CH 19 Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Injuries

The nurse instructs the patient that any injury to the skin initially puts the patient at risk for:

1. scar formation at the injury site resulting from the healing process.

2. infection with bacteria or viruses that may affect the person systemically.

3. loss of sensation caused by damage to the nerves in the area.

4. loss of body fluids and an upset in the fluid and electrolyte balance.

ANS: B

The skin (and intact mucous membrane) is the first line of defense against invasion by pathogens, and any cut or abrasion can be an entry site. Scar formation, nerve damage, and fluid/electrolyte disturbance are likely only when there is a large or deep wound.

DIF: Cognitive Level: Comprehension REF: p. 296

OBJ: Theory #1

TOP: Skin Integrity

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

When the patient returns from the physical therapy department, he is diaphoretic and his skin is flushed but cool. Nursing intervention in this situation should be for the nurse to:

1. call his primary care provider about the amount of exertion in physical therapy.

2. suggest the patient walks slowly in the hall to "cool down."

3. offer additional fluids to replace those lost through normal cooling.

4. place a light cover over the patient to prevent his chilling.

ANS: C

Diaphoresis (sweating) is the body's normal response to rid itself of heat. Drinking fluids to replace those lost prevents dehydration.

DIF: Cognitive Level: Application

REF: p. 296

OBJ: Theory #1

TOP: Fluid Replacement

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

During an admission assessment to a skilled care facility, the nurse notes that a 76-year-old man is thin and unsteady on his feet and has dry flaky skin on his arms and legs. An appropriate hygiene goal for this patient is that the:

1. patient will shower daily on an independent basis by the end of 1 month.

2. nurse will give a tub bath or full bed bath daily.

3. patient will shower or tub bathe with assistance twice a week.

4. patient will tub bathe or shower with assistance daily.

ANS: C

Older adults have decreased sweat and sebaceous gland activity and do not need a full bath or shower daily. Their skin is thinner and it becomes drier and itchy with overly frequent bathing. Because of the patient's unsteadiness, it is not safe to have him shower alone.

DIF: Cognitive Level: Application

TOP: Hygiene and Safety

REF: p. 301

OBJ: Theory #6

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

In assessing the skin condition of an older adult patient, the nurse notes that, over the sacral area, there is a 2 cm x 3 cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:

1. "Patient has stage Il ulcer on sacrum. No blanching of perimeter."

2. "Reddened area over sacrum, skin open in center."

3. "Pressure ulcer on sacrum. Massaged with no improvement in color."

4. "2 cm × 3 cm reddened area on sacrum with open center. Does not blanch."

ANS: D

Description of a pressure ulcer should be specific and give a visual picture of the area. Such documentation will be useful in calculating the Medicare reimbursement for the facility.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #2

REF: p. 300

TOP: Pressure Ulcers

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

When instructing a nursing assistant about hygiene needs of a frail older adult patient, the nurse correctly educates the nursing assistant to:

1. "Use warm, not hot, water and be sure the room is warm beforehand to avoid chilling."

2. "Put bath oil in the tub and use plenty of soap to really clean the patient's skin while she is in the tub."

3. "Use brisk drying and an alcohol rub to close the patient's pores and prevent heat loss after the bath."

4. "Completely dry the patient's skin and apply a mild moisturizer."

ANS: A

Older adults have drier, thinner skin and less subcutaneous fat. Therefore, warm, not hot, water is needed, and chilling should be avoided. The older adult should use less soap (to decrease dryness), and the use of oils in the water can be hazardous. Older adults should be patted, not rubbed, dry, and moisturizer should be applied to skin that is still damp.

DIF: Cognitive Level: Knowledge

REF: p. 301

TOP: Skin Care

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #6

An important factor to consider when assessing the hygiene needs of a patient is that:

1. the patient knows best what is needed in his hygiene routine.

2. the routine of the agency will determine when the patient is able to bathe.

3. hygiene is not as important as other needs of the patient.

4. the patient may not have the same hygiene practices as the nurse.

ANS: D

Different cultures have different views of hygiene practices, such as use of deodorant, shaving, or daily bathing. These needs are an important part of health and recovery from illness.

DIF: Cognitive Level: Application REF: p. 290

OBJ: Theory #2

TOP: Culture and Hygiene

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

What nursing interventions related to hygiene are appropriate for a patient who has had a recent stroke that caused right-sided (dominant) paralysis and inability to speak?

1. Perform a full bed bath, brush and floss his teeth, and give him a good back massage.

2. Encourage the patient to use his nondominant hand to wash his face, brush his teeth, and perform other hygiene activities with assistance as necessary.

3. Set up a washbasin and supplies, tell the patient to wash what he can, and provide privacy for the patient to do what he can.

4. Teach a family member to give a full bath so that the family member will be able to care for the patient at home.

ANS: B

Patients should be encouraged to do as much of their hygiene as possible (and allowed) in order to increase their sense of independence.

DIF: Cognitive Level: Application REF: p. 288

OBJ: Theory #2

TOP: Promoting Independence

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The patient most at risk for a pressure ulcer would be:

1. a 46-year-old man in traction for a fractured femur, who exercised regularly before his accident and is alert and oriented.

2. a 54-year-old overweight man who is unconscious from a stroke, has a urinary catheter in place, and has been incontinent of liquid stool since a feeding tube was placed.

3. a 72-year-old man admitted for elective surgery to replace his hip joint, who was an avid bowler and gardener before his hip disease slowed him down.

4. an 84-year-old man with Alzheimer disease who is pacing in the halls and who is incontinent of urine if not toileted every 2 hours.

ANS: B

With risk factors of obesity, immobility, lowered mental awareness, and incontinence of stool, this patient clearly is at greatest risk of developing a pressure ulcer.

DIF: Cognitive Level: Analysis

REF: p. 297|Box 19-1

OBJ: Theory #3 TOP: Risks for Skin Breakdown

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

Because the older adult patient lies curled up in a side lying position most of the time, the nurse, seeking to avoid a pressure ulcer, makes frequent assessments of the:

1. sacrum.

2. heels.

3. ilium.

4. scapula.

ANS: C

A patient who lies in a constant side lying position puts pressure on the bony prominence of the ilium. The sacrum, heels, and scapula are at risk in a patient who lies on his or her back.

DIF: Cognitive Level: Application

REF: p. 291

OBJ: Theory #3

TOP: Pressure Ulcers

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

A patient has a quarter sized blackened eschar on both heels surrounded by a 1 to 2 cm indurated reddened area. The nurse is aware that these lesions are:

1. a pressure ulcers that cannot be accurately staged because of the eschar.

2. stage I pressure ulcers because of the induration and redness.

3. stage Il pressure ulcers because the skin has been broken.

4. stage III or IV pressure ulcers because of the eschar.

ANS: A

Eschar must be removed to accurately stage an ulcer, because the nurse cannot know how deep the ulcer is.

DIF: Cognitive Level: Analysis

OBJ: Clinical Practice #1

REF: p. 299

TOP: Pressure Ulcer Staging

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient with a nursing diagnosis of Skin integrity, risk for impaired, is noted to have reddened areas on his right shoulder and hip when he is repositioned on a 2-hour turning schedule. The nurse should:

1. massage the areas vigorously to restore circulation to the pressured areas.

2. document that the patient has a stage I pressure ulcer of the right shoulder and hip.

3. not position the patient on the right side for at least 8 hours.

4. reassess the area after 30 to 45 minutes for reactive hyperemia.

ANS: D

Redness and nonblanching that remain after relief of pressure for 30 to 45 minutes are an indication of a stage I pressure ulcer. Therefore, the area needs to be reassessed before it is labeled a stage I pressure ulcer.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #1

REF: p. 299

TOP: Pressure Ulcers

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

To perform oral care for an unconscious patient, the nurse takes which action first?

1. Position the patient in an upright sitting position with the bed at a comfortable working height for the nurse.

2. Raise the bed to a comfortable working height and position the patient in a flat side lying position.

3. Move the patient to the far edge of the bed with the head slightly elevated.

4. Lower the bed, lower both side rails, and turn the patient's head to one side.

ANS: B

The bed should be at a comfortable working level for the nurse. The patient should be in a flat side lying position to promote fluids draining from the mouth rather than running down the back of the throat and possibly resulting in aspiration.

DIF: Cognitive Level: Application

REF: p. 311|Skill 19-2

OBJ: Clinical Practice #3

TOP: Oral Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Integrity: Basic Care and Comfort

The nurse assessing for a pressure ulcer in a patient with darkly pigmented skin should:

1. examine the area under full florescent light.

2. look for a purple hue under natural light.

3. reassess areas that appear lighter under a halogen light.

4. identify areas of a green hue under a halogen light.

ANS: B

Patients with darkly pigmented skin will show a purple coloration under natural light in the beginning stages of a pressure ulcer.

DIF: Cognitive Level: Application

REF: p. 299

OBJ: Theory #3

TOP: Assessing for Pressure Ulcers

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient who has a dry, itchy dermatitis will most likely benefit from:

1. an oatmeal or starch therapeutic bath with tepid water.

2. having his skin patted with alcohol to decrease the itching.

3. a very warm whirlpool bath for 20 to 30 minutes.

4. avoiding any skin contact with water in the affected areas.

ANS: A

Oatmeal or starch baths are used to soothe dermatitis. Very hot water, soaps, perfumes, and alcohol rubs are contraindicated. The skin must be kept clean, even if there is dermatitis present, so although bathing may be decreased or modified, it is not eliminated.

DIF: Cognitive Level: Comprehension REF: p. 301

TOP: Skin Care

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

OBJ: Theory #5

A nurse is preparing to give a complete bed bath to an unconscious patient. After performing the standard steps done before any procedure, the nurse:

1. washes each eye with a fresh area of the washcloth before washing the rest of the patient's face.

2. wears protective gloves throughout the entire procedure.

3. begins with a back wash and rub to assess for pressure areas over the sacrum.

4. changes the water after washing the patient's face, and again after washing his back.

ANS: A

The eyes should be washed without soap and before the water is soiled by face washing.

Separate areas of the washcloth prevent the transfer of organisms from one eye to the other.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #2

REF: p. 302|Skill 19-1

TOP: Bed Bath

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

When providing perineal care for an uncircumcised male patient, the nurse:

1. provides perineal care the same as for a circumcised male.

2. ensures that the foreskin is retracted and the glans is exposed at the end of the procedure.

3. does not touch the glans during the procedure because it is very sensitive.

4. retracts the foreskin and then cleans the glans, being sure to replace it at the end of the procedure.

ANS: D

In the uncircumcised male, the foreskin covers the glans and must be retracted to adequately cleanse the secretions that accumulate under the foreskin and can lead to infection. The foreskin must be pulled down to cover the glans after cleaning or it can swell and cause pain and constriction of the glans.

DIF: Cognitive Level: Application

REF: p. 302 Skill 19-1

OBJ: Clinical Practice #4

TOP: Bathing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

Providing oral care to a patient who has dentures includes:

1. asking the patient to place his teeth directly in a covered, labeled container for overnight storage.

2. removing, cleaning, and storing the dentures in a labeled container at bedtime.

3. cleaning the dentures in hot water after each meal to remove debris and bacteria.

4. using a tooth brush and toothpaste to clean the dentures in the patient's mouth.

ANS: B

Dentures should be removed and cleaned before they are stored. Hot water should never be used. Dentures may be cleaned in the patient's mouth, but they need to be removed to clean the patient's palate and gums, as well as the undersides of the dentures.

DIF: Cognitive Level: Application

REF: p. 312 Skill 19-3

OBJ: Clinical Practice #4

TOP: Oral Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse caring for a patient who is not taking any food or fluids by mouth because he is unconscious is aware that the patient:

1. does not need mouth care as frequently as the patient who is eating and drinking.

2. should have complete mouth care once a day when the nurse assesses the condition of his skin and mucous membranes.

3. needs to have his mouth swabbed to moisten and remove secretions every 4 hours.

4. should have his lips lubricated and his teeth brushed with mouthwash once a shift.

ANS: C

An unconscious patient needs mouth care about every 4 hours to prevent drying of secretions, halitosis, and possible blocking of the respiratory passage with accumulated dried secretions.

DIF: Cognitive Level: Application

REF: p. 311

OBJ: Clinical Practice #3

TOP:

Oral Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

It is most important for the nurse to write specific personal care plan modifications for the patient who:

1. is 76 years old, alert, oriented, and able to provide his own care.

2. had a hip replacement 2 years ago and uses a cane to ambulate.

3. has an artificial eye and poor vision in the other.

4. prefers a tub bath to a shower, preferably before bedtime.

ANS: C

Special care is necessary for the artificial eye, especially because the patient has poor vision in the remaining eye.

DIF: Cognitive Level: Analysis

REF: p. 318

TOP: Hygiene

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Theory #6

A 20-year-old male patient is admitted after an auto accident. He has blood and dirt matted in his hair. The nurse should:

1. blot the tangled, bloodied hair and then provide a bed shampoo to remove the remaining dirt and debris.

2. comb the tangles out with a fine toothed comb, starting at the scalp and working down to the ends of the strands.

3. remove tangles by using alcohol or water on small sections of hair, holding the hair between the scalp and the area the nurse is brushing or combing.

4. shampoo the hair as well as possible and leave the tangles alone.

ANS: C

Removing tangles in small sections is more comfortable for the patient. Trying to shampoo before removing some of the tangles makes the situation worse.

DIF: Cognitive Level: Application

REF: p. 314|Skill 19-4

OBJ: Clinical Practice #4

TOP: Hair Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

When the nurse is assisting a male patient to shave his face, it is most important for her to:

1. practice on a male friend or relative before trying it on a patient.

2. have the patient shave first before any other hygiene measures are performed.

3. be sure the patient knows to draw the razor in the direction the hair grows.

4. check whether a safety razor can be used or whether it is contraindicated.

ANS: D

razor.

A patient who is on anticoagulants or who has a bleeding tendency should use an electric

DIF: Cognitive Level: Application

OBJ: Clinical Practice #4

KEY: Nursing Process Step: Planning

REF: p. 315

TOP: Shaving

MSC: NCLEX: Physiological Integrity

A usual routine for providing nail care to a patient includes:

1. soaking the nails in warm soapy water to soften before cleaning under the nail edge with an orangewood stick.

2. gently cleaning under the nails with a metal file to remove dirt and dead skin and then soaking hands or feet afterward.

3. cutting toenails with rounded edges to prevent scratching or ingrown nails.

4. cutting toenails and fingernails every 2 or 3 days to keep them short and clean.

ANS: A

Soaking nails softens them and makes it easier to remove dirt or to cut them. A metal file should not be used under the nails.

DIF: Cognitive Level: Knowledge

OBJ: Clinical Practice #4

REF: p. 316

TOP: Nail Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse is caring for a patient who is wearing contact lenses. If the patient cannot care for the lenses himself, and the nurse has difficulty removing a hard lens by hand, it is correct for the nurse to:

1. leave the contacts in place for up to a month.

2. use a lens suction cup to remove the lens.

3. request an ophthalmologist (eye specialist) to come in to remove the lenses.

4. irrigate the eye with saline until the lens floats out.

ANS: B

A lens suction cup is usually available in health care facilities to remove contact lenses.

DIF: Cognitive Level: Knowledge

OBJ: Clinical Practice #5

REF: p. 318

TOP: Eye Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

During the provision of oral care to an unconscious patient, the nurse uses suction primarily to:

1. remove secretions that might block respiratory passages.

2. remove emesis if the patient should vomit.

3. prevent fluids from collecting in the patient's mouth and being aspirated.

4. stimulate the patient's gums and mucous membrane.

ANS: C

An unconscious patient may not have a gag or swallowing reflex, and thus fluids introduced during mouth care need to be suctioned out (and the patient is positioned to facilitate drainage with the head lowered and turned to the side).

DIF: Cognitive Level: Comprehension REF: p. 311|Skill 19-2

OBJ: Clinical Practice #3

TOP: Oral Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

A patient with insulin-dependent diabetes has a below the knee amputation on the right leg.

What modification of his personal care is noted as most important?

1. Perineal care should be performed at least twice a day to prevent urinary tract infections.

2. A safety razor should not be used for shaving; an electric razor should be used.

3. The patient should be assisted to the shower, where he can use a shower chair.

4. The patient's left foot should be soaked and gently dried, but his toenails should not be cut.

ANS: D

A diabetic with a below the knee amputation is likely to have circulatory problems in the remaining foot. Therefore, good foot care is essential, but toenail cutting should be performed by a podiatrist.

DIF: Cognitive Level: Comprehension

REF: p. 316

OBJ: Theory #4

TOP: Diabetic Foot Care

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse notes that her patient has an area of intact, red skin that does not blanch with fingertip pressure. The nurse documents this finding as a stage:

1. I pressure ulcer.

2. Ill pressure ulcer.

3. I pressure ulcer.

4. Il pressure ulcer.

ANS: A

A stage I pressure ulcer is characterized by an area of intact skin that is red, deep pink, or mottled skin that does not blanch with fingertip pressure.

DIF: Cognitive Level: Comprehension

REF: p. 299

OBJ: Clinical Practice #1

TOP: Skin Integrity

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse stages a pressure ulcer as a stage II based on the knowledge that such lesions have:

1. mottled skin and induration.

2. full-thickness skin loss and a deep crater.

3. partial thickness skin loss with the appearance of a blister.

4. a deep pink area of unblanchable skin.

ANS: D

A stage Il pressure ulcer is characterized by an area of partial thickness skin loss involving the epidermis and/or dermis. It may look like an abrasion, blister, or shallow crater. The area surrounding the damaged skin may feel warmer.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #1

REF: p. 299

TOP: Skin Integrity

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The culturally sensitive nurse caring for a Muslim woman who has noticeable body odor as well as abundant underarm hair should:

1. use soap and water under the arms.

2. apply a cream-type deodorant.

3. shave the underarms.

4. cut hair close to the armpit with scissors.

ANS: A

Washing the area with soap and water will reduce odor. Several cultures do not consider the use of deodorant or shaving underarms essential. These personal preferences should be respected

DIF: Cognitive Level: Application

REF: p. 297

OBJ: Theory #2

TOP: Cultural Considerations

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse admitting a 76-year-old patient to the unit carefully documents the appearance of a

Stage III pressure ulcer and informs the charge nurse because:

1. the presence of an ulcer suggests previous lack of care.

2. the charge nurse will need to report the presence of the ulcer.

3. Medicare will reimburse the facility if the ulcer advances.

4. documentation of a Stage IlI ulcer on admission is part of good assessment.

ANS: C

Medicare will reimburse the facility at a higher rate if Stage III and IV ulcers are documented within 2 days of admission.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #1

REF: p. 299

TOP: Documentation of Pressure Ulcer

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

One of the facility's unlicensed assistive personnel (UAPs) is being instructed on foot care for a 74-year-old patient with severely overgrown ragged toenails. The UAP should be reminded to:

1. use an emery board to smooth the nail edges.

2. use scissors to round off the nail near the end of the toe.

3. apply lotion to the feet and apply bed socks.

4. cut the nail straight across with a nail clipper.

ANS: D

Cutting the nails straight will prevent ingrown toenails.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #4

REF: p. 316

TOP: Skin Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse is instructing a nursing student regarding prevention of pressure ulcers. The nurse would recognize further instruction is warranted when the nursing student states, "I will:

1. position the patient directly on the trochanter."

2. use a written schedule for turning and repositioning."

3. gently rub around a reddened area to restore circulation."

4. wash and dry the incontinent patient promptly."

ANS: A

Prevention of pressure ulcers includes not positioning the patient directly on the trochanter.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #1

REF: p. 300

TOP: Prevention of Pressure Ulcers

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse shampooing the hair of an African American takes into consideration that the hair:

1. is oilier than the hair of whites.

2. should only be washed every 7 to 10 days.

3. should be dried with a hair dryer.

4. should be combed with a fine toothed comb.

ANS: B

The hair of African Americans should be washed only every 7 to 10 days because the hair is fragile and may be easily injured or damaged. Heat and the use of a fine toothed comb cause the hair to break.

DIF: Cognitive Level: Comprehension REF: p. 313

OBJ: Theory #2

TOP: Hair of African Americans

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

Which of the following are main functions of the skin? (Select all that apply.)

1. Protection

2. Warmth

3. Excretion

4. Sensation

5. Secretion

6. Cleansing

ANS: A, C, D, E

Understanding the functions of the skin is imperative for providing proper care for patients and for identifying risk factors for skin integrity.

DIF: Cognitive Level: Knowledge

OBJ: Theory #1 TOP: Skin Functions

KEY: Nursing Process Step: N/A

REF: p. 297|Box 19-1

MSC: NCLEX: N/A

The changes in the integumentary system that are part of the normal aging process are:

(Select all that apply.)

1. hair becomes thin and grows more slowly.

2. temperature control is altered because of the increased sebaceous gland activity.

3. skin is more fragile because of loss of collagen fibers.

4. skin wrinkles and sags.

5. nail growth increases.

ANS: A, C, D

Noting normal aging processes helps the nurse detect abnormal changes earlier. Sebaceous gland activity is decreased and nail growth decreases.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #1

KEY: Nursing Process Step: N/A

REF: p. 296

TOP: Aging

MSC: NCLEX: N/A

A stage III pressure ulcer is indicated by: (Select all that apply.)

1. full-thickness skin loss.

2. widespread infection.

3. drainage from the ulcer.

4. damaged subcutaneous tissue.

5. induration.

6. warmth of surrounding tissue.

ANS: A, C, D

Stage III includes full-thickness skin loss, drainage, and damage to the subcutaneous tissue.

Stage I may have an induration. Stage II may be indicated by warmth of the surrounding tissue. Stage IV may be indicated by widespread infection.

DIF: Cognitive Level: Comprehension

OBJ: Clinical Practice #2

KEY:

Nursing Process Step: N/A

REF: p. 299

TOP: Pressure Ulcer Staging

MSC: NCLEX: N/A

Skin that is frequently wet leads to __________,the softening of tissue that increases the chance of trauma or infection.

ANS: maceration

Knowing the risk factors for impaired skin integrity allows for prevention.

DIF: Cognitive Level: Knowledge

REF: p. 297|Box 19-1

OBJ: Theory #4

TOP: Skin Integrity

KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

The buildup of tough necrotic tissue found with a pressure ulcer is called_________.

ANS: eschar

Eschar is necrotic tissue that needs to be removed before a pressure ulcer can be accurately staged.

DIF: Cognitive Level: Knowledge

REF: p. 299

OBJ:

Clinical Practice #1

TOP: Pressure Ulcer Staging

KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A