24.7.0: Review Questions

Review Questions

1 .

What term would the nurse document when describing the depth of a laceration through the second layer of skin?

1. Langerhans
2. keloid
3. keratin
4. dermis

2 .

Which layer of the epidermis is only present in the soles of the feet?

1. stratum basale
2. stratum granulosum
3. stratum lucidum
4. stratum spinosum

3 .

What is the primary function of the skin?

1. protection
2. store and release fat
3. vitamin B production
4. digestive enzyme production

4 .

The nurse is educating a patient on how their skin helps with temperature regulation. The nurse explains to the patient that when the body temperature decreases, the blood vessels do what?

1. vasoconstrict to increase blood flow
2. vasoconstrict to decrease blood flow
3. vasodilate to increase blood flow
4. vasodilate to decrease blood flow

5 .

The nurse caring for a dark-skinned patient knows that the patient is more susceptible to which of the following?

1. freckles
2. keloids
3. skin cancer
4. sunburns

6 .

The pediatric nurse is educating a new mother on risk factors that may contribute to her young infant’s risk for hypothermia. What statement from the mother would suggest that she understood the teaching?

1. “My child is at risk for hypothermia because he has a lesser amount of subcutaneous tissue, meaning his blood vessels are farther away from the surface.”
2. “My child is at risk for hypothermia because he has more subcutaneous tissue, meaning his blood vessels are farther away from the surface.”
3. “My child is at risk for hypothermia because he has more subcutaneous tissue, meaning his blood vessels are closer to the surface.”
4. “My child is at risk for hypothermia because he has a lesser amount of subcutaneous tissue, meaning his blood vessels are closer to the surface.”

7 .

What is an example of a lifestyle choice that is a behavioral risk factor for impaired skin integrity?

1. diabetes
2. illicit drug use
3. medication use for congenital heart disease
4. impaired mobility

8 .

A 67-year-old patient presents to the clinic with redness, edema, and fluid-filled vesicles on the right leg that is hot to the touch. The patient also complains of pain and tenderness. The patient’s heart rate is 110 and temperature is 100.8°F (38.2°C). The nurse should suspect what skin abnormality?

1. folliculitis
2. carbuncles
3. impetigo
4. cellulitis

9 .

The nurse is caring for an adult who has just been diagnosed with shingles. What statement from the patient would suggest that she understood the teaching?

1. “Varicella lies dormant after having the vaccination or chickenpox. It can reactivate later in life and present as shingles.”
2. “Shingles can only occur if you have had the varicella vaccine.”
3. “I had chickenpox as a kid, so I should not be getting this virus.”
4. “Shingles only affect women.”

10 .

You are educating a patient on preventing skin cancer. What statement from the patient would suggest that she understood the teaching?

1. “I will only go to the tanning salon twice a week.”
2. “I will avoid the sun from 9 a.m. to 1 p.m. when the ultraviolet rays are the strongest.”
3. “I will wear protective clothing like long sleeves, hats, and sunglasses, and use sunscreen at the lake this weekend.”
4. “I will use a sunscreen that has an SPF factor of five or greater.”

11 .

What is not a benign skin change found in older adults?

1. cherry angiomas
2. wrinkles
3. carbuncle
4. melasma

12 .

Identify an example of an intentional wound.

1. bullet
2. stab wound
3. surgical incision
4. fracture

13 .

The nurse recognizes that what factor does not put a patient at risk for pressure injury development?

1. altered mental status
2. loss of appetite
3. advanced age
4. weightlifting

14 .

Maceration can be defined as:

1. loss of superficial layers of the skin
2. tissue softened by prolonged wetting or soaking
3. tissue hardened by pressure
4. tissue that has development of slough

15 .

The nurse is assessing a patient with a deep red area of intact skin that does not blanche. At what stage of pressure injury is this classified?

1. stage I injury
2. deep-tissue injury
3. unstageable injury
4. stage II injury

16 .

The nurse is educating a new graduate nurse on pressure injuries. What statement from the student would suggest that she understood the teaching?

1. “The difference in stage III and IV pressure injuries is the visibility of fascia, tendon, ligament, muscle, cartilage, and bone.”
2. “Slough and eschar are present at every stage.”
3. “If the area blanches, it is stage I.”
4. “A diabetic ulcer is also called a deep-tissue pressure injury.”

17 .

During which phase of the healing process do leukocytes move into the interstitial space to ingest bacteria and cellular debris?

1. hemostasis
2. inflammatory phase
3. proliferation phase
4. maturation phase

18 .

The nurse is explaining complications associated with wound healing to a new patient at the clinic. How should the nurse describe maceration?

1. occurs when hydration leads to cell death
2. occurs when there is trauma the wound
3. occurs when there is swelling that interrupts blood flow
4. occurs where the cells are overhydrated, leading to skin softening and breakdown

19 .

What nursing intervention is appropriate when performing a dressing change?

1. administering pain medication prior to wound care when the patient states that wound care is painful
2. telling the patient that they just need to look at the wound
3. explaining to the patient that the smell from the wound is not that bad
4. encouraging the patient that they do not have to make any changes in their activities of daily living

20 .

What type of debridement promotes the body’s own defense mechanisms?

1. enzymatic debridement
2. mechanical debridement
3. autolytic debridement
4. wet-to-dry debridement