Homework Lance
MULTIPLE CHOICE
1. When the older adult complains of the multiple raspberry-colored bruises on his extremities (senile purpura), the nurse explains that these colorful marks of increasing age are the result of:
a.
arteriosclerotic changes in the vessels.
b.
prolonged clotting time.
c.
fragility of capillary walls.
d.
reduction of subcutaneous fat.
ANS: C
Age-related fragility of the capillary walls allows bright raspberry-colored bruises to develop with the mildest injury.
DIF: Cognitive Level: Comprehension REF: 266 OBJ: 3
TOP: Senile Purpura KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse assesses an area of skin on the patient’s upper thigh that is different in appearance than the surrounding skin. The documentation that is most informative is:
a.
red area on upper right thigh. Patient denies discomfort.
b.
erythematous scaly patch 2 ´ 2 cm on lateral aspect of right thigh. Patient denies pain.
c.
painless red patch on right thigh 2 ´ 2 cm.
d.
medium-size red scaly patch on right thigh. 0 drainage. 0 pain.
ANS: B
The second option describes color and texture alterations, location, size, and subjective and objective data related to the lesion.
DIF: Cognitive Level: Analysis REF: 267 OBJ: 1
TOP: Skin Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The nurse is aware that progressively graying hair is caused by:
a.
reduced melanocytes.
b.
altered blood circulation to the scalp.
c.
decreased density of hair.
d.
environmental factors.
ANS: A
Decreasing melanocytes in the hair cause the hair to lose color and turn gray.
DIF: Cognitive Level: Comprehension REF: 267, Table 17-1
OBJ: 1 TOP: Gray Hair KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. When the assessment of a patient’s toenails reveals brittle thick nails with longitudinal lines in the nail, the nurse should assess for:
a.
fungal infection of the toenails.
b.
pedal pulses.
c.
history of gout.
d.
intake of dietary calcium.
ANS: B
The nail changes are the result of decreased peripheral circulation. Checking for the strength of pedal pulses can add extra information related to circulation.
DIF: Cognitive Level: Analysis REF: 267, Table 17-1
OBJ: 2 TOP: Age-Related Nail Changes
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. The 80-year-old woman newly admitted to a long-term care facility complains of intense itching in her axillae and antecubital fossa. There are small red lesions in linear patterns. These are all signs of:
a.
rosacea.
b.
keratosis.
c.
pruritus.
d.
scabies.
ANS: D
Scabies is common in older adults, causing intense itching and small red lesions in a linear pattern. The condition is communicable and, unless treated, can spread to the entire facility.
DIF: Cognitive Level: Comprehension REF: 268 OBJ: 1
TOP: Scabies KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
6. The nurse reminds the CNAs that to prevent skin trauma from shearing force, the patients must:
a.
be slid across the bed linens to change position.
b.
have generous amounts of lotion applied to the skin.
c.
be lifted on draw sheets when being pulled up in bed.
d.
have frequent tub baths to soften the skin.
ANS: C
Lifting patients up clear of the bed linens to move or change position will reduce the risk of shear force injury.
DIF: Cognitive Level: Comprehension REF: 268 OBJ: 2
TOP: Prevention of Shear Force Injury KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. To prevent pressure ulcers in the bedridden patient, the most effective intervention would be to:
a.
perform skin assessment every day.
b.
use a drawsheet to move the patient.
c.
change the patient’s position every 2 hours.
d.
remove wet bed linen promptly.
ANS: C
Repositioning is the most effective intervention. Long periods of pressure over bony prominences are the primary cause of pressure ulcers, not wet linens, frequent assessments, or not using a drawsheet.
DIF: Cognitive Level: Analysis REF: 270 OBJ: 3
TOP: Prevention of Pressure Ulcers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. The admitting nurse gives the new long-term care facility resident a score of 20 on both the Norton Risk Assessment Scale and the Braden Scale for Predicting Pressure Sore Risk. These scores indicate that the resident has:
a.
a high probability of developing a pressure ulcer.
b.
a moderate risk of developing a pressure ulcer.
c.
a low risk of developing a pressure ulcer.
d.
at least one pressure ulcer at the time of admission.
ANS: C
Scores of 20 on the Norton and Braden Scales indicate a very low probability of developing a pressure ulcer.
DIF: Cognitive Level: Application REF: 271-272, Tables 17-3 and 17-4
OBJ: 3 TOP: Braden and Norton Skin Assessment Tools
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9. On the admission assessment of an 80-year-old to a long-term care facility, the nurse notes that the resident’s toenails are dark, thick, and brittle; extremely misshapen; and growing at an angle from the toe. The nurse recognizes these as signs of _____ nails.
a.
fungal infection of the
b.
ram’s horn
c.
ingrown
d.
expected age-related changes in the
ANS: A
Fungal nail infections cause nails to be dark, brittle, and misshapen. The nails grow at odd angles from the toes because they are lifted from the nail bed by the infection.
DIF: Cognitive Level: Application REF: 273 OBJ: 2
TOP: Fungal Infection of Toenails KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The home health nurse suggests to the 80-year-old woman that to reduce the pruritus from dry skin, the patient should change her bathing schedule to:
a.
a hot shower every night before going to bed.
b.
a cool shower every morning using a detergent soap.
c.
a soak in a warm sudsy bath, leaving a film of soap on the skin.
d.
one shower a week, with sponge baths in between.
ANS: D
A weekly shower with sponge baths in between provides adequate cleanliness and decreases dryness. Soap should be completely rinsed off. Hot showers and detergent soaps dry the skin.
DIF: Cognitive Level: Application REF: 274 OBJ: 3
TOP: Bathing KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
11. To reduce pressure ulcers in a bedridden patient, the nurse places the patient _____ bearing the weight.
a.
directly on his side, with the trochanter
b.
supine, with the sacrum and iliac crest
c.
in a semi-Fowler position, with the sacrum and ischium
d.
in a lateral position, with body rotated 30 degrees with gluteus
ANS: D
The 30-degree lateral position places weight on the gluteus muscle, avoiding weight-bearing on bony prominences such as the trochanter, sacrum, and ischium.
DIF: Cognitive Level: Application REF: 275 OBJ: 3
TOP: Positioning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
12. The long-term care facility nurse requests a dental consult to treat gingivitis in a resident. The nurse is aware that gingivitis, if not treated, can ultimately cause:
a.
receding gums.
b.
tooth loss.
c.
bleeding.
d.
halitosis.
ANS: B
The bleeding, swelling, and receding gums of gingivitis ultimately lead to tooth loss.
DIF: Cognitive Level: Comprehension REF: 279 OBJ: 3
TOP: Gingivitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. The long-term care facility resident who has not worn his dentures for several months complains that the dentures no longer fit. The nurse explains that the dentures do not fit now because although he was not using them, his:
a.
gums have hypertrophied.
b.
gums have receded.
c.
jaw shape has altered.
d.
dentures have warped from disuse.
ANS: C
The arch of the jaw changes to compensate for the absence of teeth.
DIF: Cognitive Level: Comprehension REF: 280 OBJ: 1
TOP: Dentures KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. When the patient complains of dry mouth, the nurse should inquire about and assess for:
a.
difficulty in chewing and swallowing.
b.
mouth ulcerations.
c.
adequate intake of vitamin B.
d.
inflammation of the tongue.
ANS: A
Xerostomia causes difficulty in chewing and swallowing because food sticks to the mucous membranes and tooth surfaces.
DIF: Cognitive Level: Application REF: 280 OBJ: 1
TOP: Xerostomia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. When the older man complains of a hard white patch that has developed on the side of his tongue, the nurse should:
a.
request a dental consult to evaluate his dentures for adequate fit.
b.
examine his teeth to assess for a lost filling, which has left sharp edges on his teeth.
c.
request a medical consult for evaluation of a precancerous lesion.
d.
provide frequent, warm, salt water rinses for his mouth.
ANS: C
Leukoplakia is a precancerous condition that requires a medical consultation.
DIF: Cognitive Level: Application REF: 280 OBJ: 3
TOP: Leukoplakia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16. When the male patient who has been on long-term antibiotic therapy inquires what may have caused his thrush, the nurse’s most informative response would be that the yeast infection occurred because:
a.
of a vitamin A deficiency.
b.
long-term antibiotic therapy has destroyed the normal flora of his mouth.
c.
he has developed an allergy to the antibiotic.
d.
oral hygiene has been inadequate.
ANS: B
Long-term antibiotic therapy destroys the normal flora of the oral cavity, allowing opportunistic infections to occur. Thrush is a common yeast infection.
DIF: Cognitive Level: Application REF: 280 OBJ: 2
TOP: Superinfection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. The nurse explains that the purpose of the hydrocolloid dressing applied to a clean stage II pressure ulcer is to __________. (Select all that apply.)
a.
débride the ulcer
b.
prevent shear force trauma
c.
absorb the exudate
d.
harden eschar
e.
make an air-occlusive seal
ANS: A, B, C, E
The hydrocolloid dressing prevents shear force trauma to the ulcer while granulation tissue and reepithelialization are occurring during healing. It also forms an air-occlusive seal, protects the ulcer from infection, and absorbs exudate. If there were eschar present, it would soften it.
DIF: Cognitive Level: Application REF: 278, Table 17-6
OBJ: 3 TOP: Hydrocolloid Dressing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. The nurse is diligent in skin care to prevent pressure ulcers. Older adults are at risk because __________. (Select all that apply.)
a.
the epidermal layer has thickened
b.
subcutaneous fat has diminished
c.
bruising is prevalent
d.
skin receptor cells have reduced in sensitivity
e.
the skin is dry and scaly
ANS: B, D
Lack of subcutaneous fat to pad the bony prominences and reduced sensitivity to touch and pressure put older adults at risk for pressure ulcers.
DIF: Cognitive Level: Analysis REF: 266 OBJ: 1
TOP: Pressure Ulcers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The nurse is aware that the common symptom of pruritus in the older adult is the result of __________. (Select all that apply.)
a.
a reduction of sebaceous gland function
b.
a reduction in the amount of perspiration
c.
excessive bathing
d.
use of emollients
e.
environmental conditions
ANS: A, B, C, E
Emollients keep the skin moist and reduce dryness. All other options listed contribute to pruritus.
DIF: Cognitive Level: Comprehension REF: 267 OBJ: 1
TOP: Pruritus KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. When performing a skin assessment for pressure ulcers on an older man who is bedridden and prefers to lie on his right side, the nurse will pay special attention to the __________. (Select all that apply.)
a.
right ear
b.
lateral edge of the right foot
c.
sacrum
d.
medial edge of the left foot
e.
right scapula
ANS: A, B, D
For this right side–lying patient, the right ear, lateral edge of the right foot, and medial edge of the left foot are probable areas for pressure ulcers.
DIF: Cognitive Level: Comprehension REF: 269, Figure 17-5
OBJ: 2 TOP: Pressure Ulcers
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. To fully assess a suspected skin breakdown over the trochanter of a dark-complexioned African American, the nurse would __________. (Select all that apply.)
a.
use a halogen light to examine the area
b.
palpate for local edema in the area
c.
touch the area to feel for changes in tissue temperature
d.
assess for localized pain
e.
press the area to test for blanching
ANS: A, B, C
Halogen lights make a stage I area appear blue in a dark-skinned person. There is usually a local area of heat and edema. Stages I and II pressure ulcers are painless. Testing for blanching when erythema cannot be assessed is useless.
DIF: Cognitive Level: Application REF: 267, Cultural Considerations
OBJ: 3 TOP: Pressure Ulcer Assessment
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. The long-term care facility nurse making a list of residents whose foot care must be referred to the podiatrist would include the __________. (Select all that apply.)
a.
90-year-old poststroke patient with right hemiparesis
b.
85-year-old diabetic patient who is 100 lb overweight
c.
80-year-old resident with phlebitis and a stasis ulcer on the left ankle
d.
75-year-old resident with congestive heart failure (CHF)
e.
70-year-old resident with chronic obstructive pulmonary disease (COPD)
ANS: B, C
Persons with diabetes or circulatory disorders should have foot care performed by a specialist.
DIF: Cognitive Level: Application REF: 273 OBJ: 2
TOP: Nail and Foot Care KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. The nurse explains that xerostomia (dry mouth) in the older adult may be caused by __________. (Select all that apply.)
a.
age-related reduction in saliva
b.
allergy
c.
eating highly seasoned foods
d.
inadequate fluid intake
e.
use of diuretic medications
ANS: A, D, E
Reduction of saliva, inadequate fluid intake, and fluid loss through the use of diuretics can cause xerostomia.
DIF: Cognitive Level: Application REF: 280 OBJ: 1
TOP: Xerostomia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. The nurse recognizes the signs and symptoms of Vincent angina in a newly admitted patient, which include __________. (Select all that apply.)
a.
an advanced state of malnutrition
b.
enlargement of the cervical lymph nodes
c.
epistaxis
d.
dysphagia
e.
a discolored tongue
ANS: A, B, D
Enlargement of the cervical lymph nodes, difficulty swallowing, and mouth ulcers in a malnourished person are indications of Vincent angina.
DIF: Cognitive Level: Application REF: 280 OBJ: 2
TOP: Vincent Angina KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. While giving a report to the CNAs, the nurse reviews interventions that will aid in maintaining the skin integrity of the residents. Appropriate interventions would include __________. (Select all that apply.)
a.
changing the briefs and bed linens when damp
b.
maintaining the temperature in the room at 80 degrees
c.
rinsing excess soap off the skin during a shower
d.
administering frequent pericare on the continent resident
e.
laying residents down after lunch
ANS: A, C, E
Waste products and soap are irritating to the skin and must be removed promptly. Rest periods during the day will relieve pressure. Exposure to a hot, dry environment and frequent pericare to a resident who is not incontinent is going to make the skin more prone to breakdown.
DIF: Cognitive Level: Application REF: 274 OBJ: 3
TOP: Skin Integrity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. The nurse instructs a group of older adults on how to maintain intact skin by __________. (Select all that apply.)
a.
altering their body position every 30 minutes while sitting in the chair
b.
changing incontinent products when they become soiled
c.
using a pressure-relieving device like the “donut” to sit on
d.
routinely checking their feet for redness and indentations
e.
patting the skin dry after a shower or bath
ANS: A, B, E
Frequent changes in body position, changing damp pads and briefs, and patting the skin dry will promote skin integrity. The “donut” causes pressure to surrounding area when used. Checking the feet routinely will alert the older adult to a potential problem but will not maintain skin integrity. Changing socks daily or applying lotion to the feet will aid in maintaining skin integrity.
DIF: Cognitive Level: Application REF: 269, Table 17-2
OBJ: 3 TOP: Skin Integrity
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
COMPLETION
1. On the admission assessment of a resident to a long-term care facility, the nurse notes a painless area on the patient’s coccyx that has partial skin loss. The nurse would record this as a stage _____ pressure ulcer.
ANS: II 2
DIF: Cognitive Level: Application REF: 270, Figure 17-6
OBJ: 1 TOP: Staging a Pressure Ulcer
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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