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nurs 246 vvc skills final Questions
With Complete Solutions
what are 8 functions of the skin? correct answer: 1.protection 2.temp. regulation 3.psychosocial 4.sensation 5.vitamin D production 6.immunologic 7.absorption 8.elimination what are 5 health statuses that may predispose patients to skin alterations? correct answer: *very thin skin and very obese people-skin irritation and injury *fluid loss/dehydration (makes skin appear loose and flabby)- fever, vomiting, or diarrhea *excess moisture (perspiration or moisture related to incontinence)-breakdown of skin, especially in skin folds *jaundice (a condition caused by excessive bile pigments in the skin, results in yellowish skin)-skin is often itchy and dry making patients more likely to scratch and cause open lesions, with potential for infection *diseases of the skin (eczema and psoriasis)-may have genetic predisposition and often cause lesions that require special care what is a wound? correct answer: a break or disruption in the normal integrity of the skin and tissues
what is necrosis of tissue? correct answer: -death of tissue present in wound delays healing -skin appears moist, yellow, stringy tissue and eschar appears as dry, black, leathery tissue -healing will not occur until dead tissue is removed what is an infection? correct answer: -results when the patient's immune system fails to control the growth of microorganisms -especially when involving surgery of the intestines (fecal contamination) -usually takes 2-7 days after injury/surgery to become apparent what are 5 symptoms of infection? correct answer: -purulent drainage -increased body temp -increased white blood cell count -delayed healing and discoloration of granulation tissue in the wound -can cause chronic wounds (bone infection, sepsis-presence of pathogenic organisms in the blood or tissues) (infection in a chronic wound may only have the symptoms of delayed healing and pain) what do the 5 (includes unstageable) ulcers look like? correct answer: *stage 1: -intact skin with nonblanchable redness of a localized area usually over a bony prominence -area may be painful, firm, soft, warmer, or cooler -may indicate "at risk" persons *stage 2:
*stable (dry, adherent, intact, without erythema or fluctuance) eschar on the heels serves as the body's natural cover and should not be removed what are 5 uses for transparent films/dressings? correct answer: -wounds with minimal drainage -wounds that are small -stage 1 pressure ulcers -cover dressings for gels, foams, and gauze -secure IV cath, nasal cannulas, chest tube dressing, central venous access devices describe cold therapy application effects and uses for wound therapy correct answer: -local application constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort -reduces the formation of edema and inflammation -reduces blood flow to tissues and decreases the local release of pain-inducing substances such as histamine -used for direct trauma, dental pain, muscle spasms after sprains, and to treat some chronic pain syndromes what effect does prolonged cold applications have? correct answer: produces systemic effects of increased BP, shivering, and goose bumps and may cause tissue injury describe heat therapy application effects and uses for wound therapy. correct answer: -dilates peripheral blood vessels, increases tissue metabolism, reduces blood viscosity and increases capillary permeability, reduces muscle tension and stiffness, and helps relieve pain, treat infections, surgical wounds, inflamed tissue, arthritis, dysmenorrhea
-accelerates the inflammatory response to promote healing what effects does prolongs heat applications have? correct answer: increased cardiac output, sweating, increased HR, and decreased BP causing hypovolemic shock (increasing blood flow to one area and decreasing it in other areas) -occurs when two surfaces rub against each other -the injury resembles an abrasion -also can damage superficial blood vessels directly under the skin -wrinkled sheets increases risk -skin over the elbows and heels often affected when helping move positions in bed -burns can also occur if patient is pulled or slid over sheets while being moved up correct answer: friction -results when one layer of tissue slides over another layer -this injury separates the skin from underlying tissues -the small blood vessels and capillaries are stretched and possible tear, resulting in decreased circulation to the tissue cells under the skin -commonly occurs when patient is pulled up in bed rather than lifted, when moving from surface to surface, patient who sits in a chair but slides down, and patient who is partially sitting up in bed is susceptible if the skin sticks to the sheet and underlying tissue moves downward with the body toward the food of bed correct answer: shear (shear force) compromised circulation secondary to pressure or pressure combined with friction correct answer: pressure ulcers
describe papule correct answer: -palpable, elevated solid mass -MASSis less than or equal to 0.5 cm -example: mole describe macule correct answer: -circumscribed, flat, non palpable change in skin color -LESION is less than or equal to 1 cm -examples: petechia and freckles describe tumor correct answer: -palpable, elevated solid mass -MASS is greater than 2 cm -example: lipoma what does PERRL stand for? correct answer: Pupils Equal, Round, Reactive To Light what are the differences between a female and male urethra? correct answer: *male: -functions in the excretory system and the reproductive system -about 5.5-6.25 inches long -consists of 3 parts: the prostatic, the membranous, and the cavernous portions -the external urethral sphincter consists of striated muscle and is located just beyond the prostatic portion of the urethra -external sphincter is under voluntary control *female: -about 1.5-2.5 inches long -the external, or voluntary, sphincter is located in the middle of the urethra -no portion is external to the body
-muscles at the meatus is usually called the external sphincter the process of emptying the bladder is known as urination or... correct answer: micturition or voiding transports urine from the bladder to the exterior of the body correct answer: urethra any involuntary loss of urine that causes such a problem correct answer: urinary incontinence -occurs when urine is produced normally but is not excreted completely from the bladder -factors associated that may cause this are medications, an enlarged prostate, or vaginal prolapse correct answer: urinary retention describe toilet training. correct answer: -voluntary control of the urethral sphincters occurs between 18-24 months old however toilet training usually begins at about 2-3 years old *toilet training should not begin until: -the child is able to hold urine for 2 hours -recognize the feeling of bladder fullness -communicate the need to go and can hold it until seated -occasional daytime incontinence in a child is usually not a cause for concern -continued incontinence is called enuresis -nighttime enuresis usually subsides by 6 years of age
Strong-smelling urine Pelvic pain, in women — especially in the center of the pelvis and around the area of the pubic bone what are the 9 steps in removing an indwelling catheter? correct answer: 1.wash hands before and after and wear gloves 2.deflate the balloon by aspirating all the sterile water 3.ask patient to take several deep breaths to relax and wrap the removed catheter in a towel or disposable waterproof drape
- clean the perineal area after removal 5.ensure generous fluid intake and record amount, time, and amount of fluid output for at least 24 hours 6.inform patient that it make take a little while for the bladder to reestablish voluntary control and that an accident is not unusual 7.tell patient there may be a slight burnin sensation when voiding for the first couple times after removal 8.observe urine carefully for abnormalities document the volume of the first void to validate adequate emptying of bladder (if patient doesn't void within 8-10 hours of removal, notify the provider) 9.record and report any unusual signs such as discomfort, a burning sensation when voiding, bleeding, or changes in vital signs (especially temp.) precautions with the use of absorbent products for incontinence correct answer: -can communicate acceptance of incontinence and can interfere with ability to toilet self -can place patient at risk for skin breakdown and UTIs where to assess the bladder correct answer: -positioned below the symphysis pubis
-can not be palpated or percussed when empty -before palpating, as the patient when they voided last observe lower abdominal wall, note any swelling and palpate for tenderness continued incontinence after the age of toilet training correct answer: enuresis (uncontrolled voiding) assessment of a full bladder correct answer: when the bladder is distended , it rises above the symphysis pubis and may reach to just below the umbilicus -can also use a bedside scanner differences in stool characteristics for infant and adult correct answer: *infant: (breast milk) -easier for the infant's intestines to break down and absorb compared to formula -frequent -yellow to golden and loose and have little odor -curds and mucus -no voluntary control (formula) -yellow to brown -paste-like consistency and stronger odor -curds and mucus *adult: -brown -odor -soft, semisolid, and formed
-parasitic infection -side effects of drugs -laxative abuse -surgery -alcohol abuse -radiation and chemotherapeutic agents non-pharmacological treatments for constipation and diarrhea correct answer: *constipation: -high fiber foods -exercise -60-80 oz of fluid daily -sitting upright on the toilet *diarrhea: -wash hands -drink fluids if tolerated -gatorade, weak tea, water, clear soup, and gelatin (rehydration and electrolyte replacement) -avoid highly spiced foods and foods with laxative effects -low fiber foods types of enemas correct answer: -tap water (hypotonic) -normal saline (isotonic) -soap -hypertonic -oil (mineral, olive, or cottonseed oil) tone normally heard in gastric area correct answer: -high- pitched, gurgling, and soft, indicating bowel motility and peristalsis
-may range from 5-30 bowel sounds per minute -continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors -often heard in patient's with asthma, tumors, or buildup of secretions correct answer: wheezing lung sound senses used for inspection correct answer: sight smell hearing cause for abnormal breath sounds (adventitious breath sounds) correct answer: -air moving through moisture, mucus, or narrowed airways -also result from sudden opening of collapsed alveoli Subjective data correct answer: information from the client's point of view ("symptoms"), including feelings, perceptions, and concerns obtained through interviews objective data correct answer: observable and measurable data ("signs") obtained through observation, physical examination, and laboratory and diagnostic testing.
