NURS 2700-Chapter 41: The Integumentary System deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

NURS 2700-Chapter 41: The Integumentary System deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition MULTIPLE CHOICE 1. What underlying pathophysiology explains the gradual graying of an older adult’s hair? a. Reduced hair follicles b. Less sebaceous gland activity c. Loss of collagen fibers in dermis d. Decreased melanocytes at hair follicle ANS: D Reduction in melanocytes at the hair follicle is the cause of graying hair. A reduction in the number of hair follicles will result in thinning hair. Reduced sebaceous gland activity and collagen will result in drying. PTS: 1 DIF: Cognitive Level: Comprehension REF: 957 OBJ: 2 (clinical) TOP: Skin Assessment: Hair KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. An 80-year-old resident prefers to lie in bed on her left side. The nurse anticipates that the risk for skin breakdown is greatest over which area? a. Left buttock b. Left heel c. Left trochanter d. Left ribs ANS: C The areas that are most prone to break down in the immobile patient are over bony prominences. PTS: 1 DIF: Cognitive Level: Application REF: 963 OBJ: 5 (theory) TOP: Pressure Ulcer: Risk KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. Which chemical irritant causes the most damage to skin of the immobilized patient? a. Urine b. Topical medication c. Bath soap d. Laundry soap ANS: A Urine and feces are the most common chemical irritants that cause skin breakdown. PTS: 1 DIF: Cognitive Level: Comprehension REF: 957 OBJ: 5 (theory) TOP: Skin Injury: Chemical KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. The nurse observes the CNA who is changing a patient’s bed. Which action demonstrates that the CNA requires additional teaching? a. Lifting the patient on the draw sheet to the stretcher. b. Pulling the draw sheet out from under the patient. c. Rolling the patient to the side to change the draw sheet. d. Using the gait belt to lift the patient from the bed to a wheelchair. ANS: B Pulling linens out from under a patient instead of rolling or lifting the patient causes a shearing type of skin tear. Use of a lift sheet, rolling the patient from side to side, and the use of the gait belt are recommended. PTS: 1 DIF: Cognitive Level: Application REF: 959 OBJ: 5 (theory) TOP: Skin Injury: Shearing KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. When planning care for an 80-year-old African American woman, which intervention is most important for the nurse to include? a. Bathe the patient twice weekly. b. Use liberal amounts of soap and water. c. Use quick, brisk motions to dry the patient’s skin. d. Apply emollient to limbs and back. ANS: B People with dark complexions need to be bathed frequently due to the oiliness of their skin. Liberal amounts of water and soap are beneficial. Twice weekly bathing is insufficient for cleanliness. Friction and application of emollient are not conducive to skin health. PTS: 1 DIF: Cognitive Level: Application REF: 958, Older Adult Care Points OBJ: 4 (theory) TOP: Bathing: Dark Complexion Considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. A 93-year-old resident eats only a few bites at meals and then refuses to eat more. Which intervention might the nurse use to help delay skin breakdown from diminished nutrition? a. Spoon-feed the resident. b. Request an order for a feeding tube. c. Inform the resident of the need to increase intake. d. Offer 4 ounces of fluid every hour. ANS: D Dehydration can cause loss of skin turgor and predisposes the skin to break down. Spoonfeeding and instructing about increased intake may only result in a power struggle with the resident. PTS: 1 DIF: Cognitive Level: Comprehension REF: 959 OBJ: 2 (theory) TOP: Skin Damage: Dehydration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 7. The school nurse is advising a group of high school girls about ways to avoid permanent skin damage from sun exposure. Which information is most important to include in the teaching plan? a. Avoid using cosmetics that have sunscreen added. b. Consider a spray tan in the summer. c. Limit sunbathing times on a cloudy day. d. Wear light, loose clothing while in sun. ANS: B A spray-on tan is the safest method to acquire a tan. Cosmetics with added sunscreen are an easy way to remem