Integumentary System, integumentary, NURS 3107 - Exam 4 - EAQs: Integumentary Assessment, Ch. 24 NCLEX Practice, DavisEdge Quiz: Nursing Care of Patients with Skin Disorders

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."

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 should the nurse give to the client's question?

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

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

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should 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 health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection?

Red, shiny skin around the nail bed

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 should document the pressure injury as which category?

Stage II

The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should 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

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 assessing a white patient's skin color and notices cyanosis. Where on the patient's body would the nurse most likely see this cyanosis? Lips Legs Wrists Sclera

Lips On light-skinned individuals, cyanosis, or grayish blue tone, initially appears in lips, nail beds, earlobes, mucous membranes, palms of the hands, and soles of the feet. It is not as likely on the legs, wrists, or sclera.

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 reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? 1. "I need to wear sunscreen when participating in outdoor activities." 2. "I need to avoid sun exposure before 10:00 AM and after 4:00 PM." 3. "I need to wear a hat, opaque clothing, and sun glasses when in the sun." 4. "I need to examine my body monthly for any le sions that may be suspicious."

2. "I need to avoid sun exposure before 10:00 am and after 4:00 pm."

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

Which patient would be more likely to have the highest risk of developing malignant melanoma? A. A fair-skinned woman who uses a tanning booth regularly B. An African American patient with a family history of cancer C. An adult who required phototherapy as an infant for the treatment of hyperbilirubinemia D. A Hispanic male with a history of psoriasis and eczema that responded poorly to treatment

A. A fair-skinned woman who uses a tanning booth regularly Risk factors for malignant melanoma include a fair complexion and exposure to ultraviolet light. Psoriasis, eczema, short-duration phototherapy, and a family history of other cancers are less likely to be linked to malignant melanoma.

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply:* A. Acute kidney injury B. Dysrhythmia C. Iceberg effect D. Hypernatremia E. Bone fractures F. Fluid volume overload

A. Acute kidney injury B. Dysrhythmia C. Iceberg effect E. Bone fractures Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart's electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved.

Which nursing intervention would be most helpful in managing a patient newly admitted with cellulitis of the right foot? A. Applying warm, moist heat B. Wrapping the foot snugly in blankets C. Limiting ambulation to three times daily D. Keeping the foot at or below heart level

A. Applying warm, moist heat The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris. Immobilization and elevation is also used. Snug blankets would not be helpful and could decrease circulation to this sensitive tissue.

The patient has been diagnosed with tinea unguium (Onychomycosis) under her nails. She does not like the oral antifungal medication. What is the best alternate treatment the nurse should describe for her? A. Nail avulsion B. Antifungal cream C. Thinning of fingernails D. Soaking nails in salt water

A. Nail avulsion Nail avulsion is the best alternate treatment to the oral antifungal medication. Antifungal cream is minimally effective. Thinning fingernails is not needed if the tinea unguium is under her toenails. Soaking the nails will not be helpful.

The patient with a stage IV pressure ulcer on the coccyx will need a skin graft to close the wound. What postoperative care should the nurse expect to use to facilitate healing? A. No straining of the grafted site B. The wound will be exposed to air. C. Soft tissue expansion will be done daily. D. The pressure dressing will not be removed.

A. No straining of the grafted site Straining or stretching of the grafted site must be avoided to allow the graft to be vascularized and fixed to the new site for healing. The wound may or may not be exposed to air depending on the type of graft, and the donor site will be covered with a protective dressing to prevent further damage. Soft tissue expansion and pressure dressings will not be used after this wound's skin graft.

The nurse would assess a patient admitted with cellulitis for what localized manifestation? A. Pain B. Fever C. Chills D. Malaise

A. Pain Pain, redness, heat, and swelling are all localized manifestation of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection.

In a patient admitted with cellulitis of the left foot, which clinical manifestation would the nurse expect to find on assessment of the left foot? A. Redness and swelling B. Pallor and poor turgor C. Cyanosis and coolness D. Edema and brown skin discoloration

A. Redness and swelling Cellulitis is a diffuse, acute inflammation of the skin. It is characterized by redness, swelling, heat, and tenderness in the affected area. These changes accompany the processes of inflammation and infection.

The nurse should teach a patient who is taking which drug to avoid prolonged sun exposure? A. Tetracycline B. Ipratropium C. Morphine sulfate D. Oral contraceptives

A. Tetracycline Several antibiotics, including tetracycline, may cause photosensitivity. This is not the case with ipratropium, morphine, or oral contraceptives.

The nurse should recognize which patient as likely to have the poorest prognosis? A. A 60-year-old diagnosed with nodular ulcerative basal cell carcinoma B. A 59-year-old man who is being treated for stage IV malignant melanoma C. A 70-year-old woman who has been diagnosed with late squamous cell carcinoma D. A 51-year-old woman whose biopsy has revealed superficial squamous cell carcinoma

B. A 59-year-old man who is being treated for stage IV malignant melanoma Late detection of malignant melanoma is associated with a poor outcome. Basal cell carcinomas often have very effective treatment success rates. Although late squamous cell carcinoma (SCC) has worse outcomes than superficial SCC, these are both exceeded in mortality by late-stage malignant melanoma.

Which assessment finding of a 70-year-old male patient's skin should the nurse prioritize? A. The patient's complaint of dry skin that is frequently itchy B. The presence of an irregularly shaped mole that the patient states is new C. The presence of veins on the back of the patient's leg that are blue and tortuous D. The presence of a rash on the patient's hand and forearm to which the patient applies a corticosteroid ointment

B. The presence of an irregularly shaped mole that the patient states is new Although all of the noted assessment findings are significant, the presence of an irregular mole that is new is suggestive of a neoplasm and warrants immediate follow-up.

The patient has had rashes and alopecia. What vitamin in which foods should be encouraged as a nutritional aid to these problems? A. Vitamin A in sweet potatoes, carrots, dark leafy greens B. Vitamin B7 (biotin) in liver, cauliflower, salmon, carrots C. Vitamin C in peppers, dark leafy greens, broccoli, and kiwi D. Vitamin D in canned salmon, sardines, fortified dairy, and eggs

B. Vitamin B7 (biotin) in liver, cauliflower, salmon, carrots A deficiency of Vitamin B7 (biotin) may result in rashes and alopecia. Eating foods with biotin will help decrease these problems. Vitamins A and C are needed for wound healing. Vitamin D is needed for bone and body health.

The nurse is providing preoperative teaching for the patient having a face-lift (rhytidectomy) surgery. Which patient response indicates the patient understands the teaching? A. "I am afraid of the pain afterwards, while it is healing." B. "I can't wait to have my forehead and lip wrinkles eliminated." C. "I have some time off work so I will not look so bad when I go back." D. "Now I can be excited to go to my 50th high school reunion this week.

C. "I have some time off work so I will not look so bad when I go back." A rhytidectomy or face-lift surgery will not have immediate results and will take time to heal, so taking time off from work will allow more healing to be accomplished before returning to work. There is not much pain with most cosmetic surgeries. A rhytidectomy will not eliminate forehead lines and vertical lip wrinkles.

The patient with diabetes mellitus has peripheral vascular disease. Knowing this, for which dermatologic manifestations should the nurse expect to assess? A. Redness of exposed areas of the skin on the hand, foot, face, or neck and infected dermatitis B. Leathery, brownish skin on lower leg, pruritis, concave lesions with edema, scar tissue with healing C. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing D. Atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck

C. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing The patient with diabetes mellitus and peripheral vascular disease is likely to have loss of peripheral hair, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing. The patient with a nicotinic acid (niacin) deficiency manifests redness of exposed areas of the skin on the hand or foot, face, or neck and infected dermatitis. The patient with venous ulcers will have leathery, brownish skin on the lower leg, pruritus, concave lesions with edema, and scar tissue with healing. The patient with glucocorticoid excess (Cushing syndrome) may have atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck, clavicles, abdomen, and face.

A 56-year-old white patient presents with a flat, dry, scaly area on her eyebrows that is treated with a chemical peel. What should the nurse include in the discharge teaching? A. Metastasis of this type of cancer is rare. B. The patient has an increased risk for melanoma. C. Recurrence of the premalignant lesion is possible. D. Untreated lesions may metastasize to regional lymph nodes.

C. Recurrence of the premalignant lesion is possible. The flat or elevated dry scaly area is actinic keratosis from sun damage and is a premalignant skin lesion common in older whites with possible recurrence even with adequate treatment. Metastasis of basal cell carcinoma is rare; it is a small slowly enlarging papule. There is an increased risk for melanoma with atypical or dysplastic nevi. With squamous cell carcinoma, untreated lesions may metastasize to regional lymph nodes and distant organs, but it has a high cure rate with early detection and treatment.

The _____________ layer of the skin helps regulate our body temperature.* A. Epidermis B. Dermis C. Hypodermis D. Fascia

C.Hypodermis. This layer contains fatty tissue, veins, arteries, nerves and helps insulate the muscles, bones, organs and helps REGULATE our body temperature.

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

Chicken breast, broccoli, strawberries, milk

To determine the presence of petechiae in a patient with dark skin, the nurse should assess what part of the body? Nail Face Buttocks Conjunctiva

Conjunctiva Petechiae are small pinpoint lesions. The nurse should check for these lesions in the conjunctiva of the eye or buccal mucosa in dark-skinned people. Unlike fair-skinned people, these lesions are difficult to see on the nail, face, or buttocks of dark-skinned people.

A 26-year-old patient is looking down as she tells the nurse that she is afraid to use the treatment recommended for her psoriasis because her mother had a lot of problems with all the creams she used to try to treat her psoriasis. How should the nurse respond to the patient? A. "You will only know if you try it and see." B. "You may need to get counseling to help you cope." C. "No treatment is medically necessary, but it can be removed." D. "Topical, light therapy, and systemic medications are now available."

D. "Topical, light therapy, and systemic medications are now available." Treatment of psoriasis usually involves a combination of strategies including topical treatments, phototherapy, and/or systemic medications including biologic drugs. Telling her that she will only know if she tries or that she may need counseling is denying the patient's concern. Psoriasis is treated to manage the disease as the patient may have a weakened immune system and be at risk for cardiovascular disease.

What practice should the nurse teach a patient to follow when the patient is applying topical medication? A. Avoid applying medications directly on to dressings. B. Use a tongue blade whenever the patient's skin integrity allows. C. Avoid covering skin regions that have topical medication in place. D. Apply a layer of medication that is just thick enough to ensure coverage.

D. Apply a layer of medication that is just thick enough to ensure coverage. Patients should be directed to avoid applying topical medications too thickly. Medications may be applied directly on to dressings, and regions with medications may be covered. A tongue blade is not normally used for the application of a thin coat.

The nurse is teaching the residents of an independent living facility about preventing skin infections and infestations. What should be included in the teaching? A. Use cool compresses if an infection occurs. B. Oral antibiotics will be needed for any skin changes. C. Antiviral agents will be needed to prevent outbreaks. D. Inspect skin for changes when bathing with mild soap.

D. Inspect skin for changes when bathing with mild soap. Individuals living in independent living facilities are usually older, which means their skin does not need cleaning with hot water and vigorous scrubbing or as often as a younger person. Mild soap (e.g., Ivory) should be used to avoid loss of protection from neutralization of the skin's surface. The skin should be inspected for changes with bathing. Cool compresses are used with ringworm or stings for the antiinflammatory effect. Oral antibiotics are used for Lyme disease from ticks. Antiviral agents are used for viral infections but not to prevent outbreaks.

A nurse is discussing the health changes associated with aging with a group of older adults in a community clinic. One of the members of the group asks about dry skin and aging. The nurse explains that, in the elderly population, dry skin comes with aging due to what? Select all that apply. Decreased production of sebum. Decreased immunocompetence. Decreased subcutaneous fat tissue. Decreased blood supply to the skin. Decreased water content in the body.

Decreased production of sebum. Decreased water content in the body. Dry skin comes with aging because of decreased activity of the sweat and sebaceous glands. Sebum is a lipid-rich substance that prevents the skin and hair from becoming dry. Decreased water content in the skin is another important cause for drying of skin in old age. A decrease in immune functioning with aging increases the patient's susceptibility to infections. A decrease in subcutaneous fat content as a person ages causes wrinkling of skin and inelasticity of fibrous tissue of breasts and abdomen. A decreased blood supply causes a pale appearance and low temperature of the extremities.

Which data would a nurse consider least important during an assessment of skin integrity? Family history of pressure ulcers Presence of existing pressure ulcers Overall risk as indicated by a low Braden score Areas at risk for the development of pressure ulcers

Family history of pressure ulcers Family history is not an important factor in the development of pressure ulcers and general skin integrity. A patient deemed to be at risk on the basis of a validated tool such as the Braden scale and existing areas of skin breakdown requires immediate assessment and intervention.

When assessing the patient's integumentary system, which dermatologic manifestations may indicate systemic problems? Select all that apply. Pallor Jaundice Skin tags Cyanosis Cherry angiomas

Pallor Jaundice Cyanosis Pallor, jaundice, and cyanosis are dermatologic manifestations that may indicate systemic problems. Jaundice is often an indication of a liver problem. Pallor indicates anemia, and cyanosis may be due to a respiratory disorder. Skin tags and cherry angiomas are benign neoplasms related to aging.

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

Silvery-white scaly lesions

The nurse is reinforcing instructions to a client diagnosed with eczema about measures that decrease itching and moisturize the skin. Which should 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 nurse assessed the patient's skin lesions as circumscribed, with a superficial collection of serous fluid, and less than 0.5 cm in diameter. What term describes these lesions? Wheals Papules Pustules Vesicles

Vesicles Vesicles are circumscribed, with superficial collection of serous fluid, less than 0.5 cm in diameter. Examples include varicella (chickenpox), herpes zoster (shingles), and second-degree burn. Wheals are firm, edematous areas such as insect bites. Papules are solid lesions (warts). Pustules are fluid-filled lesions (acne or impetigo).

A nurse is assessing a patient with chalky, white patches on the face. The nurse learns that the patient's parent and grandparent have had similar signs. On the basis of this information, what is the most likely patient diagnosis? Keloid Vitiligo Intertrigo Hypopigmentation

Vitiligo Vitiligo is a skin condition characterized by complete loss of melanin in the affected area, which results in chalky, white patches. This condition is usually inherited. Keloid is an overgrowth of scar tissue at the site of skin injury. Intertrigo is characterized by presence of rashes in intertriginous areas, such as the axillae and the area under the breast. It is usually due to inflammation of the overlying surface of skin. Hypopigmentation also occurs due to loss of pigmentation but is not an inherited disorder. Hypopigmentation is usually due to chemical agents, nutritional factors, burns, inflammation, or infection.

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

White skin that is insensitive to touch

A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions should 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.

The nurse is assessing a patient who has dark skin for cyanosis. What assessment findings would indicate cyanosis in individuals with dark skin? Reddish skin tone Deeper brown or purple skin tone Grayish blue tone noted in nail beds, earlobes, lips, mucous membranes, palms, and soles Ashen or gray color noted in the conjunctiva of the eye, mucous membranes, and nail beds

Ashen or gray color noted in the conjunctiva of the eye, mucous membranes, and nail beds In dark-skinned individuals, cyanosis may be noted as an ashen or gray color most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds. Reddish, deep brown, purple, and grayish blue skin tones are not signs of cyanosis in dark-skinned individuals. The grayish blue tone noted in nail beds, earlobes, lips, mucous membranes, and so forth indicates cyanosis in light-skinned individuals.

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 should 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 nurse is obtaining a sample for an indirect immunofluorescence test for a patient suspected of having systemic lupus erythematosus (SLE). Which type of sample does the nurse expect to collect? Blood Throat swab Punch biopsy specimen of the skin Shave biopsy specimen of the skin

Blood Indirect immunofluorescence is an investigation required to identify the abnormal antibodies causing diseases such as SLE. A blood sample is required for indirect immunofluorescence testing. A throat swab specimen is not required for this test. Throat swabs are generally required for identifying the causative organisms of throat infections. Punch biopsy and shave biopsy skin specimens are not useful for indirect immunofluorescence but can be used as a test sample for direct immunofluorescence.

A nurse asks a nursing student to determine the skin color of a patient whose skin is tanned in the exposed areas. Where is the best place on a patient's body to accurately determine skin color? Face Palms Buttocks Nail beds

Buttocks In order to find out the actual skin color of the patient, the nursing student should observe the skin color in photo-protected areas such as the buttocks. The face is not a reliable area to assess skin color because it is exposed to the sun. The nail beds and palms have less melanin content and are therefore not reliable areas to assess skin color.

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."

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 nurse educator explains to a group of nursing students why skin becomes darker in color when exposed to sunlight. Which statement by a student indicates the teaching has been understood? "The rays from the sun stimulate the production of melanin, giving a tan to the skin." "The rays from the sun inhibit the production of melanin, causing the skin to darken." "The rays from the sun burn the outer layer of the skin, making the skin dark and painful." "The rays from the sun cause increased blood flow to the skin, giving a dark red color to the skin."

"The rays from the sun stimulate the production of melanin, giving a tan to the skin." Sunlight stimulates an organelle known as melanosome, which is present in the melanocytes (the cells responsible for production of melanin). Stimulation of melanosome causes increased production of melanin, which gives the dark color (tan) to the skin. Extreme sun exposure can burn the skin, and the skin may become dark and painful due to sunburns. Heat in summer causes vasodilatation, which causes temporary reddening of the skin.

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. 1. Lesion has a waxy border 2. an irregularly shaped lesion 3. Pearly papule,with a central crater 4. a small papule with a dry rough scale 5.a firm nodular lesion topped with a crust

1. Lesion has a waxy border 2. An irregularly shaped lesion

A patient had an infection underneath the toenail, and the entire nail was removed. The patient asks the nurse how long it will take the toenail to grow back to its normal size. What should be the nurse's answer? 1-2 months 3-6 months 6-12 months 12-24 months

12-24 months Sometimes toenails may be removed due to ingrowth and infection. Toenails grow at a rate of 30% to 50% slower than fingernails. The nail growth may vary depending upon the person's age and health. A toenail would usually fully regenerate in 12 months or longer. Fingernails grow back in 3-6 months.

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. Fill in the blank. Refer to figure.

19

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 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. 1.Metastasis is rare 2. It is encapsulated 3.Its highly metastatic 4.It is characterized by local invasion 5. Lesion is a nevus that has changed in color

3. It is highly metastatic. 5. Lesion is a nevus that has changed in color.

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?

36%

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color of the skin which is insensitive to touch

4. A white color of the skin which is insensitive to touch

A patient is having a diagnostic test performed to check a skin rash for a possible fungal infection. The nurse will prepare for which test? A patch test A shave biopsy A potassium hydroxide (KOH) microscopic test The Tzanck test (Wright's and Giemsa's stain)

A potassium hydroxide (KOH) microscopic test A KOH test is done to examine hair, scales, or nails for superficial fungal infection. A patch test is done to check for allergic reactions. A shave biopsy is done to provide a thin specimen for diagnostic purposes. The Tzanck test is done to assess for the presence of the herpes virus.

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 should 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

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 30-year-old patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system? Warm, flushed skin, alopecia, and thin nails General hyperpigmentation and loss of body hair Pale skin, pale mucous membranes, hair loss, and nail dystrophy Cold, dry, pale skin; dry, coarse hair; and brittle, slow growing nails

Cold, dry, pale skin; dry, coarse hair; and brittle, slow growing nails With hypothyroidism the patient will manifest with cold, dry, pale skin; dry, coarse, brittle hair; and brittle, slow growing nails. With hyperthyroidism the patient will have warm, flushed skin, alopecia with fine soft hair, and thin nails. With Addison's disease the patient will have loss of body hair and generalized hyperpigmentation, especially in folds. With anemia, the patient will display pallor, pale mucous membranes, hair loss, and nail dystrophy.

Which medication is most likely to have an effect on the patient's integumentary system? Diuretic Corticosteroid Benzodiazepine Calcium channel blocker

Corticosteroid Corticosteroids can have unwanted integumentary side effects, such as telangiectasia. Integumentary effects are less likely to occur with benzodiazepines, calcium channel blockers, and diuretics.

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the 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 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

A patient reports excessive itchiness all over the body that has caused an inability to sleep for three days. What nursing assessment finding indicates a lack of proper sleep? Dry, scaly skin Supple, moist skin Reddening of the skin Dark circles under the eyes

Dark circles under the eyes Excessive tiredness or sleeplessness causes dark circles under the eyes because of dullness and dehydration. Dry and scaly skin causes itching but is not directly associated with sleeplessness. Reddening of the skin and the presence of supple, moist skin are not indicative of disturbed sleep. Reddening of skin is a manifestation of dilated blood vessels. Suppleness and good hydration are indicators of healthy skin.

When assessing the skin of an older adult, which findings would the nurse consider normal? Select all that apply. Fissure Dry skin Wrinkling Excoriation Decreased turgor

Dry skin Wrinkling Decreased turgor

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

Elevated hematocrit levels

A nurse is assessing a patient who has yellow skin and nails. Which chemical or pigment abnormality does the nurse expect the patient to have? Excess melanin Excess carotenes Excess oxyhemoglobin Excess deoxyhemoglobin

Excess carotenes Excess carotene in the body gives a yellow color to the skin. Excess melanin in the body gives a brown color to the skin. Excess oxyhemoglobin gives a red color to the skin. Excess deoxyhemoglobin gives a blue color to the skin.

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. How should the nurse document this finding? Scar Fissure Atrophy Excoriation

Fissure The secondary skin lesion, called a fissure, is a linear crack or break from the epidermis to the dermis and can be dry as in athlete's foot or moist as in cracks at the corner of the mouth. A scar is an abnormal formation of connective tissue that replaces normal skin when a wound heals. Atrophy is a depression in skin resulting from thinning of the epidermis or dermis. Excoriation is an area in which the epidermis is missing, which exposes dermis (e.g., abrasion or scratch).

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

It is caused by a tick carried by deer.

The patient has diffuse distribution of moles on the body. A biopsy of one on the patient's back will be done to assess for malignancy. The nurse knows that what is the rationale for doing a punch biopsy? It is used for a superficial lesion. It provides a full-thickness of skin. It is used for good cosmetic results. It is used because the lesion is too large to remove.

It provides a full-thickness of skin. The punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy is used for a superficial lesion or when only a small sample is needed for diagnostic purposes. An excisional biopsy is used when a good cosmetic result is desired. An incisional biopsy is a wedge-shaped incision made in a lesion that is too large for an excisional biopsy. It is useful when a larger specimen is needed than a shave or punch biopsy can provide.

Which disease condition can be found more in fair-skinned patients than in patients with more pigmentation in their skin? Keloids Melanoma Nevus of ota Traction alopecia

Melanoma Fair-skinned people are more prone to developing melanoma as compared to people with more pigment in their skin. People with darker skin have an increased amount of melanin pigment produced by the melanocytes. This increased melanin forms a natural sun shield for darker skin tones and results in a decreased incidence of skin cancer in these individuals. However, individuals with dark skin may have increased incidence of keloids, nevus of ota, and traction alopecia.

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.

When assessing a 73-year-old female patient, the nurse found wrinkles, sagging breasts, and tenting of the skin, gray hair, and thick, brittle toenails. The nurse knows that what normal changes of aging occur that can cause these changes in the integumentary system? Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails Decreased extracellular water, surface lipids, and sebaceous gland activity, decreased scalp oil, and decreased circulation Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply The normal changes of aging include muscle laxity, degeneration of elastic fibers, and collagen stiffening that contribute to the wrinkles, sagging breasts, and tenting of the skin. Decreased melanin and melanocytes in the hair lead to gray hair, and decreased peripheral blood supply leads to thick, brittle nails with diminished growth. Decreased apocrine and sebaceous glands would lead to dry skin with minimal to no perspiration and uneven skin color. Decreased density of hair leads to thinning and loss of hair. Increased keratin in nails leads to longitudinal ridging of the nails. The decreased extracellular water, surface lipids, and sebaceous gland activity lead to dry flaking skin. Decreased scalp oil leads to dry coarse hair and a scaly scalp, and decreased circulation leads to prolonged return of blood to nails on blanching. Increased capillary fragility and permeability in aging leads to bruising. A cumulative androgen effect and decreased estrogen levels lead to facial hirsutism in women and baldness in men. Decreased circulation leads to prolonged return of blood to nails on blanching.

When jaundice is suspected in a patient, which areas should the nurse check for skin color? Select all that apply. Tongue Nail beds Earlobes Conjunctiva Buccal mucosa

Nail beds Conjunctiva Buccal mucosa Changes in skin color may vary from one person to another. The skin color depends on the amount of melanin, carotene, oxyhemoglobin, and reduced hemoglobin present at a particular time. The most reliable areas to assess for erythema, cyanosis, pallor, and jaundice are the sclerae, conjunctivae, nail beds, lips, and the buccal mucosa, as these areas are the least pigmented. The tongue and earlobes are not reliable areas to assess for skin color.

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

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

Normal saline

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

Palms of the hands

To assess the skin turgor, the most appropriate technique for the nurse to use is which of these? Palpation Inspection Percussion Auscultation

Palpation Turgor refers to the elasticity of the skin. Assess turgor by gently pinching an area of skin under the clavicle or on the back of the hand. Skin with good turgor should move easily when lifted and should immediately return to its original position when released. Inspection, percussion, and auscultation are not useful for assessing skin turgor.

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

Palpation Induration

To obtain information about temperature, turgor, moisture, and texture, which assessment technique should the nurse use? Inspection of skin color Examination for vascularity Palpation of skin with the hand Percussion of the skin on the back

Palpation of skin with the hand Palpation of the skin with the back of the hand will assess temperature. Turgor is assessed by gently pinching the skin on the back of the hand and observing its return to original position when released. Moisture and texture of skin is assessed by touching it to assess it. Percussion does not assess the skin, but the organs beneath the skin.

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area?

Partial-thickness skin loss of the epidermis

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

Pat the skin dry after bathing.

The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which locations should the nurse inspect for cyanosis? Select all that apply. Patient's sclera Patient's nail beds Soles of the patient's feet Palms of the patient's hands Conjunctiva of the patient's eyes

Patient's nail beds Conjunctiva of the patient's eyes In patients with darkly pigmented skin, the conjunctiva and nail beds often are examined to assess for cyanosis. Palms of the hands, soles of the feet, and the sclera are not the focus when assessing for cyanosis.

A patient is examined by the nurse and found to have pink-purple, nonblanching macular pinpoint lesions. Which term best describes these findings? Purpura Petechiae Hematoma Ecchymosis

Petechiae Petechiae are small pink-to-purplish macular lesions 1 to 3 mm in diameter, usually caused by minor hemorrhage of capillary blood vessels. Purpura are red or purple discolorations of the skin that do not blanch when pressure is applied. Purpura are associated with bleeding under the skin and are seen in various bleeding disorders. A hematoma is a localized collection of blood outside blood vessels that is generally the result of hemorrhage. Ecchymosis is a collection of blood under the skin, larger than a petechiae, with diffuse borders.

A nurse is assessing a male client who reports small papules and pustules in the beard area. The papules started appearing after he shaved his beard the previous day. Based on this information, what is the most likely patient diagnosis? Acne Moles Comedo Pseudofolliculitis

Pseudofolliculitis Pseudofolliculitis is an inflammatory reaction that occurs in the beard area after shaving too closely. This inflammation is a response to the in-growth of hair after shaving and is manifested as pustules or papules. Acne is also characterized by papules and pustules but is unlikely to occur in the beard area after shaving. Acne is usually due to an infection or hormonal changes. Moles are small, dark lesions caused by benign overgrowth of melanocytes. Comedos (blackheads and whiteheads) are enlarged hair follicles that are plugged with sebum, bacteria, and skin cells. They may occur due to heredity, drugs, or hormonal changes.

A 14-year-old girl and her mother come to see the nurse practitioner for treatment of the daughter's acne. For what should the nurse assess the patient to show the existence of acne? Ulcers Wheals Vesicles Pustules

Pustules Pustules are elevated, superficial lesions filled with purulent fluid, such as those commonly associated with acne. Wheals, ulcers, and vesicles are not common manifestations of acne.

Which process should a nurse follow when obtaining a wound culture from a surgical site? Rolling a sterile swab from the center of the wound outward Using a sterile swab, starting on the outer edge of the wound Thoroughly irrigating the wound before collecting the culture Using a sterile swab to wipe the crusted area around the outside of the wound

Rolling a sterile swab from the center of the wound outward Rolling the swab from the center outward is the correct procedure for culturing a wound. Starting on the outer edge of the wound, irrigating the wound before collecting the culture specimen, and using a sterile swab to wipe the crusted area may contaminate the wound, produce inaccurate results, or both.

A nurse is giving a lecture on nutrition to a group of nursing interns. The nurse says that sunlight is the best source of vitamin D. Based on their previous knowledge, what would be the most appropriate interpretation of this statement by the interns? Sunlight stimulates the production of vitamin D in the body. Sunlight contains vitamin D, which is easily absorbed by the skin. Exposure to sunlight increases craving for foods rich in vitamin D. Sunlight causes proliferation of the cells containing vitamin D precursors.

Sunlight stimulates the production of vitamin D in the body. The ultraviolet (UV) rays present in sunlight act on the vitamin D precursors present in epidermal cells and form Vitamin D. Sunlight does not contain vitamin D. Exposure to sunlight does not increase craving for foods rich in Vitamin D. The UV rays do not help in proliferation of Vitamin D precursors but simply convert them to vitamin D.

On inspection of a patient's skin, the nurse notes dilated, superficial, cutaneous small blood vessels on the patient's face. What is this assessment finding called? Vitiligo Intertrigo Petechiae Telangiectasia

Telangiectasia Telangiectasia are visibly dilated, superficial, cutaneous small blood vessels, commonly found on face and thighs. Vitiligo is a chalky, white patch that occurs because of a complete absence of melanin (pigment). Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membrane. Intertrigo is a dermatitis of overlying surfaces of the skin.

The nurse in a 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.

A nurse is caring for a patient who has taken a potassium hydroxide (KOH) skin test. The results of the test are positive. What would be the interpretation of this test? The patient has a skin allergy. The patient has a malignant skin condition. The patient has a fungal infection of the skin. The patient has systemic lupus erythematosus (SLE).

The patient has a fungal infection of the skin. The KOH test indicates the presence of a fungal infection. The KOH test cannot be used to establish the presence of skin allergy, malignant skin condition, or SLE. A skin allergy is best tested with the patch test. The diagnosis of a malignant skin condition is done by a skin biopsy. Direct immunofluorescence is a special diagnostic technique used on a biopsy specimen to confirm SLE.

A nurse is assessing a patient with psoriasis. The nurse explains the pathology of psoriasis, stating that it occurs due to abnormal changes in the cell cycle of the skin layers. Which change in the cell cycle is the nurse referring to? The outer dead layer of skin cells is not shed. The inner layer of skin stops producing new skin cells. The rate of removal of outer dead skin is much more than the rate of production of new skin cells. The rate of new skin cell production is much more than the rate of removal of outer dead skin cells.

The rate of new skin cell production is much more than the rate of removal of outer dead skin cells. In psoriasis, new skin cells are formed faster than old cells are shed. This causes the skin in psoriasis patients to become scaly and thickened. In psoriasis, the outer layer of the dead skin is shed at a normal rate. The inner layer of the skin does not stop producing new skin cells but produces new skin cells at a much faster rate. If the rate of removal of outer dead skin is much more than the rate of production of new skin cells, the skin becomes too thin.

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

The return of distal pulses

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.

During the change-of-shift report, the outgoing nurse reports a new finding of petechiae in a new patient admitted with a yet-to-be diagnosed hematologic disorder. On assessment of this patient, what should the incoming nurse expect to find? Tiny, purple spots on the skin Large ecchymotic areas on the skin Hyperkeratotic papules and plaques Small, raised red areas on the soles of the feet

Tiny, purple spots on the skin Petechiae present as tiny, purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler's nodes.

A nurse scrapes off the superficial layer of the skin lesion of the patient. This specimen is sent to the laboratory for culture. What is the purpose of this culture? To identify an allergen To identify a fungal infection To identify a viral infection To identify a bacterial infection

To identify a fungal infection Culture of the skin lesion specimen is used to identify the fungal, bacterial, or viral infection. Scraping or swab of the skin is performed to obtain the specimen for identification of fungal infection. For bacteria, the sample for culture is obtained from intact pustules, bullae, or abscesses. For a virus, the vesicle or bulla and exudates are taken from the base of the lesion. Culture cannot be used to determine the agent causing skin allergies. The patch test is used to determine the allergen causing the skin lesions.

While explaining the structure of the skin to a patient, the nurse says that the outermost layer of the skin consists mainly of dead cells. The patient asks the nurse, "Why do our bodies need these dead cells?" What is the most appropriate answer for the nurse to give? To protect the viable cells underneath To preserve water for the viable cells underneath To provide nutrition to the viable cells underneath To provide antiseptic properties that prevent infection in the body

To protect the viable cells underneath The outermost layer of the skin is known as the epidermis. This layer is composed primarily of dead cells, which act as a protective layer for the deeper viable skin tissue. Because this layer is composed mainly of dead cells, these are not useful to provide nutrition to the deeper skin tissues (dermis). The epidermis is a dry layer of cells; it does not preserve water. The epidermal layer has no antiseptic properties.

A nurse is dressing the wound of a patient whose fingers were injured in an accident. One of the fingernails is missing. The patient asks the nurse about when the fingernail will grow back. What is the most appropriate answer? Within 3 months Within 6 months Within 12 months Within 15 months

Within 6 months In healthy individuals, a lost fingernail usually regenerates in three to six months. Therefore, the most appropriate answer given by the nurse would be within six months.

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

Which of the following individuals is least likely to be at risk of developing psoriasis? a. A 32 year old African American b. A woman experiencing menopause c. A client with a family history of the disorder d. An individual who has experienced a significant amount of emotional distress

a. A 32 year old African American Rationale: The incidence is lower in darker skinned races and ethnic groups.

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following? a. An irregularly shaped lesion b. A small papule with a dry, rough scale c. A firm, nodular lesion topped with crust d. A pearly papule with a central crater and a waxy border

a. An irregularly shaped lesion Rationale: Melanoma is an irregularly shaped pigmented papule with a red, white, or blue-toned color. Squamous cell carcinoma (firm, nodular lesion topped with crust or central area of ulceration). Basil cell carcinoma (a pearly papule with a central crater and rolled waxy border)

The nurse is assigned to care for a client with herpes zoster (shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection? a. Clustered skin vesicles b. A general body rash c. Small blue-white spots with a red base d. A fiery red, edematous rash on the cheeks

a. Clustered skin vesicles Rationale: Classic presentation is group vesicles on an erythematous base along a dermatome. The lesions do not cross the midline of the body because the follow the nerve pathways

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which statement by a client indicate a need for further instructions? a. I will avoid sun exposure after 3PM b. I will use sunscreen when participating in outdoor activities c. I will wear a hat, opaque clothing, and sunscreen when in the sun d. I will examine my body monthly for any lesions that may be suspicious

a. I will avoid sun exposure after 3PM Rationale: Sun exposure should be avoided between the hour of 11AM and 3PM

The client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. The nurse base the response on the understanding that the characteristic of cellulitis include: a. an inflammation of the epidermis only. b. A skin infection into the dermis and subcutaneous tissue c. An acute superficial infection of the dermis and lymphatics d. An epidermal and lymphatic infection caused by Staphylococcus

b. A skin infection into the dermis and subcutaneous tissue Rationale: It is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red, erythema w/o sharp borders and spreads widely throughout tissue spaces. Skin is red swollen, tender, and sometimes nodular.

The nurse is implementing a teaching plan to a group of adolescents regarding the cause of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder? a. Acne is caused by oily skin b. The actual cause is unknown c. Acne is caused by eating chocolate d. Acne is caused as a result of exposure to heat and humidity

b. The actual cause is unknown Rationale: Oily skin and eating chocolate does NOT cause acne. Exacerbations may happen during menstrual due to hormonal activity.

Ultraviolet light therapy is prescribed as a component of the treatment plan for a client with psoriasis and the nurse provide instructions to the client regarding the treatment. Which statement by the client indicate a need for further instructions? a. Treatments are limited to two or three times a week b. The ultraviolet light treatments are given on consecutive days c. Eye goggles need to be worn to prevent exposure to ultraviolet light d. Just the area requiring treatment should be exposed to the ultraviolet light

b. The ultraviolet light treatments are given on consecutive days Rationale: Treatments are limited to two or three times a week and ultraviolet light treatments are NOT given on consecutive days. Safety precautions are required during therapy

The nurse begins to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which of the following will be prescribed for the client? a. Cold compresses to the affected area b. Warm compresses to the affected area c. Intermittent heat lamp treatments four times daily d. Alternating hot and cold compress continuously

b. Warm compresses to the affected area Rationale: Warm compresses can be used to decrease the discomfort, reddness, and edema.

The clinic nurse notes that the physician has documented a diagnosis of 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 following which diagnostic test? a. Patch test b. Skin biopsy c. Culture of the lesion d. Wood's light examination

c. Culture of the lesion Rationale: A viral cultural of the lesion provides the definitive diagnosis. Patch test(allergies), Biopsy (tissue), and Wood's light (identify superficial infection of the skin)

A client returns to the client 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 which of the following describes a characteristic of this type of lesion? a. Metastasis is rare b. Melanoma is encapsulated c. Melanoma is highly metastatic d. Melanoma is characterized by local invasion

c. Melanoma is highly metastatic Rationale: This skin cancer is highly metastatic and survival rate depends on early diagnosis and treatment

A male client calls the emergency room and tells the nurse that he had been cleaning a wooded area in the backyard and 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. Which of the following is the appropriate nursing response? a. Come to the emergency room b. Apply calamine lotion immediately to the exposed skin areas. c. Take a shower immediately, lathering and rinsing several times. d. It is not necessary to do anything if you cannot see anything on your skin.

c. Take a shower immediately, lathering and rinsing several times. Rationale: Because the ivy plant forms an invisible film on the human skin so client needs to shower immediately lathering and rinsing the skin several times.

The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes zoster? a. The nurse who never had roseola b. The nurse who never had mumps c. The nurse who never had chickenpox d. The nurse who never had German measles

c. The nurse who never had chickenpox Rationale: Caused by a reativation of the varicella-zoster virus. It is very contagious to those who has not has the virus(responsible for chickenpox)

The client arrives at the emergency room and has experience frostbite to the right hand. Which of the following would the nurse note on assessment of the client's hand? a. A pink, edematous hand b. A fiery red skin with edema in the nail beds c. Black fingertips surrounded by an erythematous rash d. A white color to the sin, which is insensitive to touch

d. A white color to the sin, which is sensitive to touch Rationale: Frostbite includes white or blue color, skin will be hard, cold, and insensitive to touch

The nurse prepares discharge instructions for a client following cryosurgery for the treatment of a malignant skin lesion . Which of the following should the nurse include in the instructions? a. Avoid showering for 7 to 10 days b. Apply ice to the site to prevent discomfort c. Apply alcohol-soaked dressings twice a day d. Clean the site with hydrogen peroxide to prevent infection

d. Clean the site with hydrogen peroxide to prevent infection Rationale: Done to prevents secondary infection

The evening nurse reviews the clients documentation in the chart and notes that the day nurse has documented that the client has stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? a. Intact skin b. Full thickness skin loss c. Expose bone, tendons, or muscle d. Partial-thickness skin loss of the dermis

d. Partial-thickness skin loss of the dermis Rationale: Stage I(skin intact), stage III (full-thickness skin loss occurs), and Stage IV (expose bone, tendons, or muscle)

The nurse prepares to treat a client with frostbite of the toes. Which of the following do the nurse anticipate to be prescribed for this condition? a. Rapid and continuous rewarming of the toes after flushing returns b. Rapid and continuous rewarming of the toes in cold water for 45 minutes c. Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes d. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs

d. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs Rationale: Cold and hot water are NOT used.

The clinic nurse assesses the skin of a white client diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder? a. Clear, thin nail beds b. Red-purplish scaly lesions c. Oily skin and no episodes of pruritus d. Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions

d. Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions Rationale: Psoriatic patches are covered with silvery-white scales. Affected areas include the scalp, elbows, knees, shins, trunk, and sacral area

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