ADULT INTEGUMENTARY
STAGE 2 ULCER
A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage I ulcer is characterized by a reddened area and intact skin. Stage III ulcers are full-thickness lesions of the skin. Stage IV ulcers also are full-thickness lesions, with exposed muscle, bone, or supportive tissue.
The nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client makes which statements? Select all that apply. 1. "I need to avoid baths or showers for 7 to 10 days." 2. "I need to clean the site as prescribed to prevent infection." 3. "I need to apply ice to the site continuously to prevent swelling." 4. "I need to expect some swelling and tenderness in the affected area." 5. "I need to apply alcohol-soaked dressings twice a day for 30 minutes each time."
"I need to clean the site as prescribed to prevent infection." "I need to expect some swelling and tenderness in the affected area." Cryosurgery involves the local application of liquid nitrogen to isolated lesions, causing cell death and tissue destruction. The nurse teaches the client to expect swelling and increased tenderness of the treated area when the skin thaws. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister formation. The nurse instructs the client to clean the treatment site as prescribed to prevent secondary infection. A topical antibiotic also may be prescribed. Intermittent application of a warm, damp washcloth to the site will provide relief from any discomfort. Alcohol-soaked dressings will cause irritation. It is not necessary to avoid bathing or showering. Because cryosurgery involves tissue freezing, the application of ice is avoided following the procedure.
The nurse has provided home care instructions to a client after blepharoplasty. Which statement by the client indicates a need for further instruction? 1. "I need to keep ice on my eyes for at least 3 days." 2. "I need to avoid vigorous activities for about 1 month." 3. "I need to sleep on my back with at least 2 pillows under my head." 4. "I need to avoid activities requiring bending over at the waist for at least 48 hours."
"I need to keep ice on my eyes for at least 3 days." Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Home care instructions after blepharoplasty include the administration of cool compresses for 24 (not 72) hours. Vigorous activities, such as sports, need to be avoided for 1 month. Because lying on the side increases the possibility of swelling in the dependent eye area, the client should sleep supine with at least 2 pillows to elevate the head. The client should understand the importance of not bending over at the waist for the first 48 hours after the procedure. Bending would increase pressure to the operative area.
The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction? 1. "I should use tepid water for bathing." 2. "I need to keep my skin lubricated and cool." 3. "After bathing, I should pat my skin dry rather than rubbing it." 4. "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."
"I should apply a lubricant to my skin after bathing when my skin is thoroughly dry." The client should be instructed that a lubricant is applied immediately after the bath, while the skin is still damp, to help increase hydration of the stratum corneum. Options 1, 2, and 3 are appropriate home care measures to control the symptoms associated with pruritus.
A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client? 1. "Come to the emergency department." 2. "Apply calamine lotion immediately to the exposed skin areas." 3. "Take a shower immediately, and lather and rinse several times." 4. "It is not necessary to do anything if you cannot see anything on your skin."
"Take a shower immediately, and lather and rinse several times." When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.
The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? 1. "Each treatment will last at least 30 minutes." 2. "Your entire body will be exposed to the light treatment." 3. "You will need to wear cotton clothes during the treatment." 4. "You will need to wear dark eye goggles during the treatment.
"You will need to wear dark eye goggles during the treatment. Safety precautions are required during UV light therapy. Protective dark eye goggles are required to prevent exposure of the eyes to the UV light; it may be necessary to wear the goggles for the remainder of the day following treatment. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Most UV light therapies require the client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UV light. Direct contact with the lightbulbs used for the treatment should be avoided to prevent burning of the skin.
In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? 1. Fatigue 2. Constipation 3. Impaired safety 4. Altered body image
Altered body image Psoriasis is an autoimmune dermatitis that is expressed as silvery scales on reddish-colored skin on areas such as scalp, elbows, hands, and knees. Onset of the disease generally occurs before age 40, with symptoms varying in intensity from mild to severe. Skin disorders, particularly when experienced by young persons and particularly when visible on exposed body parts, can cause significant psychosocial distress. Altered body image is a priority client problem that should be considered when planning care for a client with psoriasis. The remaining options are not priority client problems associated with psoriasis.
The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. 1. Antibiotic therapy 2. Cold compresses to the affected area 3. Warm compresses to the affected area 4. Intermittent heat lamp treatments 4 times daily 5. Alternating hot and cold compresses continuously
Antibiotic therapy Warm compresses to the affected area Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.
The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? 1. Venous stars noted on trunk and thighs 2. Spider angiomas observed on trunk and thighs 3. Appears to have purpura on trunk and thighs 4. Appears to have cherry angiomas on trunk and thighs
Appears to have cherry angiomas on trunk and thighs A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby-colored round lesions on the trunk and/or extremities. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology. Purpura results from hemorrhage into the skin.
The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure? 1. Avoid the use of sunscreen on the skin for at least 2 years. 2. Apply an emollient lotion to the skin to enhance softening. 3 Scrub the skin vigorously with soap and water to remove the dead skin. 4. Soak the skin for 1 hour 6 times daily to assist in removing any dry scales.
Apply an emollient lotion to the skin to enhance softening. The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days; however, soaking for 1 hour 6 times daily is excessive and could lead to skin breakdown. The skin should not be scrubbed vigorously because this action also could lead to skin breakdown. The skin should be patted dry, and a lubricating lotion should be applied. The client should avoid overexposing the skin to the sunlight.
The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? 1. Run a dehumidifier in the home. 2. Apply astringents to the skin twice daily. 3. Apply emollients to the skin after bathing. 4. Take baths twice daily using a dilute solution of alcohol and water.
Apply emollients to the skin after bathing. One bath or one shower per day for 15 to 20 minutes with warm water and a mild soap should be followed immediately by the application of an emollient to prevent evaporation of water from the hydrated epidermis. The client should avoid using a dehumidifier because this will further dry room air. The client should be instructed to avoid applying rubbing alcohol, astringents, or other drying agents to the skin. A bath using a dilute alcohol solution will cause further drying of the skin.
A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem? 1. Skin that is uniformly dark 2. Very pale skin with little pigmentation 3. Patches of skin with loss of pigmentation 4. Blotchy brown macules across the cheeks and forehead
Blotchy brown macules across the cheeks and forehead Chloasma is a condition caused by hormonal influences on melanin production and is characterized by blotchy brown macules across the cheeks and forehead. Options 1 and 2 refer to normal variations in skin color. Option 3 describes vitiligo.
The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? 1. Clustered skin vesicles 2. A generalized body rash 3. Small blue-white spots with a red base 4. A fiery-red edematous rash on the cheeks
Clustered skin vesicles The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Options 2, 3, and 4 are incorrect descriptions.
The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure? 1. Ensure that the consent form has been signed. 2. Ensure that a Foley catheter has been inserted. 3. Provide chlorhexidine wipes to be used before the procedure. 4. Verify the blood bank has 1 unit of packed red blood cells available if needed.
Ensure that the consent form has been signed.
The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? 1. Disorientation to time only 2. Heart rate of 95 beats/minute 3. +1 palpable peripheral pulses 4. Urine output of 30 mL over the past 2 hours
Heart rate of 95 beats/minute When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.
The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? 1. Pallor of all extremities 2. Pulse oximetry reading of 93% 3. Peripheral pulses are diminished 4. High pressure alarm keeps sounding on the ventilator
High pressure alarm keeps sounding on the ventilator A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction.
The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2. Bathroom privileges 3. Immobilization of the affected leg 4. Placing the affected leg in a dependent position
Immobilization of the affected leg Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.
The presence of which finding leads the home health nurse to suspect infestation of a client with scabies? 1. Patchy hair loss and round red macules with scales 2. The presence of white patches scattered about the trunk 3. Multiple straight or wavy, threadlike lines beneath the skin 4. The appearance of vesicles or pustules with a thick honey-colored crust
Multiple straight or wavy, threadlike lines beneath the skin Scabies can be identified by the presence of multiple straight or wavy, threadlike lines beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the skin and lays its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 4 are not characteristics of scabies.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue
Return of distal pulses Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.
