Integumentary

The nurse is reinforcing sun exposure precautions to a group of older clients. Which would the nurse include in the instructions? Select all that apply.

Apply sunscreen liberally 15 to 30 minutes before sun exposure. Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. It is best to avoid exposure to the sun during the day between 10:00 a.m. and 4:00 p.m.

The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching?

"If the patch comes off, I need to reapply it."

The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse would question which prescription?

Apply cold compresses to the affected area.

A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions would the nurse take before transferring the client to the burn center? Select all that apply.

Apply cool water to the area. Wrap burned fingers separately to prevent sticking together. Cover the burns with a clean dry cloth as directed by a burn center.

After 7 days of wound care, a client who has a well-granulated pressure injury reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings?

Ambulation three times daily Submit

The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching?

"I will remove the dressing when I get home and wash the site with tap water."

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?

22.5%

Rule of Nines (adult)

9% per arm 9% for head 18% each leg 18% anterior trunk 18% posterior trunk

Which clients are at risk for developing skin breakdown? Select all that apply.

A client who is underweight. A client diagnosed with heart failure. A client diagnosed with spinal cord injury.

The nurse is checking her clients for skin breakdown. Which client would have the lowest priority for concern in the development of skin breakdown?

A client with a lowered mental awareness status

The nurse is reinforcing instructions to a client on how to care for a punch biopsy site after the procedure is done. Which would the nurse include in the instructions? Select all that apply.

Change the bandage daily until site is healed. Apply topical antibiotic ointment as prescribed.

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the primary health care provider's prescription sheet expecting which to be prescribed? Select all that apply.

Wound culture. Antibiotic therapy. Warm compresses.

A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure?

"I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching?

"I should never wear warm clothing over the newly healed skin area."

The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching?

"I should use a dehumidifier, especially during the winter months."

Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?

"I will apply the ointment once a day and cover it with a sterile dressing."

The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton. Which statement by the client indicates an understanding regarding the application of this medication?

"I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application."

A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response would the nurse give to the client's question?

"It is a skin infection that involves the deeper skin layers and subcutaneous fat."

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?

"My clothes can be laundered with other household members' clothes."

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?

"Take a shower immediately, and lather and rinse several times."

A client asks the nurse about the causes of acne. The nurse would respond by making which statement to the client?

"The exact cause of acne is not known."

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse would make which response to the client?

"The local anesthetic may cause a burning or stinging sensation."

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which percentage?

36%

An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which victim would be transported to the hospital first?

A victim with singed nasal and facial hair and difficulty breathing.

The nurse in the emergency department is caring for a client who sustained a large laceration to the lips and cheek from a dog bite. Which actions would the nurse take? Select all that apply.

Administer analgesics as prescribed. Anticipate a plastic surgery consultation. Report the dog bite to the police department. Administer prophylactic antibiotics as prescribed

A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which would the nurse include in the plan of care? Select all that apply.

Administering pain medications as prescribed. Monitoring the donor site and the graft site for signs of infection.

Which individual is least likely to be at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder?

An outdoor construction worker

A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem?

Appearance

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with the early stage of cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse would expect which assessment finding?

Appearance of reddish-blue lesions on the lower extremities

The client recovering from a third-degree burn asks the nurse about grafts. The nurse explains to the client that the best type of graft is which?

Autograft

The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse would include on the poster instructions to avoid which activities?

Being in the sun for prolonged periods during the daytime hours to ensure absorption of vitamin D

A client comes to a primary health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick?

Bull's-eye rash

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?

Can stain the skin and hair

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome?

Characteristic of a thrush infection.

An older client is transferred to the nursing unit following a graft to a stage 4 pressure injury. Which combination of dietary items would the nurse encourage the client to eat to promote wound healing?

Chicken breast, broccoli, strawberries, milk

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure injury in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure injury? Select all that apply.

Clean with mild soap and water. Encourage adequate nutritional intake. Apply a dressing that allows oxygen to pass through.

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the primary health care provider to prescribe which measure to maximize the effectiveness of this therapy?

Covering the application with a warm, moist dressing and an occlusive outer wrap

The nurse is collecting data from an older adult client. Which indicates a potential complication associated with the skin of this client?

Crusting

The primary health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment?

Culture of the lesion.

The nurse prepares to assist a primary health care provider with examining the client's skin with a Wood's light. Which action would be included in the plan for this procedure?

Darken the room for the examination.

A client is undergoing radiation therapy to treat lung cancer. Which instructions would the nurse reinforce to the client with regard to skin care? Select all that apply.

Do not remove any of the markings for radiation treatment. Use the hand to wash the affected area rather than a washcloth. Shower or wash the area once a day using warm water and mild soap.

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client would monitor for which sign/symptom during the first 24 hours after the burn injury?

Elevated hematocrit levels

The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position would the nurse anticipate being prescribed for the client?

Elevating and immobilizing the affected leg.

Sodium hypochlorite is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan?

Ensure that the solution is freshly prepared before use.

The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply.

Inflammatory or (lag) phase. Maturation or (remodeling) phase. Proliferative or (connective tissue repair) phase

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable.

The nurse prepares to assist in instructing a client about Lyme disease. Which would the nurse include in the instructions?

It is caused by a tick carried by deer.

The client is receiving a full-thickness graft to a burn on the hand. The nurse understands that a full-thickness graft is being applied instead of a split-thickness graft because of which reason?

It provides better cosmetic results.

The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas? Select all that apply.

Knees. Elbows. Base of the spine

The nurse is caring for a client on transmission-based precautions who has herpes zoster, or shingles. Which are some of the most important skin issues associated with this condition? Select all that apply.

Lesions are very contagious when they are fluid-filled blisters. Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. To reduce the risk of transmitting the virus to others, clients with lesions are separated from other clients until lesions have crusted.

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply.

Lightly scrub the stoma with soap and water. Cut the opening on the appliance ½ inch larger than stoma.

The primary health care provider has prescribed a bacteriostatic agent effective against both gram-positive and gram-negative organisms for application to a burn wound. The nurse determines that which medication has been prescribed?

Mafenide acetate

The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8°F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action?

Monitor the client for signs of infection.

The nurse is reviewing a focused assessment done on a client's integumentary system. Which physical examination assessments are related to inspection? Select all that apply.

Nails for shape, contour, color, thickness and cleanliness. Skin for color, integrity, scars, lesions, and signs of breakdown. Facial and body hair for distribution, color, quantity and hygiene. Skin temperature, texture, moisture, thickness, turgor, and mobility

The client, diagnosed with Lyme disease stage 2, asks the nurse "what is indicative of stage 2?" The nurse explains to the client that which sign or symptom is assessed in stage 2?

Neurological deficits

The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area would provide the best information?

Palms of the hands

An African American client has been admitted for a skin rash on his lower back. Which techniques would the nurse best rely on when assessing the skin rash? Select all that apply.

Palpation. Induration

A client with jaundice is complaining of pruritus. Which strategy would the nurse institute to help control the problem and prevent injury?

Pat the skin dry after bathing.

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which would the nurse anticipate to be prescribed for this condition?

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

The nurse reviews a client's chart and notes that the primary health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which would the nurse expect to note during data collection?

Red, shiny skin around the nail bed

A client diagnosed with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse would perform which priority action while using this solution?

Rinse off the solution immediately following irrigation.

The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial-thickness skin loss and the formation of a blister. The nurse would document the pressure injury as which category?

Stage II

The nurse in a primary health care provider's office has scheduled a client with a possible allergen-causing dermatitis to be seen in 1 week for a patch test. The nurse explains the procedure for the patch test and includes which in the explanation? Select all that apply.

The allergen will be placed on the skin and covered with an airtight dressing. A negative reaction occurs when there is no erythema, swelling, or complaint of itching.

The nurse documents that the client has a stage 2 pressure injury on the decubitus area. Which describes a stage 2 pressure injury?

The ulcer is superficial and characterizes an abrasion.

The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate which potential complication?

There may be an infection at the central catheter site, which can lead to septicemia.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

Tinnitus

The nurse is reinforcing instructions to a client diagnosed with eczema about measures that decrease itching and moisturize the skin. Which would the nurse include in the instructions? Select all that apply.

Use moisturizers and sunscreens. Wash new clothing before it is worn. Use mild detergent and rinse clothes twice. Maintain room temperature at 68°F to 75°F. Wear open-weave fabrics and loose clothing.

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions would the nurse provide? Select all that apply.

Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun. Examine your body monthly for any lesions that may be suspicious.

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The stinger is still visible in her arm. What would be the nurse's first action?

Use the edge of a sterile surgical tool to scrape out the stinger.

A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion?

Venous circulation is being impaired.

The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment would the nurse anticipate being prescribed for the client?

Warm compresses to the affected area

The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which?

Weeping of the skin

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding would the nurse note in this condition?

White skin that is insensitive to touch

The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply.

Wound from repair of a perforated appendix. Gunshot wound that punctured the small intestine. Traumatic wound to the abdomen and intentionally left open for several days. Wound related to debridement of a chronic pressure injury resulting in a cavity-like defect

A client has a noninfected pressure injury on the left heel. The nurse would use which sterile solution to cleanse the wound as part of a dressing change procedure?

Normal saline

The nurse is caring for a client with a diagnosis of pemphigus. The nurse would include which interventions in the plan of care for the client? Select all that apply.

Applying prescribed topical antibiotic. Administering prescribed corticosteroid. Applying Domeboro solution to the affected skin.

The nurse is assigned to care for a client with a leg ulcer. Sutilains treatments are prescribed. The nurse would avoid which action when performing the treatment?

Applying the sutilains immediately followed by a dry sterile dressing