Integumentary, Burns (36, 50, 51)

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?

"Lesions most often are located on the arms and chest."

A client calls the emergency department and tells the nurse that he came directly into 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 should make which response?

"Take a shower immediately, lathering and rinsing several times."

Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is prescribed for a client with a partial thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?

"The medication will permanently stain my skin."

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?

100% oxygen via a tight-fitting, nonrebreather face mask

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

36%

The nurse is caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.

A delay in growth may occur after a burn injury, An immature immune system presents an increased risk of infection for infants and young children, Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg and asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that cellulitis has which characteristic?

A skin infection of the dermis and underlying hypodermis

A client arriving at the ED has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the clients hand?

A white color to the skin, which is insensitive to touch

The client nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid (Azelex). Because of the medication prescription, the nurse would suspect that the client is being treated for which condition?

Acne

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding?

An irregularly shaped lesion

A topical corticosteroid is prescribed by a HCP for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

Apply a thin layer of cream and rub it into the area thoroughly

Permethrin (Elimite) is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?

Apply the lotion to cool, dry skin at least 30 minutes after bathing

A client is brought to the ED with partial thickness burns to the face, neck, arms, and chest after trying to put on a car fire. The nurse should implement which nursing actions for this client? Select all that apply.

Assess for airway potency, Administer oxygen as prescribed, Elevate extremities if no fractures are present.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are more effective when applied at which times?

At least 30 minutes before exposure to the sun

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication were being applied to which body area?

Axilla

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

Culture of the lesion

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

Elevated hematocrit levels

The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?

Fine grayish red lines

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

Flushing

A burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?

Hyperventilation

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?

Immobilization of the affected leg

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?

Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour

Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. The nurse should take which most appropriate action?

Inform the client that this is expected

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristic?

It is highly metastatic

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action?

Move the victim to a safe area away from the snake and encourage the victim to rest.

The nurse is monitoring a child with burns during treatment for burn shock. The nurse understands that which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?

Neurological assessment

The evening nurse reviews the nursing documents in a clients chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the clients sacral area?

Partial thickness skin loss of the dermis

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?

Return of distal pulses

The clinic nurse assesses the skin of a client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder?

Silvery-white scaly patches

The clinics nurse is reviewing the HCP prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?

The child is 18 months old

The nurse manager is planning the clinical assignments for the day. Which staff members can be assigned to care for a client with herpes zoster? Select all that apply.

The nurse who never had roseola, The nurse who never had mumps, The nurse who never had German measles.

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

Isotretinoin (Amnesteem or Claravis) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

Triglyceride level

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial thickness burns of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

Urine output

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should 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 with severe acne is seen in the client and the HCP prescribes isotretinoin (Amnesteem or Claravis). The nurse reviews the clients medication record and would contact the HCP if the client is taking which medication?

Vitamin A

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?

Wearing gloves and a gown only when giving direct care to the client

The school nurse is conducting pediculosis capitis (head lice) assessments. Which finding indicates a child has a "positive" head check?

White sacs attached to the hair shafts in the occipital area