Nokea
Which of the following accurately summarizes the primary purpose of skin care and hygiene?
- A. Maintain skin sterility and prevent infection
- B. Prevent bodily odors by eliminating bacteria
- C. Protect the body's first line of defense
- D. Provide the client with comfort and well-being
Correct Answer: C
Rationale: The skin is the body's first line of defense against pathogens and injury, and proper skin care maintains its integrity.
You may also like to solve these questions
The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation?
- A. 4 mL x kg x Total Body Surface Area (TBSA) burned
- B. 30 mL/kg
- C. 0.5 mL/kg/hr
- D. 0.10 mL/kg/hr
Correct Answer: A
Rationale: The Parkland formula (4 mL x kg x TBSA burned) is used to calculate fluid resuscitation needs in burn patients to restore circulating volume.
The nurse is performing a head-to-toe assessment for an older adult. Which finding from the integumentary assessment does the nurse recognize as a normal age-related change:
- A. Moist skin
- B. Increased nail growth
- C. Dry, itchy skin
- D. Increased skin pigmentation
Correct Answer: C
Rationale: Dry, itchy skin is a normal age-related change due to decreased oil production and skin thinning.
A nurse is caring for a client at risk of developing pressure ulcers. Which of the following is an intrinsic risk factor that contributes to this increased risk?
- A. Shearing
- B. Friction
- C. Impaired tissue perfusion
- D. Pressure
Correct Answer: C
Rationale: Impaired tissue perfusion is an intrinsic risk factor because it originates within the body, affecting blood flow and tissue oxygenation, which can lead to pressure ulcer development. Shearing, friction, and pressure are extrinsic factors as they are external forces acting on the skin.
The nurse works with elderly clients. The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply.
- A. Pronounced wrinkles on the face
- B. Decreased size of the nose and ears
- C. Increased growth of facial hair
- D. Neck wrinkles
- E. Increased height
Correct Answer: A, C, D
Rationale: Aging causes pronounced wrinkles on the face and neck and increased facial hair due to hormonal changes. Nose and ears enlarge, and height decreases due to spinal compression.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 2 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Based on the client's injuries, the client has sustained a ..........total body surface area burn.
- A. 18%
- B. 27%
- C. 36%
Correct Answer: C
Rationale: Using the rule of nines: right arm (9%), right hand (1%), right torso (9%), back (18%) = 9 + 1 + 9 + 18 = 37% (closest to 36% in options).