Wound Healing and Skin Changes in Older Adults, Exams of Nursing

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1. Mrs. Williams is 76 years old and comes in to have a wound checked on her right leg. She fell a month ago and the wound has not healed. She is concerned that something is wrong. The nurse practitioner examines the wound and sees that it has been cleaned properly and has no signs of infection. The edges are approximated, but the skin around the wound is red and tender to touch. The best response regarding Mrs. Williams' concern is:
2. Wound healing for older people may take up to four times longer than it does for younger people.
3. Let us talk about what you are eating.
4. Had you come in earlier, I would have ordered medicine that would have healed that right up.
5. I will order an antibiotic to prevent infection. - - correct ans- - 1. Answer: 1 Page: 96 Feedback

Skin renewal turnover time increases to approximately 87 days in older adults, compared with 20 days during youth.

The perceived extended healing time is not related to diet.

This is false hope, as there is no medication that will heal this wound quickly.

Prophylactic antibiotics are not appropriate when there are no signs or symptoms of infection.

2. The nurse practitioner is conducting patient rounds in a long-term care facility. As she talks with Mrs. Jones, she notices that her arms and elbows are excoriated and the skin is shearing. The nurse practitioner explains to the staff that Mrs. Jones needs frequent assessment of her skin and protection provided to prevent skin breakdown because:
3. Her lack of activity causes the skin to tear.
4. Fat has redistributed to the abdomen and thighs, leaving bony surfaces in areas such as the face, hands, and sacrum. This can result in injury.
5. She has lost weight and is in jeopardy of falling.
6. She picks at herself and causes skin breakdown. - - correct ans- - 2. Answer: 2 Page: 96 Feedback

Lack of activity alone does not cause skin breakdown.

Fat is redistributed to the abdomen and thighs, leaving bony surfaces, such as the face, hands, and sacrum, exposed to potential injury, especially skin tears from shearing, friction forces and pressure ulcer development.

Although losing weight may be a risk factor for falling, it is not directly related to skin breakdown.

There is no evidence that she is picking at herself, as there is nothing reported anywhere else on her arms.

3. Mr. James is 91 years old. His daughter notices that he has bruises and lacerations on his arms and reports this to the nurse practitioner, who tells her that older people bruise easily due to their fragile blood vessels. The skin lacerations happen because he has thin skin. Even so, the nurse practitioner assures the daughter that she will investigate further to ensure that he is getting proper care. She says this because she understands that:
4. These markings on the patient's skin are part of aging skin.
5. Bruises and lacerations can indicate inadequate care.
6. The daughter needs assurance that her father is okay.
7. The patient is being abused. - - correct ans- - 3. Answer: 2 Page: 97 Feedback

Markings on the skin may be signs of aging, a disease, or maltreatment.

Poorly healing wounds or chronic pressure ulcers may signal a problem not only with the patient but with the caregiver's ability to provide adequate care. Welts, lacerations, burns, and distinctive markings may indicate a need for intervention.

This is a result of the nurse practitioner addressing it further rather than the reason for addressing it.

A professional cannot assume abuse without good reason.

4. The nurse practitioner assesses a patient's skin and finds an infectious lesion on the lower leg. The lesion is considered a secondary lesion. The nurse practitioner explains that a secondary lesion is one that:
5. Arises from changes to a primary lesion.
6. Is a complication of an underlying disease.
7. Is difficult to treat.
8. Is a normal sign of aging. - - correct ans- - 4. Answer: 1 Page: 97 Feedback

Secondary lesions (infections) arise from changes to the primary lesion.

Secondary lesions are not necessarily the result of an underlying disease.

Secondary lesions can be treated with medications or surgery.

Secondary lesions arise as a condition not normal to aging.

5. Ms. Rose, 88 years old, comes to the nurse practitioner with a complaint about a growth on her hand. She wants to have a biopsy done. The nurse practitioner asks the following question:
6. Have you injured your hand recently?

2. Are you using a different detergent?
3. Has this growth changed, bled, or is it painful?
4. Has this growth made it difficult to put on your rings? - - correct ans- - 5. Answer: 3 Page: 97 Feedback

An injury would not stimulate growth.

A reaction to a detergent would more likely be a rash.

Lesions that warrant biopsy are those that have changed, bleed, or are painful.

The ability to put on her ring is not the problem.

6. A 60-year-old male enters the burn center for triage and treatment due to a burn he received at a campfire. His left arm has an area that is erythematous and painful, and another area has a blister. What does the nurse practitioner record as the degree of burn?
7. First degree
8. Second degree
9. First and second degree
10. Second and third degree - - correct ans- - 6. Answer: 3 Page: 98

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First-degree burns involving the epidermis are erythematous and painful but do not blister.

Second-degree burns involve the dermis and are characterized by blisters.

The patient presents with erythematous skin, painful with blisters, which indicates both first- and second-degree burn areas.

In third-degree burns there is no sensation when the wound is pinpricked.

7. The nurse practitioner is concerned with primary prevention strategies. How can the nurse practitioner implement primary prevention strategies for an 80-year-old male patient who smokes?
8. Review home fire safety protocols, including the proper use of smoke alarms, and discuss smoking cessation.
9. Inform him that if he does not stop smoking, the nurse practitioner cannot see him again.
10. Have a conference with his family about his smoking.
11. Plan a family meeting with the patient to discuss benefits of his smoking cessation. - - correct ans- - 7. Answer: 1 Page: 115, 116 Feedback

Primary prevention includes educational programs designed to educate the public on safety. For example, the individual smoking in bed would hopefully benefit from smoking cessation programs in the community, as well as instruction in safety precautions.

Threatening refusal of care is not ethical.

The patient is at risk, not the family.

The fact that the patient smokes is not the issue; safety is the issue.

8. The nurse practitioner is conducting a safety class with community-living older adults. Which of the following should she include in her teaching of risks of burns for this population? Select all that apply.
9. Thinner skin.
10. Less vascularity.
11. Diminished nerve function.
12. A weakened immune system.
13. The burden of various comorbidities leading to enhanced wound healing and reepithelialization after burn injury. - - correct ans- - 8. Answer: 1, 2, 3, 4 Page: 98 Feedback

As one ages, there are significant changes in the skin, which becomes thinner, providing a less effective barrier to external stimuli.

With aging, there are fewer appendages and decreased vascularity.

Thinner skin and diminished nerve function often result in a higher incidence of deeper burns.

Advanced age results in a weakened immune system.

Along with the burden of various comorbidities, the fragility of older skin leads to delayed wound healing and reepithelialization after burn injury.

9. Mr. Edwards is 76 years old and received a burn on his leg when he dozed off and dropped his cigarette. The nurse practitioner examines his leg for the degree of burn and classifies it as second degree with some third degree in the center. Mr. Edwards asks what that means and why it hurts so much. What is the best answer? Select all that apply.
10. It means that this is a serious, deep burn in the center, and a less deep burn around the sides.
11. It hurts because the nerve endings are exposed in the second-degree area.
12. It means that the burn is advancing and getting worse.
13. It hurts because the nerves are destroyed.
14. It hurts because the nerves in the second-degree areas are exposed to the outside and are stimulated. - - correct ans- - 9. Answer: 1, 2 Page: 98 Feedback

Deep dermal burns extend further into the dermis; third-degree burns involve the full dermis, extending into the subcutaneous tissue.

In these burns there is pain from exposed nerve endings, but by the second day, pain is often described more as pressure.

The first step in treatment is to stop the burn.

Destroyed nerves do not register pain.

Superficial dermal burns involve the dermis and are characterized by blisters. The underlying tissue is pink, moist, and hypersensitive to touch.

10. Mrs. Thomas is 82 years old and burned her hand while cooking. The nurse practitioner assesses second- and third-degree burns over approximately half of the back of her hand. The nurse practitioner chooses which of the following for initial treatment? Select all that apply.
11. Administer appropriate pain medication.
12. Rinse with cool tap water.
13. Clean with a strong detergent.
14. Remove any loose tissue but allow the blisters to remain.
15. Diagnose as first- and third-degree burns. - - correct ans- - 10. Answer: 1, 2, 4 Page: 100 Feedback

After administration of appropriate pain medication, wound management can begin.

Burn wounds should be immediately doused in cool tap water to disperse any remaining heat in the tissue.

Detergents and antibacterial soaps are not indicated. Burn wounds should be cleaned with mild soap and rinsed.

For small surface area burns, it is good to remove any loose tissue during cleansing and allow intact blisters to remain.

First-degree burns do not exhibit blisters, and third-degree burns do not exhibit pain.

11. Mr. Watson,75 years old, comes to the urgent care center with complaints of fever, fast heartbeat, a swollen gland under his right arm, and redness in his upper left arm that has hurt for 2 to 3 days. The patient says that he has had the redness in his arm for months without any difficulty. The nurse practitioner suspects which of the following? Select all that apply.
12. Influenza
13. Upper respiratory infection
14. Cellulitis of upper left arm
15. Necrotizing fasciitis
16. Lymphangitis - - correct ans- - 11. Answer: 3 Page: 103 Feedback

Influenza is systemic and not localized in any one area.

The patient has no respiratory symptoms.

Signs of cellulitis include worsening of erythema, edema, tenderness, and pain that has occurred for a few days. Symptoms are usually sudden. Systemic symptoms which indicate serious toxicity include fever, hypotension, and tachycardia.

Necrotizing fasciitis exhibits diffuse swelling of an arm or leg with bullae.

Systemic symptoms that indicate serious toxicity include fever, hypotension, tachycardia, leucocytosis, lymphadenopathy, and lymphangitis.

12. The treatment for cellulitis includes which of the following? Select all that apply.
13. Patients with mild cellulitis may be given oral antibiotics.
14. One drug of choice is dicloxacillin, 500 mg four times a day.
15. Treatment is dependent on the culture of the cells affected.
16. The drug of choice is given for a minimum of 3 days.
17. Administration of a tetanus booster injection. - - correct ans- - 12. Answer: 1, 2 Page: 103 Feedback

Oral antibiotics are sufficient for mild cellulitis and IV antibiotics for organisms such as MRSA.

There are several drugs effective with cellulitis; dicloxacillin is one of them.

Treatment of MRSA should be guided by wound culture results, but not cellulitis.

The drug of choice is typically given for 7 days.

If the wound is grossly contaminated and the patient's last tetanus booster was 5 to 10 years ago, the practitioner should consider giving another booster at this time.

13. A 59-year-old female was admitted to the hospital for malaise, headache, fever, and flu- like symptoms. She has a decreased appetite and is having trouble sleeping. After a couple of days, she complains to the nurse practitioner of itching, burning, and tingling pain around her waist. The nurse practitioner advises the nursing staff to observe for vesicles for a few days. The patient asks why she is so sick. What would be the nurse practitioner's best response? Select all that apply.
14. We are not certain at this point, however, these symptoms often occur before a break- out of herpes zoster.
15. You have some very general systemic symptoms, so we are waiting for more specific symptoms to appear.
16. Because you had chicken pox as a child, and you now have a depressed immune system, the chance of developing herpes zoster is high.
17. These symptoms are probably a strong case of influenza.
18. Herpes zoster is more com - - correct ans- - 13. Answer: 1, 3 Page: 106

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Patients usually experience itching, burning, or tingling pain at the site 4 to 5 days before the eruption appears.

Although there are general systemic symptoms, there is also itching, burning, and pain in the waist, which is leading to a herpes zoster diagnosis.

The patient has initial contact with VZV in the form of chicken pox. Individuals who are immunosuppressed are more likely to develop herpes zoster.

Herpes zoster is characterized by pain along the dermatomes and vesicles, which is not symptomatic of influenza.

This infection is most common in adults over 55 years old. The risk of herpes zoster increases with age.

14. Mrs. Person, 82 years old, comes to the well clinic to see a nurse practitioner for a bump on her ear. This growth has been there for almost a year but has recently grown. The area around the growth appears inflamed. Why would the nurse practitioner suggest a biopsy? Select all that apply.
15. The growth is elevated and increasing in size.
16. The ear has high exposure to the sun.
17. There is inflammation around the growth.
18. The patient is 82 years old and reports having lived in the south of the United States for many years.
19. There is no concern about familial tendencies. - - correct ans- - 14. Answer: 1, 2, 3, 4 Page: 118

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Signs of malignancy include elevation; the original lesion may also have enlarged in size.

Common locations for skin cancers are the scalp, ears, lower lip, and dorsal side of the hands.

Signs of malignancy include inflammation of the lesion.

The incidence of all types of skin cancers increases with age and the degree and intensity of sun exposure.

Certain genetic predispositions can contribute to the development of skin cancer, and there is a familial tendency to develop melanoma.

15. The nurse practitioner is making patient rounds in a long-term care facility and is visiting Mr. Smith, 95 years old, who has a large amount of fungus growing from his toenails. The staff nurse asks what can be done to help alleviate this nail fungus. What does the nurse practitioner advise? Select all that apply.
16. Wash and completely dry the feet and toes daily.
17. Keep the patient's feet cool and dry.
18. Use aluminum acetate solution (Burow's solution).
19. Have the patient wear occlusive footwear.
20. Use clotrimazole (ointment, cream, or lotion). - - correct ans- - 15. Answer: 1, 2, 3 Page: 123

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The key to prevention of recurrence is to keep the area dry. Use a hairdryer to thoroughly dry the area after bathing.

The key to prevention of all types is to keep the skin cool and dry.

The use of aluminum acetate solution (Burow's) and the application of antifungal or absorbent powder have all been shown to prevent recurrence.

Avoiding occlusive footwear, wearing absorbent materials, and practicing good hygiene offer the best primary prevention.

Newer agents are more likely to cure tinea pedis than the older generation of antifungals, including clotrimazole, which is fungistatic, whereas terbinafine is fungicidal.

1. In the assessment for peripheral vascular disorders, the clinician should begin with which of the following after the general history and physical examination?
2. Auscultation of the carotid arteries bilaterally.
3. Palpation of the carotid arteries bilaterally.
4. Inspection of the carotid arteries bilaterally.
5. Order diagnostic testing. - - correct ans- - 1. Answer: 1 Page: 215

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The clinician should begin with auscultation of the carotid arteries bilaterally because cardiac murmurs will usually radiate into the carotid arteries.

After auscultation of the carotid and subclavian arteries, the clinician should proceed to palpation of the brachial, radial, and ulnar arteries.

After auscultation and palpation, careful inspection should be performed of the distal fingers and the nail beds.

Diagnostic testing is usually ordered when areas of concern are found.

2. Which of the following conditions is signaled by symptoms of swelling of the affected body part, usually the limb, because of impaired flow of lymph fluid?
3. Abdominal aortic aneurysm (AAA)
4. Venous ulcers
5. Peripheral vascular disease (PVD)
6. Lymphedema - - correct ans- - 2. Answer: 4 Page: 218 Feedback

AAA presents the signal symptoms of persistent or intermittent pain in the middle or lower abdomen, radiating to the lower back.

Venous leg ulcers present signal symptoms of swelling that subside with elevation of lower extremities, eczematous skin changes, dull ache in lower extremities, and presence of varicosities.

PVD is a disease that alters blood flow to or from the extremities and vital organs other than the heart. It presents signal symptoms of pain, intermittent claudication of the feet, and tissue loss in affected leg/arm.

Lymphedema presents the signal symptoms of swelling of the affected body part, usually the limb, because of impaired flow of lymph fluid.

3. In the initial screening for a diagnosis of AAA, which of the following is the best screening test?
4. CT scan
5. Complete blood count (CBC)
6. Ultrasound in the abdominal area
7. Angiography - - correct ans- - 3. Answer: 3 Page: 216 Feedback

CT screening is indicated when surgery is planned.

CBC may be a secondary screening when surgery is planned.

Ultrasound in the abdominal area is the best initial screening test for AAA.

Angiography screening is indicated when surgery is planned.

4. Mrs. Prentiss is diagnosed with symptomatic AAA. The initial treatment is aggressive blood pressure control. At which of the following readings should mean arterial pressure be maintained?
5. Between 100 and 120 mm Hg.
6. Between 90 and 120 mm Hg.
7. Between 60 and 70 mm Hg.
8. Between 80 and 100 mm Hg. - - correct ans- - 4. Answer: 3 Page: 217 Feedback

A reading of 100 to 120 mm Hg is too high.

A reading of 90 to 120 mm Hg is too high.

Good arterial pressure for those with AAA should fall between 60 and 70 mm Hg.

A reading of 80 to 100 mm Hg is too high.

5. Which medical specialist is the best referral for patients with symptomatic AAA?
6. Vascular surgeon
7. Neurosurgeon
8. Cardiologist
9. Internist - - correct ans- - 5. Answer: 1 Page: 217 Feedback

A vascular surgeon is a specialist who is highly trained to treat diseases of the vascular system.

A neurosurgeon is a physician who specializes in the diagnosis and surgical treatment of disorders of the central and peripheral nervous system.

A cardiologist is a doctor who specializes in the study or treatment of heart diseases and heart abnormalities.

Internists are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum, from health to complex illness.

6. Anne is a 50-year-old post-mastectomy patient diagnosed with secondary lymphedema. Based on her surgical history, which of the following may be the contributing factor to the lymphedema?
7. Gynecological cancer
8. Breast cancer
9. Urological cancer
10. Infection - - correct ans- - 6. Answer: 2 Page: 218 Feedback

Gynecological cancer is a contributing factor for secondary lymphedema, but it is not the best option for this scenario because of Anne's history.

Breast cancer is the best option and is a contributing factor for secondary lymphedema in Anne's case because of the previous mastectomy.

Urological cancer is a contributing factor for secondary lymphedema, but it is not the best option for this scenario because of Anne's history.

Infection is a contributing factor for secondary lymphedema, but it is not the best option for this scenario because of Anne's history.

7. PVD is a disease that alters blood flow to or from the extremities and vital organs other than the heart. According to studies, which of the following remains the most important risk factor for PVD?

1. Smoking
2. Hypertension
3. Family history
4. Hypercoagulopathy - - correct ans- - 7. Answer: 1 Page: 219 Feedback

Smoking remains the most important risk factor to PVD.

Hypertension is an associated risk factor to PVD.

A strong family history of the disease is an associated risk factor to PVD.

Hypercoagulopathy is an associated risk factor to PVD.

8. Which of the following differential diagnoses should be considered with the diagnosis of peripheral arterial disease (PAD)?
9. Marfan syndrome
10. Atelectasis
11. Raynaud's phenomenon
12. Carpal tunnel syndrome - - correct ans- - 8. Answer: 3 Page: 219, 220

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Marfan syndrome is a genetic disorder that affects the body's connective tissue. It is not related to the diagnosis of PAD.

Atelectasis is a condition where some, or all, of the air-filled sacs (alveoli) inside the lungs collapse, thereby reducing the lungs' capacity to deliver oxygen to the body. It is not related to the diagnosis of PAD.

Raynaud's phenomenon is a type of vascular disease characterized by a pale to blue to red sequence of color changes of the digits, most commonly after exposure to cold, and should be considered with the diagnosis of PAD. Buerger's disease is also a differential diagnosis for this disease.

Carpal tunnel syndrome is a common condition that causes pain, numbness, and tingling in the hand and arm. It is not related to the diagnosis of PAD.

9. Patient education is very important for individuals who have AAA. The patient and their family should be taught the importance of follow-up and the management of which of the following? Select all that apply.
10. Hypertension
11. Hypercholesterolemia
12. Smoking
13. Chondromalacia
14. Pain - - correct ans- - 9. Answer: 1, 2, 3, 5 Page: 220, 221

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Education about hypertension management is important for patients with AAA. Antihypertensive agents are used to reduce tension on the vessel wall in patients with AAAs who have elevated blood pressure.

Patients with AAA need to learn about control of hypercholesterolemia (also called high cholesterol). Hypercholesterolemia is characterized by high serum cholesterol levels and premature coronary atherosclerosis. Hypercholesterolemia is one of the factors promoting the arteriosclerotic process and is a major cause of aortic aneurysm.

Smoking cessation should be considered by patients with AAA. Smoking appears to increase the risk of aortic aneurysms. Smoking can be damaging to the aorta and weaken the aorta's walls.

Chondromalacia is a pain in the knee and has no relationship to AAA.

Pain is the most common symptom of an AAA. Pain associated with an AAA may be in the abdomen, chest, lower back, or groin area. The pain may be severe or dull. Sudden, severe pain in the back or abdomen may mean the aneurysm is about to rupture.

10. AAA is mostly atherosclerotic in nature, but can also be caused by trauma, infection, and inflammation. Which of the following is a true statement regarding the tendency to develop AAA? Select all that apply.
11. There is no dominant ethnic group that develops AAA.
12. Caucasians have a higher risk of developing AAA.

3. Women have a higher risk of developing AAA.
4. There is a familial history associated with AAA development.
5. AAA is the 13th leading cause of death in the United States. - - correct ans- - 10. Answer: 1, 4, 5 Page: 216 Feedback

There is no dominant ethnic group that develops AAA, but there is a familial history associated with AAA development.

There is no dominant ethnic group that develops AAA.

Onset occurs around age 50 years for men and 60 years for women. Incidence steadily increases with age and peaks at age 80 years. AAA is five times more likely in men than in women.

There is no dominant ethnic group that develops AAA, but there is a familial history associated with AAA development.

According to studies, AAAs are the 13th leading cause of death in the United States. Mortality rates for ruptured aneurysms are 70% to 90% compared with 5% operative mortality for elective open surgical repair, and 2% to 3% for endovascular stent AAA exclusion.

11. In treating AAA, arterial monitoring is recommended. Which of the following IV antihypertensive agents should be used to rapidly and consistently maintain blood pressure in the

mean arterial pressure ranges? Select all that apply.

1. Nicardipine
2. Sertraline
3. Esmolol
4. Nitroglycerin
5. Carbidopa - - correct ans- - 11. Answer: 1, 3, 4 Page: 217 Feedback

Nicardipine is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges.

Sertraline is used to treat depression, panic attacks, obsessive compulsive disorder, post- traumatic stress disorder, and social anxiety disorder.

Esmolol is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges.

Nitroglycerin is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges.

Carbidopa is a medication used with a combination to treat symptoms of Parkinson's disease or Parkinson-like symptoms.