Galen- Fundamentals I Chp. 36 Skin Integrity and Wound
Care Questions With Complete Solutions
A client asks why a cold pack has been prescribed for an arm
injury. What should the nurse explain to the client?
Standard Text: Select all that apply.
1. The application of cold dilates blood vessels.
2. The application of cold constricts blood vessels.
3. The application of cold decreases inflammation.
4. The application of cold reduces localized pain.
5. The application of cold provides a calming, sedative effect.
Correct Answer 2, 3, 4
Rationale 1: The application of heat, not cold, dilates blood
vessels.
Rationale 2: The application of cold does constrict blood
vessels.
Rationale 3: The application of cold does decrease
inflammation.
Rationale 4: The application of cold does reduce localized pain.
Rationale 5: The application of heat, not cold, provides a
calming, sedative effect.
Nursing Process: Implementation
A client has a pressure ulcer with a shallow, partial skin
thickness,
eroded area but no necrotic areas. The nurse would
treat the area with which dressing?
1. Alginate
2. Dry gauze
,3. Hydrocolloid
4. No dressing is indicated Correct Answer 3. Rationale:
Hydrocolloid dressings protect shallow ulcers
and maintain an appropriate healing environment. Alginates
(option
1) are used for wounds with significant drainage; dry gauze
(option 2)
will stick to new granulation tissue, causing more damage. A
dressing
is needed to protect the wound and enhance healing. Cognitive
Level:
Applying.
Nursing Process: Implementation
A client has a wound that is going to heal through secondary
intention. When instructing the client about this wound, the
nurse would include which statements?
Standard Text: Select all that apply.
1. Minimal tissue loss.
2. Closure of the wound will occur within 5 days.
3. Healing time will be longer.
4. Potential for scarring is greater.
5. Susceptibility to infection is greater. Correct Answer 3, 4, 5
Rationale 1: In primary intention healing, there is minimal tissue
loss.
Rationale 2: In tertiary intention healing, the closure of the
wound will occur within 5 days.
Rationale 3: In secondary intention healing, the repair time is
longer.
,Rationale 4: In secondary intention healing, the scarring is
greater.
Rationale 5: In secondary intention healing, the susceptibility to
infection is greater.
Nursing Process: Implementation
A client has a yellow wound with purulent drainage. The nurse
identifies what type of wound care as appropriate for this clients
wound?
Standard Text: Select all that apply.
1. Cover it with transparent film.
2. Apply a damp-to-damp normal saline dressing.
3. Cover it with a dry dressing.
4. Irrigate the wound.
5. Apply impregnated hydrogel. Correct Answer 2, 4, 5
Rationale 1: Covering with a transparent film is not appropriate
for a yellow wound.
Rationale 2: A damp-to-damp normal saline dressing will
remove nonviable tissue from the wound, and is appropriate for
a yellow wound.
Rationale 3: Covering with a dry dressing is not appropriate for
a yellow wound.
Rationale 4: Irrigating the wound is appropriate for a yellow
wound.
Rationale 5: Applying impregnated hydrogel is appropriate for a
yellow wound.
Nursing Process: Planning
, A client has episodes of bowel and bladder incontinence. When
planning care for this client, the nurse would identify which
nursing diagnosis as being appropriate?
1. Impaired Skin Integrity
2. Risk for Impaired Skin Integrity
3. Impaired Tissue Integrity
4. Risk for Infection Correct Answer 2
Rationale 1: Impaired Skin Integrity is appropriate if the client
has an alteration in the epidermis or dermis.
Rationale 2: Because the client is experiencing episodes of
incontinence without any current changes in skin integrity, the
client is at Risk for Impaired Skin Integrity.
Rationale 3: Impaired Tissue Integrity is appropriate if the client
has damage to mucous membranes, integument, or subcutaneous
tissues.
Rationale 4: Risk for Infection would be appropriate if the client
has severe skin impairment, the client is immunosuppressed, or
the wound is caused by trauma.
Nursing Process: Diagnosis
A client has had Braden scores of 18 and 19 and Norton scores
of 15 and 17 over the last 2 months. What does the nurse
determine as the significance of the trending of these scores?
1. Trending can only be accurate if the same scale is used.
2. There is a definite trend of low risk for pressure ulcer
development.
3. Trending would be more accurate if the same scale was used.
4. The scores indicate opposite risks for pressure ulcer
development. Correct Answer 3
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