Exam (elaborations)
Gerontological Nursing, 4e (Tabloski) Chapter 12 The Integument
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Gerontological Nursing, 4e (Tabloski) Chapter 12 The Integument
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Gerontological Nursing, 4e (Tabloski)Chapter 12 The Integument
1) Anrolderrpatientrhasrarsubnormalrbodyrtemperaturerandranrinfection.rHowrdoesrthernurserbestrdes
criberthisrphenomenon?
1. Thertemperaturerregulatingrmechanismrdeterioratesrwithraging.
2. Therpatient'srinfectionrisrimprovingrwithrmedicationrtreatment.
3. Therdiagnosisrofranrinfectionrisrinaccuraterandrwillrberchecked.
4. Thertemperaturerwasrobtainedrincorrectlyrandrisrinaccurate.rA
nswer:r 1
Explanation:r 1.rAnrelevatedrtemperaturerisrarcommonrsignrofrinfectionrbutrmayrnotrberpresentrinrtherf
railrolderradult.
2. Thererisrnorinformationrtorsupportrthatrtherpatientrisrreceivingrantipyreticsrthatrwouldralterrtherpati
ent'srbodyrtemperature.
3. Thernursershouldrnotrstaterthatrtherpatientrreceivedranrinaccuraterdiagnosis.rThisrwouldrhaverther
familyrquestionrtherqualityrofrcarertherpatientrisrreceiving.
4. Thererisrnorevidencertorsuggestrthatrtherpatient'srtemperaturerwasrmeasuredrincorrectly.rPa
gerRef:r297
CognitiverLevel:r Applying
ClientrNeed:r PhysiologicalrIntegrity
ClientrNeedrSub:rReductionrofrRiskrPotentialrNurs/Int
egrConc.:r NursingrProcess:rImplementation
LearningrOutcome:r 1.rDescribernormalrskinrchangesrassociatedrwithraging.
2) Anrolderrpatientrisrrecoveringrfromrabdominalrsurgery.rWhichrinterventionsrwillrthernurserco
nsiderrwhenrplanningrcarerforrthisrpatient?
1. Therwoundrshouldrberkeptrcoveredrwithranrantimicrobialrdressing.
2. Therwoundrdressingrshouldrberchangedrdailyrandrkeptrdry.
3. Thererisrarneedrtorkeeprtherwoundredgesrtaped.
4. Skinrnearrtherwoundrneedsrtorbermassagedrtorincreaserbloodrflow.rAn
swer:r 1
Explanation:r 1.rWoundsrmayrhaverarhighrbacterialrburdenrandrmayrbenefitrfromrantimicrobialrwo
undrdressingsrcontainingrsilver,riodine,rorrpolyhexamethylener(PHMB).
2. Ardryrwoundrsurfacerimpairsrepithelialrmigrationrandrleadsrtortissuerinjuryrandrnecrosis.
3. Tapingrtherwoundredgesrwouldrcauserdamagertortherskin.rTapingrshouldrberlimited.
4. Massagingrtherskinrwouldrcauserfurtherrdamagertortherskinrandrdelicate,rnew-
skinrgrowth.rPagerRef:r285-287
CognitiverLevel:r Analyzing
ClientrNeed:r PhysiologicalrIntegrity
ClientrNeedrSub:rReductionrofrRiskrPotentialrNurs/Int
egrConc.:r NursingrProcess:rPlanning
LearningrOutcome:r 1.rDescribernormalrskinrchangesrassociatedrwithraging.
1
Copyrightr©r2019rPearsonrEducation,rInc.
,3) Therhome-
carernurserdeterminesrthatrtheirrpatientrisratrriskrforrfurtherrinjuryrduertornormalragingrsensationrlo
ssrwhenrtheyrstatertherfollowing:
1. "IrhaverthisrlargerredrmarkronrmyrarmrandrIrthinkritroccurredryesterdayrfromrcooking."
2. "Ircan'trrememberrwhatrIraterforrlunchryesterday."
3. "IrgotrarsmallrcutronrmyrarmrfromrarzipperrwhenrIrwasrgettingrdressedryesterday."
4. "Irhaversomerdiscolorationsronrmyrarm,rbutrtheyrhaverbeenrthererforrmonths."rAn
swer:r 1
Explanation:r1.rWithrnormalragingrthererisrargradualrdeclinerinrbothrtouchrandrpressurersensat
ions,rcausingrtherolderradultrtorberatrriskrforrinjuryrsuchrasrburnsrandrpressurersores.
2. Thererisrnorindicationrthatrtherpatientrhasrmemoryrloss.
3. Arskinrtearrisrardramaticrseparationrofrtherdermis.
4. Bruisedrorrdiscoloredrskinrwouldrberseenrinrsenilerpurpura.rPa
gerRef:r276
CognitiverLevel:r Analyzing
ClientrNeed:r PhysiologicalrIntegrity
ClientrNeedrSub:rReductionrofrRiskrPotentialrNur
s/IntegrConc.:r NursingrProcess:rAssessment
LearningrOutcome:r 1.rDescribernormalrskinrchangesrassociatedrwithraging.
4) Anrolderrpatientrisrrecoveringrfromrsurgeryrtorrepairrarfracturedrhip.rWhatrinterventionsrwillrther
nurserusertorpreventrtherdevelopmentrofrarpressurerulcerrinrthisrpatient?rSelectrallrthatrapply.
1. Avoidrsittingrunlessrforrmeals.
2. Userpillowsrtorprotectrtherskin.
3. Repositionrtherpatientreveryr2rhours.
4. Keeprtherskinrdryrwithrfrequentrbathing.
5. Encouragerindependentrpositionrchanges.r
Answer:r 1,r2,r3,r5
Explanation:r1.rInterventionsrtorpreventrpressurerulcerrformationrincluderavoidingrthersittingrpositio
nrunlessritrisrforrmeals.
2. Interventionsrtorpreventrpressurerulcerrformationrincluderusingrpillowsrtorprotectrtherskin.
3. Interventionsrtorpreventrpressurerulcerrformationrincluderrepositioningrtherpatientreveryr2rho
urs.
4. Frequentrbathingrcouldrdryroutrtherskinrandrencouragertherformationrofrulcers,rwounds,randrski
nrtears.
5. Interventionsrtorpreventrpressurerulcerrformationrincluderencouragingrtherpatientrtormakerind
ependentrpositionrchanges.rEvenrsmallrshiftsrredistributertherbodyrweightrandrimproverperfusi
onrofrthertissue.
PagerRef:r302-
305rCognitiverLevel:r Appl
ying
ClientrNeed:r PhysiologicalrIntegrity
ClientrNeedrSub:rReductionrofrRiskrPotentialrNurs/Int
egrConc.:r NursingrProcess:rImplementation
LearningrOutcome:r 2.rIdentifyrriskrfactorsrrelatedrtorcommonrskinrproblemsrofrolderradults.
2
Copyrightr©r2019rPearsonrEducation,rInc.
, 5) Whatrinstructionrshouldrthernurserprovidertorarnursingrassistantrwhorisrassignedrtorcarerforranrolde
rrpatientrwithrarstagerIrpressurerinjuryronrtherrightrheel?
1. Applyrardryrdressingrtorthersite.
2. Applyrardonutrunderrtherrightrheal.
3. Cleansertherarearwithrtepidrwater.
4. Keeprtherheadrofrtherbedrelevated.rA
nswer:r 3
Explanation:r 1.rArdryrdressingrisrnotrindicatedrforrthisrtyperofrpressurerulcer.
2. Mechanicalrdevicesrcanrexacerbaterpressurerulcersrandrshouldrnotrberused.
3. Therarearatrriskrforrpressurersorerdevelopmentrshouldrberwashedrgentlyrwithrtepidrwater,randrmin
imalrsoap.rSoaprremovesrnaturalroilsrfromrtherskin,randrcleaningrthersoaproffrmayrcauseradditionalrf
rictionrdamage.
4. Elevatingrtherheadrofrtherbedrincreasesrpressureronrthersacrumrandrlowerrextremitiesrwhichrcou
ldrcausertherpressurerulcerrtorbecomerworse.
PagerRef:r305
CognitiverLevel:r Applying
ClientrNeed:r PhysiologicalrIntegrity
ClientrNeedrSub:rReductionrofrRiskrPotentialrNurs/Int
egrConc.:r NursingrProcess:rImplementation
LearningrOutcome:r 6.rExplainrthernursingrmanagementrprinciplesrrelatedrtorthercarerofrpressurerulc
ers.
6) Thernurserisrassessingranrolderrpatient'srstagerIIIrpressurerulcer.rWhatrwouldrberindicativerofrpro
perrwoundrhealing?
1. Anrincreaserinrwoundrdepth
2. Largeramountrofrundermining
3. Presencerofrleatheryrblackrtissue
4. Beefyrredrandrmoist,rgrainyrappearancer
Answer:r 4
Explanation:r 1.rTherwoundrincreasingrdepthrisrindicativerofrimproperrhealing.
2. Therwound'srunderminingrdoesrnotrindicateranrimprovementrinrhealing.
3. Escharrisrarsignrofrdelayedrwoundrhealing.
4. Healingrofrardecubitusrfillsrfromrtherwoundrbottomrsortherdepthrdecreasesrbeforertherwoundrwid
thrdecreases.rTherbeefyrredrandrgrainyrappearancerisrevidencerofrgranulationrtissuerasrthercapillary
rbedrbuilds.rTheserarerallrindicatorsrofrgoodrwoundrhealing.
PagerRef:r285
CognitiverLevel:r Analyzing
ClientrNeed:r PhysiologicalrIntegrity
ClientrNeedrSub:rReductionrofrRiskrPotentialrNu
rs/IntegrConc.:r NursingrProcess:rEvaluation
LearningrOutcome:r 6.rExplainrthernursingrmanagementrprinciplesrrelatedrtorthercarerofrpressurerulc
ers.
3
Copyrightr©r2019rPearsonrEducation,rInc.
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