Integumentary Saunders

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%

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?

2

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

1

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.

3,4,5

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 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 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?

palm of hands

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."

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."

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.

3,4,5

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."

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 is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse would expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply.

-Lesion has a waxy border -Pearly papule, with a central crater

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.

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?

1

TThe nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath?

1

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.

1,2,4

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

1.A client who is underweight 3.A client diagnosed with heart failure 4.A client diagnosed with spinal cord injury

Using the rule of nines, calculate the burn percentage for the client. Which matches your calculations? Refer to the figure; the burned area is the darkly shaded area. Refer to figure.

19

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

2

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?

2

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.

2,3

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.

2.Clean with mild soap and water. 3.Encourage adequate nutritional intake. 5.Apply a dressing that allows oxygen to pass through.

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.

2.Inflammatory or (lag) phase 5.Maturation or (remodeling) phase 6.Proliferative or (connective tissue repair) phase

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.

2.Nails for shape, contour, color, thickness and cleanliness 3.Skin for color, integrity, scars, lesions, and signs of breakdown 4.Facial and body hair for distribution, color, quantity and hygiene 5.Skin temperature, texture, moisture, thickness, turgor, and mobility

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

3

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

3

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?

3

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?

3

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the 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, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.

36 %

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?

4

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?

4

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

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

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?

Chicken breast, broccoli, strawberries, milk

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

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Elevation above the level of the heart

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 is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

Positive culture results

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding would the nurse note if this disorder is present?

Silvery-white scaly lesions

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.

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

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

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.

2,3,4,5,6

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.

2,3,5

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.

4,5

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

The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client?

2.Administer an opioid analgesic last taken 6 hours ago.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply.

3,5

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?

4

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?

4

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?

4