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Exemplar 21.3: Pressure Ulcers

Usuario eliminado 24 preguntas Actualizado el 8 may 2018

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1Pressure ulcers can result when pressure on the tissue between a bony prominence and the external surface of the body distorts the capillaries and interferes with normal blood flow.
1. AVerdadero
2. BFalso
2Pressure ulcers can also result from shearing forces that tear and injure blood vessels.
1. AVerdadero
2. BFalso
3Which of the following patients are at risk for getting a pressure ulcer?
1. AA young man who dove into the shallow end of a swimming pool and is now a quadriplegic.
2. BAn HIV patient who is experiencing a fever of unknown origin.
3. CA teenage anorexic patient who was admitted with severe hypoglycemia.
4. DA middle aged female with overflow incontinence who is recovering from mastectomy.
5. EA teenager admitted in diabetic ketoacidosis who was found to have type 1 diabetes.
4A nurse is caring for an elderly patient who was hospitalized for a myocardial infarction. She judges that he is at risk for pressure ulcers because he is intolerant to activity, elderly, and suffering from a cardiovascular disease. Which of the following interventions are appropriate for the nurse to initiate in order to decrease the patient's risk of developing a pressure ulcer?
1. AReassessing the patient's risk for pressure ulcers once a week.
2. BGently bathing him with alcohol-free soap in water that is warm.
3. CAllowing the patient to use his humidifier
4. DProviding him with a smooth, firm, and wrinkle free bed.
5. EUtilizing baby powder to reduce friction.
6. FUtilizing a lifting device when changing the client's position.
5A nurse is caring for a quadriplegic patient. He is confined to bed due to his immobility. Which of the following interventions are appropriate for preventing pressure ulcers in this patient?
1. AElevating the head of the bed to no more than 30 degrees.
2. BRubbing a petroleum-based cream on the patient's bony prominences.
3. CPlacing the client in a lateral position.
4. DUtilizing a draw string sheet that covers the patient's lower to upper back for in-bed movement.
6You are speaking with a group home employee about your immobile patient's risk for pressure ulcers. The employee is not CNA or BSN trained, but has been working with the profoundly handicapped for the past 10 years. Which of the following statements made by the group home employee indicates that she understands what you have just taught her about preventing pressure ulcers?
1. A"I should reposition my client every 2 hours."
2. B"I should look for nonblanchable red marks on my client's skin once a week."
3. C"I should put my client's doughnut pillow under her heels."
4. D"When I sit my client up for meals, it doesn't matter how I place him."
5. E"I should place a couple foam pillows under my client's elbows, shoulders, lower back, and hips."
7What stage of pressure ulcer does this describe?

Nonblanchable erythema of intact skin. Usually occurs in a localized area over a bony prominence. The affected area may be painful, and of a different temperature and consistency than the surrounding skin.
1. AStage I
2. BStage II
3. CStage III
4. DStage IV
5. EUnstagable
8What stage of pressure ulcer does this describe?

Partial thickness skin loss, with dermal involvement. It presents as shallow and open, without sloughing. It may also present as an intact or open blister with pus or blood in it, or as dry and shiny.
1. AStage I
2. BStage II
3. CStage III
4. DStage IV
5. EUnstagable
9What stage of pressure ulcer does this describe?

Full thickness skin loss, with damage or necrosis of subcutaneous tissue. It's like a deep crater. It can be with or without undermining and tunneling of adjacent tissue. Sloughing may be present, but bone, tendon, and muscle cannot be seen yet. The depth varies depending on anatomical location.
1. AStage I
2. BStage II
3. CStage III
4. DStage IV
5. EUnstagable
10What stage of pressure ulcer does this describe?

Full thickness skin loss with extensive tissue damage and necrosis. Undermining and tunneling are usually present, along with visability of the muscle, tendon, and bone. Slough or eschar may be present. The ulcer can extend into muscle and supporting structures.
1. AStage I
2. BStage II
3. CStage III
4. DStage IV
5. EUnstagable

11What stage of pressure ulcer does this describe?

Full thickness tissue loss, with depth completely obscured by slough or eschar in the wound bed.
1. AStage I
2. BStage II
3. CStage IV
4. DStage III
5. EUnstagable
12A suspected deep tissue injury looks like intact skin with purple discoloration or a blood filled blister. It indicates damage of underlying soft tissue from pressure or shear.
1. AVerdadero
2. BFalso
13Which of the following patients would have a stage II pressure ulcer?
1. AA patient that developed a blood filled blister after being moved in his bed incorrectly.
2. BA patient in a nursing home that urinated on himself and was not changed promptly, resulting in skin breakdown.
3. CA patient whose home health nurse utilized corn starch to prevent friction and moisture control, resulting in scrapes to the patient's skin.
4. DA bedridden patient whose bed was placed in a high-Fowlers position, and during showering was shown to have damage of the subcutaneous tissue.
5. EA patient who was not regularly turned during hospitalization, and during changing was shown to have a shallow ulcer on the heel.
14When may surgical debridement of a pressure ulcer be necessary?
1. AWhen subcutaneous tissue is involved
2. BWhen an eschar is preventing the wound from healing by granulation.
3. CWhen the ulcer is unstagable due to slough or eschar in the wound
4. DWhen slough becomes present.
5. EWhen the ulcer is full thickness rather than partial thickness.
15Which wound dressings are used to treat stage I pressure ulcers?
1. ASkin prep Granulex
2. BHydrocolloid dressing
3. CTransparent dressing
4. DWet-to-dry gauze dressing with sterile normal saline
5. EProteolytic enzymes
6. FVacuum assisted closure
16What type of wound dressing would be used for a stage II pressure ulcer?
1. ASkin prep Granulex
2. BHydrocolloid dressing
3. CTransparent dressing
4. DWet-to-dry gauze dressing with sterile normal saline
5. EProteolytic enzymes
6. FVacuum-assisted closure
17What type of dressing would be used for stage III pressure ulcers?
1. ASkin prep Granulex
2. BHydrocolloid dressing
3. CTransparent dressing
4. DWet-to-dry gauze dressing with sterile normal saline
5. EProteolytic enzymes
6. FVacuum-assisted closure
18What type of dressing would be used for stage IV pressure ulcers?
1. ASkin prep Granulex
2. BHydrocolloid dressing
3. CTransparent dressing
4. DWet-to-dry gauze dressing with sterile normal saline
5. EVacuum-assisted closure
19Match the drop down option with the type of dressing.

-[blank_start]Wet-to-dry gauze dressing[blank_end]: Allows necrotic material to soften and adhere to the gauze, causing debridement of the wound. By doing that, it enhances healing.

-[blank_start]Skin prep Granulex[blank_end]: Toughens intact skin, preserves skin integrity, prevents skin breakdown, increased blood supply, adds moisture, aids in removal of necrotic tissue.

-[blank_start]Vacuum-assisted closure[blank_end]: Creates a negative pressure to help reduce edema, increase blood supply and oxygenation, and decrease bacterial colonization. It also helps promote moist wound healing and granulation tissue formation.

-[blank_start]Hydrocolloid dressing[blank_end]: Prevents skin breakdown and promotes healing without crust formation over the ulcer. It is permeable to air and water vapor, and it prevents the growth of anaerobic organisms. By doing this, it enhances healing.

-[blank_start]Proteolytic enzymes[blank_end]: Serves as debriding agents in inflamed and infected lesions.

-[blank_start]Transparent dressings[blank_end]: Prevents skin breakdown, the entrance of moisture, and the entrance of bacteria. It does, however, allow oxygen and moisture vapor in. By doing this, it enhances healing.
1. AWet-to-dry gauze dressing
2. BHydrocolloid dressing
3. CSkin prep Granulex
4. DWet-to-dry gauze dressing
5. EVacuum-assisted closure
6. FTransparent dressings
7. GHydrocolloid dressing
8. HTransparent dressings
9. IProteolytic enzymes
10. JWet-to-dry gauze dressing
11. KTransparent dressings
12. LSkin prep Granulex
20Transparent and hydrocolloid dressings are still okay if the pressure ulcer is infected.
1. AVerdadero
2. BFalso
21Transparent and hydrocolloid dressings or skin barriers are contraindicated in stage IV pressure ulcers
1. AVerdadero
2. BFalso
22Which of the following does the nurse NOT report when he/she finds a pressure ulcer?
1. AProcedure performed when the ulcer was found
2. BLocation of the ulcer related to a bony prominence.
3. CLength, width, and depth of the pressure ulcer.
4. DPresence of under minding sinus tract, assessed as face on a clock.
5. EColor of the wound bed and location of necrosis or eschar.
6. FCondition of the wound margins.
7. GIntegrity of surrounding skin.
8. HSigns of infection.
9. IPatient complaint of pain or discomfort at wound site.
10. JStage of the ulcer.
23A person who scores a 16 on the Braden Scale is not at risk for a pressure ulcer.
1. AVerdadero
2. BFalso
24A nurse is teaching a client about how to take care of her newly immobilized husband's pressure ulcer. Which of the following statements spoken by the patient's wife indicates that she understands the discharge teaching you have given her about caring for, and preventing another, pressure ulcer?
1. A"I will gently clean the wound on a regular basis."
2. B"I will be sure to include yogurt in his breakfast, peanut butter in his lunch, and some sort of lean meat in his dinner."
3. C"I will use hot water when I clean his wound."
4. D"I will pull our old water mattress out of the garage and have our son help me fill it."
5. E"I will be sure that my husband is moved at least once every 2 hours."
6. F"I will close the bedroom window when it's cold outside."
7. G"I will keep my husband's skin dry."
8. H"I will make sure I have a pillow under my husband's heels at all times."

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Descripción: El usuario ha eliminado su información de asignaturas Test sobre Exemplar 21.3: Pressure Ulcers, creado por Usuario eliminado el 21/03/2018.
Autor: Usuario eliminado
Idioma: English
Visitas: 18
Historial: Creado el 21 mar 2018 · actualizado el 8 may 2018
Etiquetas: tissue integrity pressure ulcer bed sore decubitus ulcers med-surg medical-surgical nursing nclex nclex style el usuario ha eliminado su información de asignaturas
Valoración: Aún sin valoraciones
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Exemplar 21.3: Pressure Ulcers

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