Integumentary NCLEX Review

A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. During the past few weeks, the client has been spending less time in the wheelchair and, when in the wheelchair, uses a cushion. 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? A. Ask the client to explain the treatment regimen. B. Call the family contact to ask about how the treatments have been done. C. Explain pressure ulcer development in terms that the client understands. D. Provide a brief anatomy and physiology lesson on how pressure ulcers develop.

A. Ask the client to explain the treatment regimen. It is important to first assess what the client knows about the treatment regimen. The nurse should then provide further teaching in terms that the client understands; this should be done after an assessment of what the client knows. The client should be using a cushion to sit on to reduce pressure, and the wound should be kept moist to promote healing. Care decisions can be made by the client; however, the nurse must ensure that the client has available knowledge to make an informed decision. Calling the family may be an option, but the client should be the first one to explore what is known about the treatment. Providing an in-depth explanation about the anatomy and physiology of pressure ulcer development is not necessary.

The nurse is caring for an older adult client who experienced burns to the hands and forearms from a grease fire. The plan is to discharge the client home with outpatient rehabilitation services. Which action(s) should the nurse include in preparing the client for discharge? Select all that apply. A. Recommend an occupational therapy referral for a kitchen assessment. B. Assess the client's knowledge of fire safety precautions for the home. C. Recommend the client have a home safety assessment completed. D. Advise the client to refrain from cooking with grease or oil once home. E. Advise the client to wear compression sleeves to protect skin when cooking.

A. B. C. The nurse needs to ensure the client can safely be discharged into the home. This includes assessing the client's knowledge of fire safety and recommending a safety assessment of the client's home be conducted. A kitchen assessment is a functional assessment that can be performed as part of occupational therapy to determine the client's executive functioning abilities and safety in a kitchen setting. The information from this assessment can help direct the level of support the client will need in the home. The nurse should not tell the client not to cook with grease or oil as this is not a practical safety precaution. If the client is unable to safely cook, the risk will apply to all types of cooking, including methods not using grease or oil. Compression sleeves that are prescribed for burn treatment are not intended to protect the skin from splashes or spills while cooking. Compression garments are used once burns are sufficiently healed to reduce scar formation and are often prescribed to be worn 23 hours a day.

The nurse is performing diabetic education with an older adult client and notes a 1-cm (0.4 inches) black raised lesion with a crusty appearance on the client's cheek. The client says it has been present for several months, has gotten larger, and never fully heals but is not painful. Which response is the nurse's priority? A. Ask what remedies the client has used on the lesion such as over-the-counter topical antibiotics or steroids. B. Recommend the client speak to a health care provider about getting a biopsy of the lesion as soon as possible. C. Ask the client about recent exposure to allergens or irritants that may have contributed to the lesion forming. D. Teach the client how to clean the lesion due to the increased risk for infection in clients with diabetes.

B. Recommend the client speak to a health care provider about getting a biopsy of the lesion as soon as possible. A chronic lesion on the face as described should make the nurse suspect skin cancer, so the priority is to encourage the client to self-advocate and request a biopsy. Using the ABCDE rule of melanoma screening, the nurse focuses on changes in the size, shape, color, and texture of an existing mole or the appearance of a new lesion. Asymmetry, an irregular border, color that varies, a diameter greater than 6 mm (0.25 in), and evolution of the appearance of the lesion support suspicion of melanoma. Although infection is possible, it is not the priority concern. The appearance does not support an allergic reaction or contact dermatitis, and the use of over-the-counter products is not especially relevant given the duration of the lesion's presence.

A 1-year-old child is brought by a parent to the clinic with a rash on the abdomen and is diagnosed with scabies. What first line medication for the treatment of scabies does the nurse anticipate reinforcing education about? A. ivermectin orally B. lindane lotion 1% C. crotamiton lotion 10% D. permethrin cream 5%

D. permethrin cream 5% Permethrin cream 5% is an FDA approved drug that is safe for the use in children over the age of 2 months for the treatment of scabies and kills the mite and the eggs. Crotamiton lotion is safe for adults, but not FDA approved for use in children and is not first line treatment. Lindane lotion is not considered first line treatment for scabies. Ivermectin used orally is not FDA approved for use in the treatment of scabies and its safety is not established in the use of children.

The nurse is gathering data from a client with an abdominal incision and suspects there is a potential for delayed wound healing. Which observation most likely supports this finding? A. purulent drainage on a soiled wound dressing B. sanguineous drainage in a wound-collection drainage bag C. sutures dry and intact D. wound edges in close approximation

A. purulent drainage on a soiled wound dressing Purulent drainage contains white blood cells, which fight infection. The sutures from a wound that is draining purulent secretions would pull away with an infection. Wound edges can't approximate in an infected wound. Sanguineous drainage indicates bleeding, not infection.

To treat a client with acne vulgaris, the physician is most likely to prescribe which topical agent for nightly application? A. Fluorouracil (5-fluorouracil) B. Tretinoin (retinoic acid) C. Zinc oxide gelatin D. Minoxidil

B. Tretinoin (retinoic acid) Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil is used to promote hair growth. Zinc oxide gelatin is used for abrasions on the lower arms or legs; the affected area must be covered with a bandage for about 1 week. Fluorouracil is an antineoplastic topical agent used to treat superficial basal cell carcinoma.

A nurse is assisting with the development of a plan of care for a client diagnosed with ringworm. Which medication should the nurse anticipate discussing with this client? A. corticosteroid cream B. antifungal C. antibiotic D. no medication treatment is required.

B. antifungal Antifungals are the treatment of choice for clients diagnosed with ringworm (fungal rash). Antibiotics and corticosteroids will not treat fungal infections and will often make them worse.

A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client? A. "Wash the area with soap and water daily." B. "Apply lubricating lotion to the graft site." C. "Massage the area three times a day." D. "Cover the area when in direct sunlight."

D. "Cover the area when in direct sunlight." To avoid burning and sloughing, the client who has recently had a skin graft must protect the graft from direct sunlight. The client should avoid applying cosmetics to the graft site. The client should follow the instructions given for the grafted area (care of the site, any dressings, or other interventions); therefore, washing with soap and water and applying lotion are not appropriate instructions.

Which intervention has the highest priority when providing skin care to a bedridden client? A. Gently massaging the skin around the pressure areas B. Rubbing moisturizing lotion around the pressure areas C. Changing the bed linens frequently for an incontinent client D. Keeping the skin clean and dry without using harsh soaps

D. Keeping the skin clean and dry without using harsh soaps Keeping the skin clean is always the highest priority. The other measures are also important but only after the skin is cleaned.

A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may: A. increase edema in the arms. B. increase the amount of scarring. C. decrease circulation to the fingers. D. dislodge the autografts.

D. dislodge the autografts Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. None of the other options results from exercise.

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? A. Avoid sharing combs and brushes. B. Keep hair length short and well trimmed. C. Allow hair to air dry after shampooing. D. Wash hair with a dandruff-preventing shampoo.

A. Avoid sharing combs and brushes. Tinea capitis is a fungal infection of the scalp that occurs in hot, humid environments. Risk factors include exposure to daycare centers or pets with the infection, poor hygiene, diabetes, immune system disorders, and the sharing of combs, brushes, or hats. Washing the hair helps, but dandruff-preventing shampoo will not prevent the condition. The health problem can occur with any length of hair.

The nurse is reinforcing education to parents of an infant about burn prevention. Which instructions should be reinforced regarding burns from tap water? A. Before putting the infant in the tub, test the water with a hand. B. Supervise an infant in the bathroom, only leaving the infant for a few seconds if needed. C. Run the hot water first, then adjust the temperature with cold water. D. Set the water-heater temperature at 130° F (54.4° C) or less.

A. Before putting the infant in the tub, test the water with a hand. Instruct the parents to fill the tub with water first, then test all of the water in the tub with a hand for hot spots. The cold water should be run first and then adjusted with hot water. Water heaters should be set at 120° F (48.9° C). Never leave a infant alone in the bathroom, even for a second.

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at the greatest risk for skin breakdown? A. incontinence and right-sided hemiparesis B. demonstration of neglect of left side of body C. unwillingness to ask for assistance D. inability to express need for repositioning

A. incontinence and right-sided hemiparesis Incontinence and right-sided hemiparesis place the client at risk for skin breakdown. Inability to express needs would require nurses to communicate more clearly with the client. Neglect can create a problem, but does not place the patient at the highest risk.

The nurse is collecting data from several clients at the clinic. Which client does the nurse determine is most likely receive the Zostavax vaccine for the prevention of shingles? A. 38-year-old pregnant client that has gestational diabetes B. 62-year-old client that had a mild case of shingles 4 years previously C. 6-month-old infant having surgery to repair a cleft lip D. 24-year old client that will be traveling out of the country

B. 62-year-old client that had a mild case of shingles 4 years previously The Centers for Disease Control and Prevention (CDC) recommends that anyone 60 years of age or older receive the shingles vaccine, even if they have had a previous case of shingles to prevent reoccurrence of the virus. The other clients are not at greater risk for the development of shingles.

A home health nurse is evaluating a client's risk of contracting herpes zoster. Which client is most at risk for developing herpes zoster? A. 21-year-old client with a heat rash and psoriasis B. 76-year-old client taking immunosuppressant medication C. 42-year-old client with a previous myocardial infarction D. 5-year-old client recently diagnosed with strep throat

B. 76-year-old client taking immunosuppressant medication Herpes zoster (shingles) is an acute inflammation caused by infection with the herpes virus varicella-zoster (chickenpox virus). It is most common in adults age 65 years and older. Others at risk include clients with decreased immunity (transplants, HIV/AIDS, immunosuppressant medications, etc.), chronic lung or kidney disease, or clients who had chickenpox at a younger age.

The nurse observes a ring-shaped rash that has a red raised border and a clearer center on the upper arm. The client asks the nurse what kind of rash it is. What is the best response by the nurse? A. tinea capitis B. tinea corporis C. tinea cruris D. tinea pedis

B. tinea corporis Tinea corporis describes fungal infections of the body. Tinea capitis describes fungal infections of the scalp. Tinea cruris is used to describe fungal infections of the inner thigh and inguinal creases. Tinea pedis is the term for fungal infections of the foot.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? A. Ulcer B. Crust C. Scale D. Scar

C. Scale A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't accompany psoriasis.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy? A. Compromised skin graft B. Pneumonia C. Malignant tumor D. Hyperthermia

A. Compromised skin graft A compromised skin graft could benefit from hyperbaric oxygen therapy, because increasing oxygenation at a wound site promotes healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect? A. Ring or donut B. Air-fluidized bed C. Water bed D. Gel flotation pad

A. Ring or donut Rings or donuts aren't to be used because they restrict circulation. An air- fluidized bed contains beads that move under an airflow to support the client, thus reducing shearing force and friction. Gel pads redistribute with the client's weight. The water bed also distributes pressure over the entire surface.

The nurse is collecting data on a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem? A. Urine output of 20 ml/hour B. Rectal temperature of 100.6° F (38° C) C. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg D. White pulmonary secretions

A. Urine output of 20 ml/hour A urine output of less than 30 ml/hour in a client with burns indicates deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client's rectal temperature isn't significantly elevated and probably results from the deficient fluid volume.

A nurse is caring for a 12-year-old child with a diagnosis of eczema. Which nursing interventions are appropriate for a child with eczema? A. Administer antifungals as ordered. B. Administer tepid baths, and use moisturizers immediately after the bath. C. Administer hot baths, and pat dry or air-dry the affected areas. D. Administer antibiotics as prescribed.

B. Administer tepid baths, and use moisturizers immediately after the bath. Tepid baths and moisturizers are indicated for eczema to keep the infected areas clean and to minimize itching. Antibiotics are given only when superimposed infection occurs. Antifungals are not usually administered in the treatment of eczema. Hot baths can exacerbate the condition and increase itching.

A client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? A. "Apply one applicator of terconazole intravaginally at bedtime for 7 days." B. "Apply sulconazole nitrate twice daily by massaging it gently into the lesions." C. "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." D. "Apply one applicator of tioconazole intravaginally at bedtime for 7 days."

C. "Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days." A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times per day for 7 days. Terconazole and tioconazole are used to treat vulvovaginal candidiasis. Sulconazole nitrate is used to treat tinea versicolor.

The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce? A. Take the drug with milk and milk products. B. Take the drug with or without meals. C. Take the drug 1 hour before or 2 hours after meals with large amounts of water. D. Take the drug on an empty stomach with small amounts of water.

C. Take the drug 1 hour before or 2 hours after meals with large amounts of water. Tetracycline must be taken on an empty stomach to increase absorption and with ample water to avoid esophageal irritation. Milk products impede absorption.

Which nursing diagnosis would be the priority for a client who has just been admitted to the hospital with burns? A. body image disturbance B. impaired social interaction C. impaired skin integrity D. risk for altered nutrition

C. impaired skin integrity Impaired skin integrity is the priority in the situation of the burned client because of the fluid and electrolyte loss and a high risk for infection. While body image, social interaction, and altered nutrition are all concerns, they are not necessarily potentially life threatening, unlike the impaired skin integrity.

A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize? A. whole-grain products B. fruits and vegetables C. lean meats and low-fat milk D. legumes and cheese

C. lean meats and low-fat milk Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein but also fat, which should be limited to 30% or less of caloric intake. Whole-grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

Discharge instructions for a child with atopic dermatitis include keeping the fingernails cut short. Which rationale should the nurse give for this intervention? A. to prevent the child from causing a corneal abrasion B. to prevent the spread of the disorder C. to reduce breaks in skin from scratching that may lead to secondary bacterial infections D. to prevent infection of the nail bed

C. to reduce breaks in skin from scratching that may lead to secondary bacterial infections Keeping fingernails cut short will prevent breaks in the skin when a child scratches. Cutting fingernails too short or cutting the skin around the nail can increase the risk of infection. Atopic dermatitis can be found in various areas of the skin, but is not spread from one area to another. Keeping fingernails short is a good way to reduce corneal abrasions, but does not apply to atopic dermatitis.

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should: A. place the client on enteric precautions. B. apply a topical corticosteroid to the lesions. C. wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious. D. remove any observable mites.

C. wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious. To prevent the spread of scabies in other hospitalized clients, the nurse should wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Removing observable mites won't prevent infection in other clients. Treatment includes thoroughly washing the area and applying a scabicide. A topical corticosteroid may be applied after the scabicide is washed off, usually 12 to 24 hours later, to reduce itching, but it doesn't prevent the spread of scabies. This client doesn't require enteric precautions because the mites aren't found on feces.

A nurse in the emergency department is caring for a client with burns on the upper torso. What is the priority nursing action? A. Monitor respiratory status. B. Administer an IV antibiotic. C. Have the client rate the pain. D. Cover the burns with an occlusive dressing.

A. Monitor respiratory status. During the initial assessment of a client with burns of the torso or face, the nurse must first look for evidence of inhalation injury. Once oxygen saturation and respiratory status are determined, pain is evaluated. Prevention of infection with IV antibiotics and treatment of the burn with the appropriate dressing are secondary to airway issues.

The nurse obtains data from a client on bed rest reporting an itchy rash with an erythematous, slightly edematous areas on the back, posterior lower legs, and posterior elbows. What education should be reinforced regarding contact dermatitis? Select all that apply. A. The disorder is contagious. B. The skin is infected wherever the rash has developed. C. Oatmeal baths are a good treatment for a rash of this type because of the large area involved. D. This is an allergic reaction. E. Washing with antibacterial soap will help the rash. F. Based on the location, it is likely that detergents in the bed linens caused the rash.

B. C. E. Contact dermatitis is classified as a reaction to an allergen and can appear when skin remains in contact with an irritant for an extended time, especially if the skin moist (e.g., from perspiring). It is a hypersensitivity reaction but usually requires extended contact. This client has a presentation often seen when clients remain in bed and perspire on detergent-cleansed bed linens or gowns. The rash is not contagious or infectious, although areas may become exudative and crusted. Treatment varies according to the intensity of the skin reaction and other factors, but oatmeal (Aveeno) baths are frequently prescribed. Antibacterial soap will not help.

While assessing a client, a nurse notes a stage I pressure ulcer on the client's left hip. How should the nurse report this finding? A. Report the finding to a nurse-manager immediately. B. Document the size, extent, and location of the wound in the client's medical record. C. Inform the client's family of the pressure ulcer. D. Notify a physician immediately.

B. Document the size, extent, and location of the wound in the client's medical record. The nurse should properly document her finding in the client's medical record and devise a plan to prevent the pressure ulcer from worsening. It isn't necessary to notify the client's family at this time. The physician and nurse-manager should be alerted about the pressure ulcer, but they don't need to be notified immediately.

The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is most important for the nurse to tell the client? A. Avoid thermal burns. B. Avoid immunosuppression. C. Avoid exposure to sun. D. Avoid exposure to radiation.

C. Avoid exposure to sun. The sun is the best known and most common cause of basal cell epithelioma. Thermal burns, immunosuppression, and radiation are less common causes.

The nurse notes that several assigned clients are developing signs of pressure injuries. Which action should the nurse take first? A. Plan for every client to be repositioned every 2 hours while awake. B. Speak to the nurse who cared for the clients the previous day. C. Formally report the findings related to the ulcers to the nurse manager. D. Investigate the potential causes for the clients' pressure injuries.

C. Formally report the findings related to the ulcers to the nurse manager. When a quality of care issue is identified, it should be reported through the chain of command. Informing the nurse manager of the finding is the first action to take. The nurse manager would initiate an investigation, including a review of medical records, to determine the potential cause for the pressure injuries. While the nurse should plan and implement actions to reduce the risk of further pressure injury development, this would not be the first action to take. Pressure ulcers take time to develop, and the nurse should not assume the care delivered the prior day is the primary issue.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Impaired skin integrity related to disease process B. Impaired physical mobility related to the disease process C. Ineffective airway clearance related to edema of the respiratory passages D. Risk for infection related to breaks in the skin

C. Ineffective airway clearance related to edema of the respiratory passages When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process is not appropriate because burns are not a disease. Impaired skin integrity related to disease process is not the priority and Risk for infection related to breaks in the skin may be appropriate, but they do not command a higher priority than Ineffective airway clearance because they do not reflect immediately life-threatening problems.

A parent brought a child into the clinic stating the child has head lice and was sent home from school. Which instructions would the nurse reinforce for the parents about the treatment of head lice? A. Any items that came into contact with the child should be thrown away. B. If treated with a shampoo, combing to remove eggs is not necessary. C. The treatment should be repeated in 7 to 12 days. D. Treatment should be repeated every day for 1 week.

C. The treatment should be repeated in 7 to 12 days. Treatment for head lice should be repeated in 7 to 12 days to ensure that all eggs are killed. Combing the hair thoroughly is necessary to remove the lice eggs. Lice do not survive on inanimate objects and do not have to be thrown out. The parents may want to replace combs and brushes. Sheets and towels should be washed in hot water, but do not need to be disposed of.