Integumentary Disorders

A nurse is providing education to the family of a client scheduled for discharge. The client, who has severe cognitive impairments, is a recent quadriplegic. The family has questions about the need to perform range-of-motion of exercises with the client. What information should the teaching session include? Select all that apply. "Use sheepskin pads in the bed and wheelchair." "Adequate intake of carbohydrates is essential for skin health." "Friction and shear increase a paralyzed client's risk of pressure ulcers." "Positioning the client at 90 degrees from the head of the bed is most therapeutic." "You need to perform range-of-motion exercises only when the client asks you to do so."

"Use sheepskin pads in the bed and wheelchair." "Friction and shear increase a paralyzed client's risk of pressure ulcers."

In a client who has been burned, which medication should the nurse expect to use to prevent infection? gamma benzene hexachloride diazepam mafenide meperidine

mafenide

A client received burns to the entire back and left arm. Using the Rule of Nines, the nurse can calculate that the client has sustained burns on what percentage of the body? 9% 18% 27% 36%

27%

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 18% 27% 30% 36%

36%

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

36%

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at an adult child's home with six other people. During the client's visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is "All family members need to be treated." "If someone develops symptoms, tell them to see a physician right away." "Just be careful not to share linens and towels with family members." "After you're treated, family members won't be at risk for contracting scabies."

"All family members need to be treated."

A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure? "Minimize sun exposure from 10 a.m. to noon, when the sun is strongest." "Use a sunscreen with a sun protection factor of 6 or higher." "Apply sunscreen even on overcast days." "When at the beach, sit in the shade to prevent sunburn."

"Apply sunscreen even on overcast days."

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding? "I will limit my intake of red meat to once a week." "I'll make sure that I keep the site covered at all times." "Increase in redness of the ulcer means better blood flow." "I'll eat plenty of fruits and vegetables."

"I'll eat plenty of fruits and vegetables."

A client is receiving fluid replacement with lactated Ringer's solution after 40% of the body was burned 10 hours ago. The assessment reveals a temperature of 97.1°F (36.2°C), heart rate of 122 bpm, blood pressure of 84/42 mm Hg, central venous pressure (CVP) of 2 mm Hg, and urine output of 25 mL for the last 2 hours. The intravenous (IV) rate is currently at 375 mL per hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse should request which prescription from the health care provider? furosemide fresh frozen plasma IV rate increase dextrose 5%

IV rate increase

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next? Apply a wet to moist dressing, being careful to pack just the wound bed. Consult with a wound-ostomy-continence nurse specialist. Reposition the client off the reddened skin and reassess in a few hours. Complete and document a Braden skin breakdown risk score for the client.

Reposition the client off the reddened skin and reassess in a few hours.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply. Pain medication has been administered orally and was effective. This is a severe burn and nerve endings have been destroyed. This is a superficial burn, so no pain is present. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary.

This is a severe burn and nerve endings have been destroyed. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary.

Which information should the nurse include when providing discharge instructions to a client with psoriasis? Avoid applying creams after bathing. Trim fingernails regularly. Scrub vigorously when bathing to remove scales on skin. Use a washcloth when bathing.

Trim fingernails regularly.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may dislodge the autografts. increase edema in the arms. increase the amount of scarring. decrease circulation to the fingers.

dislodge the autografts.

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects squamous cell carcinoma. actinic keratoses. melanoma. basal cell carcinoma.

melanoma.

The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore? nutritional status circulatory status mobility status orientation status

mobility status

The nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client's medical record, the nurse would suspect which medication to be a probable cause of this disorder? levothyroxine phenytoin furosemide morphine sulfate

phenytoin

A nurse is performing an admission assessment on a client entering a long-term care facility. The nurse notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? stage I pressure injury stage II pressure injury stage III pressure injury stage IV pressure injury

stage II pressure injury

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate? body weight body temperature urine output urine specific gravity

urine output

An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action? Elevate the extremity above the level of the heart. Apply pressure to the radial artery of that extremity to decrease bleeding. Apply direct pressure to the finger with a clean, dry cloth. Apply a tourniquet at the biceps of the affected limb.

Apply direct pressure to the finger with a clean, dry cloth.

The nurse is caring for an immune-compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems? Avoid sharing combs and brushes. Wash hair with a dandruff-preventing shampoo. Keep hair length short and well trimmed. Allow hair to air dry after shampooing.

Avoid sharing combs and brushes.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse take? Offer the client reassurance that the complication is common and treatable. Cover the area with sterile gauze that is moistened with sterile saline solution. Irrigate the area with warmed sterile saline and apply a sterile, dry dressing. Position the client supine with the legs extended and the head of bed at 30 degrees.

Cover the area with sterile gauze that is moistened with sterile saline solution.

A client has several patches of vesicles over both arms. Which care should the nurse provide to this client? Cover the draining areas with sterile gauze. Prepare for phototherapy treatment. Apply warm soaks to the areas every 4 hours. Instruct on the application of an antiparasitic agent.

Cover the draining areas with sterile gauze.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Turn and reposition the client every 4 hours. Massage lotion over bony prominences when turning. Develop a written, individual turning schedule. Use two people when sliding the client up in bed.

Develop a written, individual turning schedule.

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assistant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first? Prepare an incident report. Prepare a disciplinary warning for the nursing assistant. Document the findings. Contact the shift supervisor.

Document the findings.

A high school student is brought to the nurse by the chemistry instructor after a classmate accidentally spilled a toxic chemical on the student's hands. Which action should the school nurse prioritize in this situation? Run water at low pressure over the hands to remove the chemical. Have the client soak their hands in a basin of warm water. Use cold water to remove the chemical from the hands. Use a neutralizing agent to decrease the effects of the chemical

Run water at low pressure over the hands to remove the chemical.

During initial rounds, a nurse notes that a norepinephrine infusion has extravasated into the forearm of a client. After stopping the infusion, the nurse follows standing orders and prepares to administer phentolamine. Which action by the nurse is appropriate when administering this drug? Inject subcutaneously in a circular fashion around the extravasation site. Massage topically in a circular fashion around the extravasation site. Dilute in saline and administer intravenously. Mix the oral form with soda or juice and have the client drink through a straw.

Inject subcutaneously in a circular fashion around the extravasation site.

What is the primary goal of nursing care during the emergent phase after a burn injury? Replace lost fluids. Prevent infection. Control pain. Promote wound healing.

Replace lost fluids.

A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. All options must be used. Assess the drainage in the dressing. Wash hands thoroughly. Slowly remove the soiled dressing. Put on latex gloves.

Wash hands thoroughly. Put on latex gloves. Slowly remove the soiled dressing. Assess the drainage in the dressing.

Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection? size of the syringe tissue turgor length of the needle amount of subcutaneous tissue

amount of subcutaneous tissue

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? strict contact respiratory enteric

contact

Sudoriferous glands secrete which type of substance? sweat oil hormones cerumen

sweat

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. Initiate an antibiotic within 3 hours of the injury. Monitor urine output once a shift. Infuse dextrose and water at 50 mL per hour to avoid overload of the circulatory system

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias.

The nurse is preparing information for a community health fair. Which information should the nurse include to promote healthy skin? Drink an adequate amount of water. Use a water temperature of 125oF (52oC) for bathing. Apply body lotion that contains a sun protection factor of 10. Limit sun exposure to 30 minutes in the afternoon.

Drink an adequate amount of water.

The nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do? Instruct the client to elevate the left leg when sitting in the chair. Encourage the client to ambulate in the halls on the unit. Massage the left leg with alcohol to stimulate circulation. Cleanse the left lower leg with perfumed liquid soap.

Instruct the client to elevate the left leg when sitting in the chair.

A client reports a firm, red nodule with a scaly crust on the back. What is the best nursing intervention? Notify the healthcare provider. Document the finding as the only action. Recommend application of lotion. Remind the client to wear sunscreen.

Notify the healthcare provider.

A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status? The LPN speaks directly to the physician. The LPN informs the RN when a wound heals. The LPN informs the RN only if a wound worsens. The RN communicates daily with the LPN about the condition of each resident.

The RN communicates daily with the LPN about the condition of each resident.

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? The dressing should keep the wound moist. The wet-to-damp dressing should be tightly packed into the wound. The dressing should be allowed to dry out before removal. A plastic sheet-type dressing should cover the wet dressing.

The dressing should keep the wound moist.

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy? client with a compromised skin graft client with chronic obstructive pulmonary disease client with Legionella-related pneumonia client with an open fracture of the femur

client with a compromised skin graft

The nurse is assessing a hospitalized older adult client for the presence of pressure injuries. The nurse notes that the client has a 1 × 1-inch (3 × 3-cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? stage I pressure injury stage II pressure injury stage III pressure injury stage IV pressure injury

stage II pressure injury

A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective? blood pressure greater than 120/80 mmHg oriented to person urine output at 0.5 mL/kg/hour heart rate 135 beats/minute

urine output at 0.5 mL/kg/hour

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? partial pressure of arterial oxygen (PaO2) value of 80 mm Hg urine output of 20 ml/hour white pulmonary secretions rectal temperature of 100.6° F (38° C)

urine output of 20 ml/hour

The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home? use of smoke detectors placement of fire extinguishers ease of initiating an emergency response system elimination of the use of candles in the home

use of smoke detectors

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education? "I should begin to use an antibacterial soap a few days before my surgical procedure." "On the morning of the surgery, I can shave my surgical area at home to save time." "On the morning of surgery, I won't use lotions or cosmetics." "I'll shower before coming to the hospital on the day of the surgery."

"On the morning of the surgery, I can shave my surgical area at home to save time."

The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include? Apply a hydrocolloidal dressing. Place the extremity in a dependent position. Cleanse the area with hydrogen peroxide, and wrap with clean gauze. Restrict protein intake, and encourage fluids.

Apply a hydrocolloidal dressing.

A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate? Use sunscreen only after going into the water. Avoid peak exposure hours from 0900 to 1300. Wear loosely woven clothing for added ventilation. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.

Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.

The nurse reviews a client's lab values and implements which intervention to help with maintenance of skin integrity? Monitor the client's oral temperature. Place the client on cardiac monitoring. Order the client a calorie controlled diet. Begin infusion of intravenous fluids.

Begin infusion of intravenous fluids.

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care? Place lamb's wool under the lift sheet. Turn the client every 2 to 4 hours. Use an egg crate mattress. Place the client on a pressure redistribution bed.

Place the client on a pressure redistribution bed.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. Reposition the client every 2 hours. Perform range-of-motion exercises. Use commercial soaps to keep the skin dry. Tuck bed covers tightly into the foot of the bed. Encourage the client to eat a well-balanced diet.

Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress note and begins planning client care based on which nursing diagnosis? deficient knowledge related to potential diagnosis of basal cell carcinoma fear related to potential diagnosis of malignant melanoma risk for impaired skin integrity related to potential squamous cell carcinoma readiness for enhanced knowledge of skin care precautions related to benign mole

fear related to potential diagnosis of malignant melanoma

A client is at risk for developing a pressure injury. The first warning of an impending pressure injury is when the nurse applies pressure and observes which skin color when pressure is released? bluish reddish whitish yellowish

reddish

While caring for a client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for which finding? paralytic ileus gastric distention hiatal hernia gastrointestinal ulceration

gastrointestinal ulceration

A school-age client is experiencing severe itching in both hands that is worse at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. Which nursing diagnosis should the nurse use to plan care for this client? acute pain impaired skin integrity sleep deprivation risk for infection

impaired skin integrity

The nurse is working as charge on a medical-surgical unit and is working with a graduate nurse who has been on orientation for the past 4 weeks. Which client should the charge nurse assign to the new nurse? a client who needs teaching before a biopsy of a facial lesion a client who requires a dressing change of a pressure injury a client who needs discharge instructions after a skin graft a client who was just admitted with periorbital cellulitis

a client who requires a dressing change of a pressure injury

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? a urine output consistently above 40 ml/hour (40 mL/hour) a weight gain of 4 lb (2 kg) in 24 hours body temperature readings all within normal limits an electrocardiogram (ECG) showing no arrhythmias

a urine output consistently above 40 ml/hour (40 mL/hour)

A male client with hair on the chest is prescribed dexamethasone cream for a rash over the midthoracic region. Which approach should the nurse use to apply this topical medication? with a circular motion, to enhance absorption with an upward motion, to increase blood supply to the affected area in long, even, outward, and downward strokes in the direction of hair growth in long, even, outward, and upward strokes in the direction opposite hair growth

in long, even, outward, and downward strokes in the direction of hair growth

A client is to receive biologic burn grafts. What should the nurse tell the client's family is the advantage of using biologic burn grafts such as porcine (pigskin) grafts? Porcine grafts: encourage formation of tough skin. promote the growth of epithelial tissue. provide for permanent wound closure. facilitate the development of subcutaneous tissue.

promote the growth of epithelial tissue.

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority? replacing fluid and electrolytes covering the wounds with antibacterial dressings supporting the lower extremities in normal anatomic position evaluating the presence and quality of pulses distal to the burn injury

replacing fluid and electrolytes

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used? specialty mattress ring or donut gel flotation pad water bed

ring or donut

A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure injuries on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. Over the past few weeks, the client has been spending less time in the wheelchair. During the appointment, the nurse notes that the client is not using a cushion and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen? Ask the client to explain the treatment regimen. Call the family contact to ask about how the treatments have been done. Explain pressure injury development in terms that the client understands. Provide a brief anatomy and physiology lesson on how pressure injuries develop.

Ask the client to explain the treatment regimen.

A client returns from the operating room with a partial-thickness skin graft on the left arm. The donor tissue was taken from their left hip. In planning the client's immediate postoperative care, which interventions would the nurse include? Select all that apply. Change the dressing on the graft site every 8 hours. Elevate the left arm and provide complete rest of the grafted area. Administer pain medication every 4 hours as ordered for pain in the donor site. Perform range-of-motion (ROM) exercises to the left arm every 4 hours. Monitor the pulse in the left arm every 4 hours. Encourage the client to ambulate as desired on the first postoperative day.

Elevate the left arm and provide complete rest of the grafted area. Administer pain medication every 4 hours as ordered for pain in the donor site. Monitor the pulse in the left arm every 4 hours.

During the emergency (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? serum creatinine level of 2.5 mg/dL (221 µmol/L) little fluctuation in daily weight hourly urine output of 60 mL serum albumin level of 3.8 g/dL (38 g/L)

serum creatinine level of 2.5 mg/dL (221 µmol/L)

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? pulse rate of 112 bpm blood pressure of 94/64 mm Hg urine output of 30 mL per hour serum sodium level of 136 mEq/L (136 mmol/L)

urine output of 30 mL per hour

A nurse assesses a client who was admitted to the emergency department with a thermal burn to the right arm and upper chest. Which assessment requires immediate action? thirst singed hair on the upper chest hoarse voice bright red skin with small blisters on the right arm

hoarse voice

The nurse is reviewing the lab reports for a client who has burns on 40% of their body. Lab values indicating which problem are of greatest concern during the first 3 days of burn care? hypernatremia hyponatremia metabolic alkalosis hyperkalemia

hyperkalemia

A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception? Human immunodeficiency syndrome (HIV) is a possible risk factor. Hepatitis B is a possible risk factor. Tattoos are easily removed with laser surgery. Allergic response to pigments is a possible risk factor.

Tattoos are easily removed with laser surgery.

A client from a nursing home arrives at an acute care facility for treatment related to complications of chronic obstructive pulmonary disease. A nurse performing the admission assessment notes the presence of a large stage III pressure injury. The client's child asks if the hospital can "treat the sore." What is the nurse's best initial response? "I am not sure what you know about this type of skin problem, but I will try to stop it from getting worse." "It is unfortunate that the client has this sore. We will have to file a report about it." "As you can see, the wound is fairly deep and may need debridement." "We will collaborate with the provider to obtain an order for the wound care nurse to see the client."

"We will collaborate with the provider to obtain an order for the wound care nurse to see the client."

A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering I.V. fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse? Assess patency of the I.V. site every 4 hours. Carefully monitor the client for signs of fluid overload. Confirm that a large-bore catheter was inserted. Ensure a fluid volume sufficient to prevent shock.

Ensure a fluid volume sufficient to prevent shock.

An autograft is taken from a client's left leg. The nurse should care for the donor site by taking which action? covering it with an occlusive dry dressing keeping the site clean and dry applying a pressure dressing wrapping the extremity with an elastic bandage

keeping the site clean and dry

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? albumin dextrose 5% in water (D5W) lactated Ringer's solution normal saline solution with 20 mEq of potassium per 1,000 ml

lactated Ringer's solution