts in the occipital area
Rationale:
Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.
The staff nurse reviews the nursing documentation in a client’s chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client’s sacral area?
- Intact skin
- Full-thickness skin loss
- Exposed bone, tendon, or muscle
- Partial-thickness skin loss of the dermis
- Partial-thickness skin loss of the dermis
Rationale:
In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulceration with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.
The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present?
- Brown-red macules with scales
- Pustules on the trunk of the body
- White patches noted on the elbows and knees
- Multiple straight or wavy thread-like lines underneath the skin
- Multiple straight or wavy thread-like lines underneath the skin
Rationale:
Scabies can be identified by the multiple straight or wavy thread-like lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.
The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply.
- Reposition every 2 hours.
- Use a bed cradle as indicated.
- Apply protective pads to heels and elbows.
- Add a small amount of alcohol to the daily bath water.
- Provide perineal care every 8 hours and after incontinence.
- Reposition every 2 hours.
- Use a bed cradle as indicated.
- Apply protective pads to heels and elbows.
- Provide perineal care every 8 hours and after incontinence.
Rationale:
Unconscious clients are completely immobile, having lost the protective reflexes to shift body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours. Use of a bed cradle can protect the client’s toes from breakdown due to weight from linens. Protective pads can be applied to the heels and elbows to reduce friction and shear. Appropriate perineal care is essential to keep waste products from excoriating the skin. The nurse can reduce skin dryness and irritation by adding a superfatty solution (i.e., baby oil or castile soap) to the daily bath water. Drying agents such as alcohol are avoided because dry skin can crack and break down.
The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder?
- An athlete
- An adolescent
- An older client
- A client who tans in an indoor tanning bed
- A client who tans in an indoor tanning bed
Rationale:
Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme conditions can damage the skin, posing the highest risk for skin disorders. An athlete would be at low risk of developing an integumentary problem. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. An older client may be at a higher risk than a younger person.
The nurse prepares to assist the primary health care provider to examine the client’s skin with a Wood’s lamp. Which should be included in the preprocedure plan of care?
- Shave the skin site.
- Prepare a local anesthetic.
- Obtain an informed consent.
- Tell the client that the procedure is painless.
- Tell the client that the procedure is painless.
Rationale:
A Wood’s light examination is a painless procedure. The skin does not need to be shaved, and a local anesthetic is not necessary. Examination of the skin under a Wood’s lamp is always carried out in a darkened room. This is a noninvasive examination; therefore, an informed consent is not required. A hand-held long-wavelength ultraviolet light source or Wood’s lamp is used. Areas of blue-green or red fluorescence are associated with certain skin infections.
