Week 5 - Tissue Integrity and Clinical Judgement

Question 1

What is tissue integrity?

Answer 1

The state of structurally intact and physiologically functioning epithelial tissues like skin, subcutaneous tissue, and mucous membranes.

Question 2

What are the three layers of the skin?

Answer 2

Epidermis, Dermis, and Subcutaneous tissue.

Question 3

What cells are found in the epidermis?

Answer 3

Squamous epithelial cells, keratinocytes, melanocytes, Merkel cells, and Langerhans cells.

Question 4

What are key components of the dermis?

Answer 4

Connective tissue, blood vessels, lymph vessels, collagen, and elastin.

Question 5

What is the function of the subcutaneous tissue?

Answer 5

Insulation, shock absorption, protection of internal organs, and assistance in thermoregulation.

Question 6

Name four protective functions of the skin.

Answer 6

Protection from injury, infection, UV radiation, and temperature changes.

Question 7

What sensory roles does the skin perform?

Answer 7

Perception of touch, pain, pressure, and vibration.

Question 8

What factors contribute to healthy skin integrity?

Answer 8

Hydration, nutrition, perfusion, mobility, and absence of chronic illness.

Question 9

How does aging affect skin integrity?

Answer 9

Decreased elasticity, collagen, subcutaneous tissue, and hydration; increased risk of tears and pressure injuries.

Question 10

Why are infants at risk for impaired skin integrity?

Answer 10

Immature skin structure and increased risk of maceration and dermatitis.

Question 11

How does diabetes affect skin integrity?

Answer 11

Causes chronic hyperglycemia which impairs perfusion and sensation, delaying wound healing.

Question 12

What lifestyle choices negatively impact tissue integrity?

Answer 12

Smoking and excessive UV exposure (tanning).

Question 13

Name subjective data relevant to a skin assessment.

Answer 13

Health history, medical conditions, lifestyle, and hygiene practices.

Question 14

What is nonblanchable erythema?

Answer 14

Redness that does not fade when pressed; indicates tissue damage.

Question 15

What is blanchable erythema?

Answer 15

Redness that turns white with pressure; typically reversible.

Question 16

What skin changes might indicate poor perfusion?

Answer 16

Pallor and cool temperature on palpation.

Question 17

How is cyanosis assessed in dark skin tones?

Answer 17

Check palms, soles, nail beds, tongue, and conjunctiva for bluish/gray discoloration.

Question 18

What is petechiae?

Answer 18

Small pinpoint red or purple spots due to bleeding under the skin.

Question 19

Q: What is skin turgor and what does it assess?

Answer 19

Skin elasticity; used to assess hydration.

Question 20

What is tenting in a turgor test?

Answer 20

Skin stays raised when pinched, indicating dehydration.

Question 21

What is the Braden Scale used for?

Answer 21

To assess risk for pressure injuries and evaluate skin integrity.

Question 22

What are nursing interventions to maintain skin integrity?

Answer 22

Repositioning, hygiene, hydration, nutrition, protective dressings, and use of supportive surfaces.

Question 23

How often should high-risk patients be repositioned?

Answer 23

At least every 2 hours or more frequently if needed.

Question 24

What is the ideal bed positioning to reduce pressure?

Answer 24

Keep the head of the bed lower than 30 degrees and use pillows or wedges for support.

Question 25

How does hygiene promote skin integrity?

Answer 25

Removes irritants, prevents infection, and maintains skin moisture balance.

Question 26

What nutritional elements support skin health?

Answer 26

Protein, omega-3 & omega-6 fatty acids, vitamins A and C.

Question 27

How can nurses promote circulation for skin health?

Answer 27

Early mobilization and frequent repositioning.

Question 28

What is clinical judgment in nursing?

Answer 28

An interpretation or conclusion about a patient’s needs, concerns, or health problems and/or the decision to act or not based on the patient’s response.

Question 29

Define critical thinking in nursing.

Answer 29

Systematic and logical thought processes used to review data, reflect, inquire, and make informed decisions.

Question 30

What are key components of critical thinking?

Answer 30

Assessing evidence, identifying relevance, analyzing sources, considering all options, and deciding based on sufficient information.

Question 31

How is critical thinking related to clinical judgment?

Answer 31

Critical thinking enables nurses to make informed clinical judgments by interpreting patient needs and planning appropriate care.

Question 32

What is the Clinical Judgment Action Model (CJAM)?

Answer 32

A model developed by NCSBN to describe steps in making clinical judgments.

Question 33

List the six steps of the Clinical Judgment Action Model (CJAM).

Answer 33

Recognize cues, analyze cues, prioritize hypothesis, generate solutions, take action, evaluate outcomes.

Question 34

What is the nursing process?

Answer 34

A framework that guides nursing care through assessment, diagnosis, planning, implementation, and evaluation.

Question 35

What is the difference between the linear and circular views of the nursing process?

Answer 35

Linear is step-by-step; circular sees steps as overlapping and happening simultaneously.

Question 36

What is the holistic caring process?

Answer 36

A nursing process that addresses the whole person—physically, emotionally, spiritually, and culturally.

Question 37

What does holistic assessment include?

Answer 37

Physical, functional, psychosocial, emotional, cultural, spiritual, and energy field aspects of health.

Question 38

How does the nursing process differ in assessment from the holistic process?

Answer 38

Nursing focuses on client responses to health problems; holistic integrates intuitive and scientific data to identify health patterns.

Question 39

What is the purpose of the diagnosis step in the nursing process?

Answer 39

To analyze data and determine actual or potential patterns, needs, or health issues.

Question 40

What is a nursing diagnosis?

Answer 40

A clinical judgment about a patient's response to health conditions, guiding nursing care.

Question 41

List the three types of nursing diagnoses.

Answer 41

Problem-focused, risk, and health-promotion.

Question 42

How does a nursing diagnosis differ from a medical diagnosis?

Answer 42

Nursing diagnoses focus on patient responses and care; medical diagnoses address disease or pathology.

Question 43

What is the structure of a problem-focused nursing diagnosis?

Answer 43

Diagnosis + related factors + defining characteristics.

Question 44

What is the purpose of the planning phase in the nursing process?

Answer 44

To develop SMART goals and identify interventions to achieve desired outcomes.

Question 45

What is a key feature of holistic planning?

Answer 45

It respects the uniqueness of each client and integrates complementary therapies.

Question 46

What happens during the implementation phase?

Answer 46

Nurses carry out interventions, provide care, and use therapeutic communication and skills.

Question 47

What is unique about implementation in holistic nursing?

Answer 47

It includes the therapeutic use of self and integrative treatments.

Question 48

What is the purpose of evaluation in the nursing process?

Answer 48

To assess if client outcomes were met and determine the need for changes in care.

Question 49

How does holistic evaluation differ from traditional evaluation?

Answer 49

It considers changes in the client's overall health experience and acknowledges care as a dynamic process.

Question 50

What are the main settings in which the nursing process is applied?

Answer 50

Individual, caregiver, family, group, and community settings.

Question 51

What does Gordon’s Functional Health Patterns help with?

Answer 51

Organizing assessment data into domains of health to identify nursing diagnoses.

Question 52

What is the goal of using the nursing process?

Answer 52

To make clinical judgments that lead to optimal client outcomes through holistic, evidence-based care.

Question 53

What guides the use of the nursing process in various practice settings?

Answer 53

Client needs, setting-specific factors, and individualized care plans.

Question 54

Name three examples of nursing diagnostic labels from Gordon’s domains.

Answer 54

Imbalanced Nutrition, Risk for Falls, Impaired Gas Exchange.

Question 55

What is the difference between subjective and objective assessment data?

Answer 55

Subjective data is what the patient reports; objective data is observed or measured.