Integumentary

On assessment what would the nurse expect to note with a primary skin lesion that may be caused by a condition such as vitiligo? 1. A circumscribed, flat area with a change in skin color that is less than 0.5 cm in diameter 2. A circumscribed, superficial collection of serous fluid that is less than 0.5 cm in diameter 3. A circumscribed, elevated, superficial, solid lesion that is greater than 0.5 cm in diameter 4. A circumscribed, raised area with a change in skin color that is greater than 5 cm in diameter

1. A circumscribed, flat area with a change in skin color that is less than 0.5 cm in diameter Rationale: Vitiligo usually presents as hypopigmented macules. A macule is described as a circumscribed, flat area with a change in skin color that is less than 0.5 cm in diameter. A vesicle is a circumscribed, superficial collection of serous fluid that is less than 0.5 cm in diameter. A circumscribed, elevated, superficial, solid lesion that is greater than 0.5 cm in diameter describes a papule. A circumscribed, raised area with a change in skin color that is greater than 5 cm in diameter does not describe a macule.

When ultraviolet light (UVL) therapy is prescribed as a component of the treatment plan for a client with psoriasis, the nurse reinforces instructions to the client. Which statement made by the client indicates a need for further teaching regarding safety measures related to the therapy? 1. "Each treatment will last 30 minutes." 2. "I will expose only the area requiring treatment." 3. "I need to wear eye goggles during the treatment." 4. "I will cover my face with a loosely applied covering."

1. "Each treatment will last 30 minutes." Rationale: Safety precautions are necessary during UVL therapy. Most UVL treatments require the person to stand in a light treatment chamber for up to 15 minutes. It is best to expose only those areas requiring treatment to the UVL. Protective wraparound goggles prevent exposure of the eyes to UVL. The face should be shielded with a loosely applied cloth if it is unaffected. Direct contact with the light bulbs of the treatment unit should be avoided to prevent burning of the skin.

The nurse is asked if there is any treatment that can prevent poison ivy from occurring once coming into contact with the plant. Which assessment question should the nurse ask first? 1. "Have you showered yet?" 2. "Has a rash developed yet?" 3. "Are you allergic to poison ivy?" 4. "Do you have any antihistamines on hand?"

1. "Have you showered yet?" Rationale: When an individual comes into contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to shower immediately and that the skin should be lathered several times and rinsed each time in running water. Therefore, questioning about showering is the first question that the nurse should ask.

Using the rule of nines, calculate the burn percentage for the client. Refer to figure (the burned area is the darkly shaded area). Fill in the blank.

19%

The nurse is assessing the operative site of a client who underwent a breast reconstruction. The nurse is inspecting the flap and the areola of the nipple and notes that the areola is deep red around the edge. The nurse should plan to take which action first after collecting data from the client and reviewing the surgeon's prescriptions? 1. Elevate the breast. 2. Notify the surgeon. 3. Document the findings. 4. Encourage nipple massage.

2. Notify the surgeon. Rationale: After breast reconstruction, the flap is inspected for color, temperature, and capillary refill. Assessment of the nipple areola is made, and dressings are designed so that this area can be observed. An areola that is deep red, purple, dusky, or black around the edge is reported to the primary health care provider immediately, because this may indicate a decreased blood supply to the area. The nurse would also document the findings as soon as the primary health care provider is notified. Elevating the breast and encouraging nipple massage are incorrect actions.

Which finding indicates that the client sustained a full-thickness burn? 1. Blisters 2. Pink to red coloring 3. Charring at the wound site 4. A wet, shiny, weeping wound surface

3. Charring at the wound site Rationale: In a full-thickness burn injury, charring is visible, extremity movement is limited, and wound sensation is absent. Blisters; pink to red coloring; and a wet, shiny, weeping surface would be noted in a partial-thickness burn injury.

Quinupristin-dalfopristin is prescribed for a client diagnosed with a skin infection. The nurse, preparing to administer the medication by intermittent intravenous (IV) infusion, should plan to administer the medication over which time frame? 1. 15 minutes 2. 30 minutes 3. 1 hour 4. 4 hours

3. 1 hour Rationale: Quinupristin-dalfopristin is an antimicrobial medication used in the treatment of skin, urinary tract, central catheter, bone and joint, and respiratory infections, and for endocarditis or bacteremia. For intermittent IV infusion (piggyback), the medication should be infused over a 1-hour period.

Which skin lesion should the nurse expect to observe if the client is diagnosed with psoriasis? 1. An elevated, superficial lesion filled with purulent fluid 2. A firm, edematous, irregularly shaped area with a variable diameter 3. A circumscribed, elevated, superficial, solid lesion that is less than 0.5 cm in diameter 4. A circumscribed, elevated, superficial, fluid filled lesion

3. A circumscribed, elevated, superficial, solid lesion that is less than 0.5 cm in diameter Rationale: Plaques are most often seen with psoriasis. A plaque is described as a circumscribed, elevated, superficial, solid lesion that is less than 0.5 cm in diameter. A lesion with purulent fluid describes a pustule. A firm, edematous area describes a wheal. A fluid-filled lesion describes a vesicle.

An older client has sustained a major burn and is receiving vigorous fluid resuscitation. The nurse understands that the older client is at risk for which complication specifically related to this treatment for the injury? 1. Sepsis 2. Pneumonia 3. Pulmonary edema 4. Urinary tract infection

3. Pulmonary edema Rationale: The older client who sustains a major burn and is receiving vigorous fluid resuscitation is at risk for pulmonary edema due to fluid overload and the inability to excrete fluid. Sepsis, pneumonia, and urinary tract infection are possibilities for the older client who has sustained a major burn; however, these complications are not specifically related to fluid resuscitation.

An adult client is admitted to the emergency department after a burn injury. The burn initially affected the upper half of the client's anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran causing subsequent burn injuries to the entire face (anterior half of the head), and the upper half of the posterior torso. Using the rule of nines, the extent of the burn injury would be what percent? Refer to the figure. Fill in the blank.

31.5%

An adult client arrives in the emergency department with burns to both entire legs and the perineal area. Using the rule of nines, the nurse should determine that approximately what percentage of the client's body surface has been burned? Fill in the blank.

37% Rationale: The most rapid method used to calculate the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the rule of nines. This method divides the body into areas that are multiples of 9%, except for the perineum. Each entire leg is 18%, each arm is 9%, and the head is 9%. The trunk is 36%, and the perineal area is 1%. Both legs and perineal area equal 37%.

A burn victim presents to the emergency department with burns of the anterior trunk, both arms, and perineum. Using the rule of nines, what is the percentage of the burns? Fill in the blank.

37% Rationale: According to the rule of nines, each body part is 9% or a multiple of 9, except the perineum, which is 1%. The head is 9%, the anterior trunk is 18%, the posterior trunk is 18%, the arms are 9% each, the legs are 18% each, and the perineum is 1%. This question identifies the anterior trunk and perineum as being the affected areas; therefore, the answer is 19%.

The nurse inspects a client's pressure injury and determines that the ulcer is at which stage? Refer to figure. 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

4. Stage 4

Using the Parkland formula, calculate the amount of intravenous fluids required in the first 24 hours for a client who sustained a burn who weighs 60 kilograms (kg) with 30% total body surface area (TBSA) burned. Fill in the blank.

Correct Answer: 7200 mL The Parkland formula is calculated multiplying 4 mL Ringer's lactate solution by the body weight in kilograms by the percentage of TBSA affected by the burns. One-half of the total is administered in the first 8 hours after the client sustains the burn. One-fourth of the total is administered in the second 8 hours after the burn. One-fourth of the total is administered in the third 8 hours after the burn.

A new staff nurse has documented care of a client diagnosed with a stage 3 pressure injury. Which documentation by a new staff nurse requires correction and follow-up by the nurse manager when reviewing chart notes? Select all that apply. 1. A deep ulcer that extends into muscle and bone 2. An area in which the top layer of skin is missing 3. Yellow eschar present near the bottom of the ulcer 4. A deep ulcer that extends into the dermis and the subcutaneous tissue 5. A reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief

1. A deep ulcer that extends into muscle and bone 2. An area in which the top layer of skin is missing 5. A reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief Rationale: A stage 3 pressure injury is a deep ulcer that extends into the dermis and the subcutaneous tissue. White, gray, or yellow eschar usually is present at the bottom of the ulcer, and the ulcer crater may have a lip or edge. Purulent drainage is common. A stage 4 pressure injury is a deep ulcer that extends into muscle and bone. A stage 2 pressure injury is an area in which the top layer of skin is missing. A stage 1 pressure injury is a reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief.

A client is being evaluated for a rash that stretches across two adjacent dermatomes but does not cross the midline of the body. Which pharmacological therapy should the nurse expect to be prescribed to treat this rash? 1. Acyclovir 2. Erythromycin 3. Indomethacin 4. Tetracycline hydrochloride

1. Acyclovir Rationale: The assessment findings are consistent with herpes zoster (shingles). The goals of treatment for herpes zoster are to relieve pain, prevent infection and scarring, and reduce the possibility of postherpetic neuralgia. Oral analgesics are prescribed to reduce the incidence of persistent pain. The lesions also may be injected with corticosteroids. Acyclovir, if started early, may reduce the severity of herpes zoster. Erythromycin and tetracycline are antibiotics that are not normally prescribed for a viral condition. Indomethacin is a nonsteroidal anti-inflammatory medication, not primarily prescribed for a viral infection.

The nursing instructor is conducting a teaching session on the integumentary system and is describing the different types of secondary skin lesions. Which finding does the nurse most likely expect to observe in a client with an anal fissure as a result of chronic constipation? 1. An abnormal formation of connective tissue that replaces normal skin 2. A linear crack or break from the epidermis to dermis, which can be dry or moist 3. A loss of the epidermis and part of the dermis, which is crater-like and irregular in shape 4. An excess of dead, epidermal cells produced by abnormal keratinization and shedding

2. A linear crack or break from the epidermis to dermis, which can be dry or moist Rationale: Anal fissures are commonly seen when a client suffers from chronic constipation. A fissure is described as a linear crack or break from the epidermis to dermis that can either be dry or moist. Abnormal connective tissue describes a scar. "Excess dead, epidermal cells" describes a scale. A "crater-like shape" describes an ulcer.

The nurse recognizes the need for follow-up to verify which prescription written for a client with a diagnosis of acute cellulitis of the lower leg? 1. Obtain blood cultures 2. Acetaminophen for fever 3. Cold compresses to the affected area 4. Administration of intravenous antibiotics

3. Cold compresses to the affected area Rationale: Warm compresses may be used to decrease the discomfort, erythema, and edema. The warmth promotes vasodilation and promotes circulation of the venous and lymphatic systems to circulate immune mediators and promote healing. Cold compresses would not be a component of the treatment measures. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms of fatigue, fever, chills, headache, and myalgia.

Tretinoin gel has been prescribed for a client with acne. What is the nurse's response when the client calls and reports that her skin has become very red and is beginning to peel? 1. "Discontinue the medication immediately." 2. "Come to the clinic immediately for an assessment." 3. "I'll notify your primary health care provider of these results." 4. "This is a normal occurrence with the use of this medication."

4. "This is a normal occurrence with the use of this medication." Rationale: Tretinoin decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel. Options 1, 2, and 3 are incorrect statements to the client.

A clinic nurse provides instructions to a client who will be taking isotretinoin for severe cystic acne. Which statement by the client indicates the need for further instruction? 1. "The medication may cause my lips to burn." 2. "The medication may cause dryness and burning in my eyes." 3. "I need to return to the clinic for a blood test to check my triglyceride level." 4. "Vitamin A supplements will improve the effectiveness of this treatment."

4. "Vitamin A supplements will improve the effectiveness of this treatment." Rationale: Although less commonly used, in severe cystic acne, isotretinoin may be prescribed to inhibit inflammation. Adverse effects include cheilitis (lip inflammation), eye discomfort such as dryness and burning, elevated triglycerides, and skin dryness. Close medical follow-up is required, and dry skin and cheilitis can be decreased by the use of emollients and lip balms. Vitamin A supplements are stopped during this treatment.

The wound of a client with an extensive burn injury is being treated with the application of silver sulfadiazine. Which finding indicates that the treatment has been effective? 1. Tissue staining 2. Decreased photosensitivity 3. Decreased pain at the wound site 4. White blood cell (WBC) count 9500 mm3 (9.5 × 109/L)

4. White blood cell (WBC) count 9500 mm3 (9.5 × 109/L) Rationale: Silver sulfadiazine is an antibacterial cream used for burn wounds. A WBC count within normal limits (5000 to 10,000 mm3 [5 to 10 × 109/L])

A home care nurse visits an older client who reports chronic dry skin and episodes of pruritus. Which suggestion should the nurse make to the client to alleviate this discomfort? 1. Purchase a dehumidifier for the home. 2. Avoid the use of astringents on the skin. 3. Avoid the use of emollients on the skin. 4. Bath in a diluted solution of vinegar and water.

Avoid the use of astringents on the skin. The client should avoid applying rubbing alcohol, astringents, or other drying agents to the skin. The client should avoid using a dehumidifier because this will further dry room air. The client can take one bath or one shower per day for 15 to 20 minutes with warm water and a mild soap, after which the client should apply an emollient to prevent evaporation of water from the hydrated epidermis. A bath using a diluted vinegar solution will further dry the skin.

A client sustained full-thickness burns to both hands from scalding water. A sheet graft was surgically applied to the wounds. The client is concerned about altered body image. The nurse formulates a response based on which best information regarding this type of graft? 1. Better cosmetic result 2. Easier to care for initially 3. Better donor-site availability 4. Better adherence to the wound bed

1. Better cosmetic result Rationale: Sheet grafts are often used to graft burns in visible areas. Sheet grafts are done on cosmetically important areas, such as the face and hands, to avoid the meshed pattern that occurs with meshed grafts. Easier care, better availability, and adherence to wound bed are not the primary purposes of using sheet grafts.

Which baseline assessment is the priority for the client who has been prescribed amphotericin B? 1. Allergies 2. Temperature 3. Respirations 4. Blood pressure

1. Allergies Rationale: Amphotericin B is classified as an antifungal medication. For the client who has been prescribed this medication, a variety of baseline assessments should be performed. The priority assessment is questioning the client about an allergy to sulfites because this can result in anaphylaxis. Other parameters that should be assessed and continually monitored throughout medication administration include temperature, respirations, blood pressure, pulse, and assessing for adverse reactions (fever, tremors, chills, anorexia, nausea, vomiting, and abdominal pain), and monitoring renal function. The expected effects on vital signs are not as much of a safety risk as anaphylaxis.

The nurse is preparing to move a quadriplegic client out of bed into a chair. What pad devices should the nurse place on the seat of the chair as the most appropriate device for pressure relief? Select all that apply. 1. Alternating air 2. Air ring 3. Water 4. Foam 5. Gel

1. Alternating air 3. Water 4. Foam 5. Gel Rationale: The client who cannot independently shift weight should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client's weight on the device. These include foam, water, gel, or alternating air pads. An air ring relieves pressure in some spots but causes pressure in others by its design.

The nurse is performing a skin assessment on a client diagnosed with a cancerous skin lesion that has a blue tone. The nurse should expect to note which other characteristic of this type of skin lesion? 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border

1. An irregularly shaped lesion Rationale: A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue tone. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with dry, rough adherent yellow or brown scale. Squamous cell carcinoma is a firm nodular lesion topped with a crust or a central area of ulceration. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border.

The nurse reviews the health care record of a client who never received a varicella vaccine and now presents with a rash and very painful headache. Which finding should the nurse expect to note as characteristic of this client's suspected disorder? 1. Clustered and grouped skin vesicles 2. A generalized red body rash that causes pruritus 3. A fiery red edematous rash on the cheeks and neck 4. Small, blue-white spots with a red base noted on the extremities

1. Clustered and grouped skin vesicles Rationale: The client's findings are consistent with herpes zoster. The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Many clients also complain of severe pain and/or headache. A generalized rash, blue-white spots, and a rash on the cheeks and neck are not characteristics of herpes zoster.

The home care nurse performing an initial assessment of a client suspects the presence of herpes zoster. Which assessment finding would be noted as characteristic of this disorder? 1. Clustered and grouped skin vesicles 2. A generalized red body rash that causes pruritus 3. A fiery red edematous rash on the cheeks and neck 4. Small blue-white spots with a red base noted on the extremities

1. Clustered and grouped skin vesicles Rationale: The primary lesion of herpes zoster is a vesicle. The classic presentation consists of grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Generalized rash, rash on cheeks and neck, and blue-white spots are not characteristics of herpes zoster.

A new staff nurse, being observed by the clinic nurse manager, is gathering data from a client who is taking the natural supplement Simmondsia chinensis (jojoba). The new staff nurse requires further teaching about this supplement if the nurse asks the client which questions? Select all that apply. 1. Do you experience frequent diarrhea? 2. Do you suffer from stomach irritation? 3. Have you experienced weight gain or fatigue? 4. How many areas of scaly, dry skin do you have? 5. Do you suffer from frequent blemish breakouts?

1. Do you experience frequent diarrhea? 2. Do you suffer from stomach irritation? 3. Have you experienced weight gain or fatigue? Rationale: Simmondsia chinensis (jojoba) is a shrub found in Mexico and the southwestern region of the United States. It has been used to treat skin disorders such as chapped, dry skin; scaling; eczema; psoriasis; and seborrhea. Diarrhea, stomach irritation, and weight gain and fatigue are not known side effects of this supplement.

A client sustained a major burn injury 3 days ago. The nurse monitors the client, knowing that which signs would be expected findings at this time? Select all that apply. 1. Hyponatremia and hypokalemia 2. Presence of S3 and S4 heart sounds 3. Jugular venous distention and dry cough 4. Decreased hematocrit and metabolic acidosis 5. Polyuria and a decreased urine specific gravity

1. Hyponatremia and hypokalemia 4. Decreased hematocrit and metabolic acidosis 5. Polyuria and a decreased urine specific gravity Rationale: Remobilization of fluid from the interstitial to the intravascular space, which may occur beginning 48 to 72 hours after the injury, can lead to overwhelming cardiac and renal reserve, especially in the older client or otherwise compromised clients. Metabolic acidosis can occur as the loss of sodium depletes the fixed base, and relative carbon dioxide content increases. Sodium and potassium will be lost from fluid shifts. Potassium commonly shifts back into cells as cell membranes stabilize. Increased intravascular plasma volume will occur during the diuretic phase, causing a relative or dilutional anemia. Copious, dilute urine should be expected during the diuretic phase of the burn injury. Jugular venous distention, dry cough, and the presence of S3 and S4 heart sounds indicate possible heart failure.

The nurse notes the previous shift's documentation that a client has a mild pitting edema with slight indentation and no perceptible swelling of the legs. What is the nurse's next action? 1. Imprint thumb firmly against legs. 2. Raise both legs on 2 to 3 pillows. 3. Administer diuretic intravenously. 4. Ask client to dangle both legs off side of bed.

1. Imprint thumb firmly against legs. Rationale: The nurse has reviewed chart documentation and needs to perform further assessment next to determine the current extent of edema. Edema is fluid accumulating in the intercellular spaces and is not normally present. To check for edema, the nurse should imprint her or his thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, "pitting" edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen. None of the other options are related to assessment of this condition.

What product should the nurse use when giving mouth care to a client with impaired oral mucous membranes? Select all that apply. 1. Lip moistener 2. Soft toothbrush 3. Lemon-glycerin swabs 4. Nonalcoholic mouthwash 5. A prescribed pain reliever

1. Lip moistener 2. Soft toothbrush 4. Nonalcoholic mouthwash 5. A prescribed pain reliever Rationale: The nurse should avoid using lemon-glycerin swabs for the client with impaired oral mucous membranes, because they dry the membranes further and could cause pain. Items that are helpful include lip moistener to prevent lip cracking; a soft toothbrush to prevent trauma; soothing cleansing rinses, such as nonalcoholic mouthwash or other prescribed mixture; and a pain reliever, if not contraindicated.

The nurse is developing a plan of care for a client who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions should be included in the nursing care plan to prevent skin breakdown? Select all that apply. 1. Minimize the force and friction applied to the skin. 2. Massage vigorously over bony prominences twice daily. 3. Perform a systematic skin inspection at least once a day. 4. Cleanse the skin at the time of soiling and at routine intervals. 5. Use pillows to keep the knees and other bony prominences from direct contact with one another. 6. Use hot water and a mild cleansing agent that minimizes irritation and dryness of the skin when bathing the client.

1. Minimize the force and friction applied to the skin. 3. Perform a systematic skin inspection at least once a day. 4. Cleanse the skin at the time of soiling and at routine intervals. 5. Use pillows to keep the knees and other bony prominences from direct contact with one another. Rationale: The client in this question is at high risk for pressure injury. Interventions for prevention of pressure injuries include minimizing the force and friction applied to the skin; performing a systematic skin inspection at least once a day, giving particular attention to the bony prominences; cleansing the skin at the time of soiling and at routine intervals; avoiding the use of hot water; and using a mild cleansing agent that minimizes irritation and dryness of the skin. Pillows should be used to keep the knees and other bony prominences from direct contact with one another, because skin contact can promote breakdown. Massaging over bony prominences (especially vigorous) can be harmful to at-risk skin surfaces.

The client diagnosed with jaundice is reporting pruritus. Which strategy should the nurse institute to help control the problem and avoid injury? 1. Pat the skin dry after bathing. 2. Maintain a warm environment. 3. Bathe the client with hot water only. 4. Avoid application of emollient creams.

1. Pat the skin dry after bathing. Rationale: The nurse should pat the client's skin dry after bathing or showering. Rubbing should be avoided because it may lead to further injury. A cool environment should be maintained because a warm environment may promote further drying and increased sweating, which should be avoided. The client should be bathed with tepid water rather than hot water. Emollient creams and lotions can be applied regularly to alleviate dryness.

The nurse reviews the record of a client scheduled for removal of a skin lesion. The record indicates that the lesion is an irregularly shaped, pigmented papule with a blue tone. Which is the most likely initial treatment to be prescribed for the client? 1. Radiation therapy 2. Antiviral therapy 3. Topical antibiotics 4. Continued observation

1. Radiation therapy Rationale: A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue tone. Treatment includes surgical excision followed by chemotherapy, radiotherapy, and/or possibly immunotherapy. Melanoma is cancerous, not viral or bacterial. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with dry, rough, adherent yellow or brown scale. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm nodular lesion topped with a crust or a central area of ulceration.

An industrial nurse is providing instructions to a group of employees regarding care to a victim in the event of a chemical burn injury. Which immediate action should the nurse instruct the employees to perform? 1. Remove all clothing, including gloves and shoes. 2. Determine the antidote for the chemical and place the antidote on the burn site. 3. Leave all clothing in place until the client is brought to the emergency department. 4. Lavage the skin with water, and avoid brushing powdered chemicals off the clothing to prevent further spread of the injury.

1. Remove all clothing, including gloves and shoes. Rationale: In a chemical burn injury, the burning process continues as long as the chemical is in contact with the skin. All clothing, including gloves and shoes, is immediately removed and water lavage is instituted before and during the transport to the emergency department. Trying to determine the antidote will delay necessary and immediate intervention. Additionally, depending on the type of chemical that caused the injury, there may not be an antidote. Powdered chemicals are first brushed from the clothing and the skin before lavage is performed.

During the inspection of a client's skin, the nurse notes redness and an abrasion-type wound on the sacral area. What is the nurse's most appropriate action? 1. Turn client and re-position often. 2. Apply antibiotic cream twice a day. 3. Direct massage at frequent intervals. 4. Leave the area open to air and monitor.

1. Turn client and re-position often. Rationale: The assessment findings are consistent with a stage 2 pressure injury. The client should be turned and re-positioned often to relieve pressure and prevent further skin breakdown. Another appropriate intervention is to cover the area with a clear semipermeable dressing versus leaving open to air. Direct massage is not indicated and may cause further damage. Antibiotic cream is not indicated unless obvious infection is noted.

The nurse is reviewing the nursing care plan of a client for whom a stage 4 pressure injury has been documented. Which should the nurse expect to note on assessment of the client? 1. Intact skin over all other bony prominences 2. A deep injury that extends into muscle and bone 3. An area in which the top layer of skin is missing 4. A reddened area that eventually returns to normal skin color

2. A deep injury that extends into muscle and bone Rationale: A stage 4 pressure injury is a deep ulcer that extends into muscle and bone. It has a foul smell, and the eschar is brown or black. Purulent drainage is common. In a stage 1 injury, the skin is intact, but the area may appear pale when pressure is first removed. A stage 1 injury is also identified by a reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief. A stage 2 injury is an area in which the top layer of skin is missing.

A client is due in hydrotherapy for a burn dressing change in 30 minutes. What intervention should the nurse implement immediately? 1. Get out a robe and slippers for the client. 2. Administer an opioid analgesic to the client. 3. Gather dressing supplies to send with the client. 4. Place the client on nothing per mouth (NPO) status.

2. Administer an opioid analgesic to the client. Rationale: The client should receive pain medication approximately 20 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. A robe and slippers are given to the client for transport but are not indicated 30 minutes ahead of time. Dressing supplies are not sent with the client because they are available in the hydrotherapy area. The client does not need to be NPO for this procedure.

The nursing instructor is conducting a teaching session on the integumentary system and is describing the different types of secondary skin lesions. Which skin lesion does the nurse expect to observe when a client picks at the skin often and the skin becomes excoriated? 1. Loss of the epidermis and the dermis 2. An area in which epidermis is missing, exposing the dermis 3. Abnormal formation of connective tissue that replaces normal skin 4. Depression in the skin resulting from thinning of the epidermis or dermis

2. An area in which epidermis is missing, exposing the dermis Rationale: Excoriation is described as an area in which epidermis is missing, exposing the dermis. Loss of epidermis and dermis describes an ulcer. Abnormal formation of connective tissue describes a scar. Depression of the skin from thinning describes atrophy.

Skin closure with heterograft will be performed on a client with a burn injury. When the client asks the nurse where the heterograft comes from, the nurse should explain it is from which source? 1. A cadaver 2. Another animal species 3. The burned client themselves 4. A man-made synthetic source

2. Another animal species Rationale: Biologic dressings are usually heterograft or homograft material. Heterograft is skin from another species. The most commonly used type of heterograft is pig skin because of its availability and its relative compatibility with human skin. Homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank. Autograft is skin from the client. Synthetic dressings are also available for covering burn wounds.

Which nursing intervention is initially best to preserve skin integrity for an immobile client? 1. Provide assistive devices to decrease inactivity. 2. Establish an individualized turning and repositioning schedule. 3. Obtain consent for side rails, which can be used for the client to reposition self in bed. 4. Obtain consent from the client's family to provide physical therapy service to the client.

2. Establish an individualized turning and repositioning schedule. Rationale: Initially, the best intervention for the client who is immobile is to place the client on an individualized turning and repositioning schedule. Additionally, the nurse should take measures to reduce friction and shear and provide a pressure-relief surface for the client. The client who is immobile may or may not benefit from assistive devices or side rails. Although a certain degree of passive physical therapy can be provided, a more effective intervention in preventing breaks in skin integrity is a consistent and individualized turning and repositioning schedule.

The nurse is caring for a client diagnosed with a fungal disease of the nails caused by dermatophytes. The client is receiving terbinafine hydrochloride 250 mg orally daily. Which sign/symptom indicates that the client is experiencing a side effect of the medication? 1. Fever 2. Headache 3. Constipation 4. Tingling of the extremities

2. Headache Rationale: Terbinafine hydrochloride is an antifungal medication. A frequent side effect of the medication is headache. Occasional side effects include diarrhea, rash, dyspepsia, pruritus, taste disturbances, and nausea. Abdominal pain, flatulence, urticaria, and visual disturbances can occur but are rare. Fever, constipation, and tingling of the extremities are not associated with this medication.

A client was evacuated from under a burning car and transported to the emergency department. In route to the emergency department, the client received oxygen via nasal cannula at 2 liters per minute. An intravenous (IV) line was initiated, and lactated Ringer's was infused at 125 mL per hour. The initial assessment on arrival at the emergency department revealed an oxygen saturation of 84%, and lung sounds were diminished on the left side. An obvious deformity of the left femur was present. The nurse analyzes this information and determines that what is the priority intervention? 1. Place a splint on the left leg to stabilize the fracture. 2. Increase the oxygen delivery by placing a 100% oxygen mask on the client. 3. Increase the IV infusion rate of lactated Ringer's to help perfusion to vital organs. 4. Cover the burn wounds to decrease the risk of contamination and prevent hypothermia.

2. Increase the oxygen delivery by placing a 100% oxygen mask on the client. Rationale: The client is exhibiting numerous symptoms, but the inadequate oxygenation, evidenced by the low oxygen saturation and decreased breath sounds, is the priority. Although burn wound contamination and hypothermia are concerns, they are not the priority at this time in this situation. Adequate fluid resuscitation is a concern secondary to oxygenation. Stabilization of the fracture would also be done once adequate oxygenation is ensured.

A client diagnosed with severe psoriasis has low self-esteem. Which therapeutic strategy should the nurse use when working with this client? 1. Keep communications brief. 2. Listen attentively to the client. 3. Approach the client in a formal manner. 4. Pretend not to notice affected skin areas.

2. Listen attentively to the client. Rationale: Clients with chronic skin disorders may have low self-esteem because of the disorder itself and possible rejection by others. The nurse uses a quiet, unhurried manner, as well as appropriate visual contact, facial expression, and therapeutic touch to demonstrate acceptance of the client. Communications that are purposefully brief and formal may reinforce the feelings of rejection. These feelings may also be reinforced if the nurse obviously pretends not to notice the affected skin areas.

A client with compartment syndrome from a burn injury on the leg has undergone fasciotomy. The nurse reads the primary health care provider prescription sheet, anticipating a prescription for which type of dressings to be used on this wound? 1. Occlusive dressing 2. Moist, sterile, saline dressing 3. Dry, sterile dressing wrapped with an elastic bandage 4. Betadine-soaked dressing covered with a plastic wrap

2. Moist, sterile, saline dressing Rationale: A fasciotomy site is not sutured, but it is left open to relieve pressure and edema. The site is covered with moist, sterile, saline dressings because underlying tissue is exposed. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. The other types of dressings are not used on a fasciotomy site.

The nurse analyzes the test results of a client who sustained a high-voltage electrical injury. Which finding should the nurse interpret as increasing the client's risk of developing acute tubular necrosis? 1. Hyperkalemia 2. Myoglobin in the urine 3. Carbonaceous sputum 4. Cloudy cerebrospinal fluid

2. Myoglobin in the urine Rationale: Myoglobin can be released from damaged muscles and precipitate out in the renal tubules, causing acute tubular necrosis. Hyperkalemia commonly occurs after any cellular trauma or as a result of deteriorating renal function and cardiac dysrhythmias. Carbonaceous sputum occurs as a result of inhalation of smoke, as during a fire; this finding would indicate an inhalation injury. Cloudy cerebrospinal fluid would indicate meningitis. Additionally, assessing cerebrospinal fluid would not routinely be performed in a burn injury.

A client says to the nurse, "I hate these discolored areas on my skin." Based on this statement which problem should the nurse include in this client's plan of care? 1. Difficulty coping 2. Negative body image 3. Diminished skin integrity 4. Unrelieved low self-esteem

2. Negative body image

Which intervention will the nurse include in the care of a client scheduled for heterograft? 1. Suture care for the permanent graft 2. Postoperative care of temporary graft site 3. Blood sampling to cross match for human donor 4. Removal of staples 5 to 7 days postoperatively

2. Postoperative care of temporary graft site Rationale: A heterograft is a skin graft derived from another species, such as a pig. The heterograft is a temporary graft to allow for granulation formation until a more permanent graft is stapled into place. Cross matching is not necessary for a heterograft. Staples or sutures may be used after the more permanent autograft, not usually the heterograft.

The nurse is visiting a client who has been prescribed topical clotrimazole. The nurse should educate the client to the fact that this medication will alleviate which condition? 1. Pain 2. Rash 3. Fever 4. Sneezing

2. Rash Rationale: Clotrimazole is a topical antifungal used in the treatment of cutaneous fungal infections and will alleviate an associated rash. The nurse teaches the client that it is used for this purpose. It is not used for pain, sneezing, or fever.

The nurse performing a skin assessment of a client who is immobile notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents these findings as which stage pressure injury? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2. Stage 2 Rationale: In a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and may be characterized as an abrasion, blister, or shallow crater. The skin is intact in stage 1. A deep, craterlike appearance occurs in stage 3, and sinus tracts develop in stage 4.

The nurse is planning to teach a client with a below-the-knee amputation about skin care to prevent breakdown. Which point should the nurse include in the teaching plan? 1. The residual limb is washed gently and dried every other day. 2. The socket of the prosthesis must be dried carefully before it is used. 3. A sock must be worn at all times over the residual limb and changed twice a week. 4. The socket of the prosthesis needs to be washed with a strong bactericidal agent daily.

2. The socket of the prosthesis must be dried carefully before it is used. Rationale: The socket of the prosthesis is cleansed with a mild detergent, rinsed, and dried carefully each day. A strong bactericidal agent would not be used. A residual limb sock must be worn at all times to absorb perspiration, and it is changed daily. The residual limb is washed, dried, and inspected for breakdown twice each day.

A client is prescribed diphenhydramine 1% as a topical agent for allergic dermatosis. The nurse evaluates that the medication is having the intended effect when the client reports relief of what complaint? 1. Pain 2. Urticaria 3. Headache 4. Skin redness

2. Urticaria Rationale: Diphenhydramine is an antihistamine medication that has many uses. When used as a topical agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not act to relieve pain, headache, or skin redness.

A client has experienced a burn injury and demonstrates absent sensation to pinprick. Based on this assessment finding, which other finding does the nurse anticipate to observe? 1. A dry wound surface 2. White, waxy appearance 3. Charring superior to the wound site 4. A wet, shiny, weeping wound surface

2. White, waxy appearance Rationale: Decreased or absence of wound sensation would occur in full-thickness or deep full-thickness burns, along with a white, waxy appearance. Charring is observed at the wound site, not just superior to the site, in deep full-thickness burns. A partial-thickness superficial burn appears wet, shiny, and weeping, or it may contain blisters. The wound blanches with pressure, is painful, and is very sensitive to touch or air currents. A dry wound surface occurs in a more serious injury.

The emergency department nurse is caring for a client who experienced a burn injury. The client verbalizes decreased sensation to the injury site, and the wound appears dry with just a small amount of exudate. After providing first aid care and cleansing the burn injury, what is the nurse's best action? 1. Debride the injury to prevent any charring. 2. Pack the injury site with sterile, dry gauze. 3. Cover the injury with an antibacterial dressing. 4. Request a consult from the diabetes nurse educator.

3. Cover the injury with an antibacterial dressing. Rationale: A partial-thickness deep burn appears dry with little exudate and may be red or white in appearance. No blanching occurs, and thrombosed vessels may be visible. Decreased wound sensation will be present. Treatment includes covering with an antibacterial dressing. Charring would occur in deep full-thickness burns. The description in the question about the burn injury is not characteristic of charring; therefore, debridement is not a treatment. Total absence of wound sensation would occur in deep full-thickness burns due to damage to nerve endings, not diabetic neuropathy. In addition there is no information indicating that the client has diabetes. Packing with a dry gauze may cause further damage to a dry wound and is not an appropriate action.

During the emergent phase after a major burn injury, which abnormality should the nurse expect to note? 1. Increased albumin and decreased hematocrit 2. Decreased hemoglobin and increased sodium 3. Increased hematocrit and increased potassium 4. Decreased hemoglobin and decreased potassium

3. Increased hematocrit and increased potassium Rationale: During the emergent phase of the burn injury, the client's hemoglobin and hematocrit will be elevated because of fluid loss; sodium will be decreased because of trapping in edema fluid and loss through plasma leakage; potassium will be increased because of disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis; and albumin will be low because of loss through the wound and increased capillary permeability.

A client with a peripheral intravenous (IV) site tells the nurse that the IV site is swollen. The nurse assesses the IV site and notes that it is also cool and pale and that the IV has stopped running. The nurse documents which has occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

3. Infiltration Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution stops. The corrective action is to remove the catheter and start a new IV line. The other 3 options are likely to be accompanied by warmth at the site, not coolness.

A client is seen in the health care clinic where a biopsy confirms that a skin lesion is a malignant melanoma. The nurse prepares a plan of care for the client, based on which characteristic of this type of skin cancer? 1. It is the most common form of skin cancer. 2. It is a slow-growing cancer and seldom metastasizes. 3. It is an aggressive cancer that requires aggressive therapy to control its rapid spread. 4. It can grow so large that an entire area, such as the nose, the lip, or the ear, must be removed and reconstructed if it occurs on the face.

3. It is an aggressive cancer that requires aggressive therapy to control its rapid spread. Rationale: Malignant melanoma, commonly called melanoma, is cancer of the melanocyte cells of the skin. It is an aggressive cancer that requires aggressive therapy to control its spread. Basal cell carcinoma, also known as basal cell epithelioma, is the most common form of skin cancer. It is a slow-growing cancer and seldom metastasizes, but it can grow so large that the entire area of the nose, the lip, or the ear must be removed and reconstructed.

The nurse notes a new stage I pressure injury on a client's coccyx. Which interventions should the nurse implement? Select all that apply. 1. Use heat lamps in order to prevent further break in skin integrity. 2. Massage the reddened area to increase circulation to the affected area. 3. Measure and document the size of the pressure injury and its characteristics. 4. Use pressure-relieving devices such as a special air mattress in order to decrease pressure. 5. Place the client on an individualized turning and repositioning schedule to decrease pressure.

3. Measure and document the size of the pressure injury and its characteristics. 4. Use pressure-relieving devices such as a special air mattress in order to decrease pressure. 5. Place the client on an individualized turning and repositioning schedule to decrease pressure. Rationale: If an area is noted to be reddened, such as with a stage I pressure injury, the nurse should measure and document the size of the pressure injury and its characteristics for future assessment of the effectiveness of treatment. The use of pressure-relieving devices such as a special air mattress is warranted in order to decrease pressure. The client should be placed on an individualized turning and repositioning schedule to decrease pressure to the affected area. The nurse should also avoid the use of heat lamps because this can cause drying and cracking of the skin. The nurse should avoid massaging the area because this can result in a further break in skin integrity.

A client has undergone laser surgery to remove two nevi. What information should the nurse include in the discharge instructions given to the client? 1. Scrub the affected areas daily to prevent infection. 2. Expect frequent episodes of discomfort after the procedure. 3. Protect the areas from direct sunlight for at least 3 months. 4. Report any swelling or redness to the primary health care provider immediately.

3. Protect the areas from direct sunlight for at least 3 months. Rationale: After laser surgery removal of any type of skin lesion, the skin should be protected from direct sunlight for a minimum of 3 months. The area should be cleansed gently with half-strength hydrogen peroxide twice a day after the dressing is removed, which is usually done 24 hours after the procedure. There should be minimal or no discomfort after the procedure; if present, it should be easily relieved with acetaminophen. Redness and swelling are expected after this procedure.

The emergency department nurse prepares to treat a client who has frostbite of the toes. What should the nurse anticipate to be prescribed for this condition? 1. Rapid rewarming of the toes in hot water 2. Rapid and continuous alternating cold and hot soaks of the toes 3. Rapid and continuous rewarming of the toes in a warm water bath 4. Rapid rewarming of the toes by soaking in cold water for 45 minutes

3. Rapid and continuous rewarming of the toes in a warm water bath Rationale: Acute frostbite is ideally treated with rapid and continuous rewarming of the tissue in a water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because this can contribute to increased cellular damage. Thawing can cause considerable pain, and the nurse would administer analgesics as prescribed.

A client is seen in the health care clinic for the treatment of lesions on the elbows and the knees. The lesions consist of red raised papules, and large plaques covered by silvery scales. The nurse determines that the client needs further teaching if the client states that which is a component of the treatment plan? 1. Tar baths 2. Topical lubricants 3. Systemic corticosteroids 4. Ultraviolet light treatments

3. Systemic corticosteroids Rationale: The client's symptoms are consistent with psoriasis. Systemic corticosteroids are not normally used to treat psoriasis. Even though systemic corticosteroids will quickly stop an exacerbation, after withdrawal of the corticosteroids, a rebound effect occurs. This steroid rebound will cause an immediate exacerbation or will convert the plaque or exfoliative type of psoriasis to pustular. Tar baths, topical lubricants, and UV lights are appropriate treatments for psoriasis.

A client tells the clinic nurse that her skin is very dry and irritated. Which product should the nurse suggest that the client apply to the dry skin? 1. Myoflex 2. Aspercreme 3. Topical emollient 4. Acetic acid solution

3. Topical emollient Rationale: A topical emollient is used for dry, cracked, and irritated skin. Aspercreme and Myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected with Pseudomonas aeruginosa.

A client is seen in the health care clinic with reports of pruritus. After diagnostic studies, it has been determined that there is not a pathophysiological process causing the pruritus. The nurse prepares instructions for the client to assist in reducing the problem and should tell the client to follow which instructions? 1. Use a dehumidifier in the home. 2. Avoid the use of skin moisturizers after a bath. 3. Use a cool-mist vaporizer, especially in winter months. 4. Ensure that the temperature in the home is high.

3. Use a cool-mist vaporizer, especially in winter months. Rationale: Itching can be a symptom of systemic disease, such as severe liver or renal disease. It can also occur because of medication hypersensitivity or blood reactions, and it may occur in the older client as a result of dry skin. Heat and low humidity also induce pruritus. During the winter months, using a moisturizer and increasing room humidity with a cool-mist vaporizer are advantageous to alleviate the problem.

The nurse is preparing a plan of care for a client with a diagnosis of acute cellulitis of the lower leg. The nurse anticipates which measure will be prescribed to treat this condition? 1. Heat lamp treatments 4 times daily 2. Cold compresses to the affected area 3. Warm, moist compresses to the affected area 4. Alternating hot to cold compresses every 2 hours

3. Warm, moist compresses to the affected area Rationale: Warm, moist compresses may be used to decrease the discomfort, erythema, and edema that accompany cellulitis. After tissue and blood cultures are obtained, antibiotic therapy will be initiated. The nurse should provide supportive care, as prescribed, to manage symptoms such as fatigue, fever, chills, headache, and myalgia

The nurse is caring for a client diagnosed with a venous stasis ulcer that is clean and has a growing bed of granulation tissue. The nurse reviews the primary health care provider's prescription for the dressing change and should question which dressing material if prescribed for this wound? 1. Hydrocolloid dressing 2. Vaseline gauze dressing 3. Wet-to-dry saline dressing 4. Wet-to-wet saline dressing

3. Wet-to-dry saline dressing Rationale: The use of wet-to-dry saline dressings provides a nonselective mechanical debridement, whereby both devitalized and viable tissues are removed. This method should not be used on a clean, granulating wound. Granulation tissue in a venous stasis ulcer is protected through the use of wet-to-wet saline dressings, Vaseline gauze, or moist occlusive dressings, such as hydrocolloid dressings.

A client describes a rash as red, raised, and itchy. The client used an over-the-counter hydrocortisone cream for 1 week, and the rash seemed to worsen. After assessment of the situation, which statement by the nurse would be appropriate? 1. "Ask your pharmacist what to use." 2. "Give the hydrocortisone cream another week." 3. "Take diphenhydramine hydrochloride because you must be allergic to the cream." 4. "You should call your primary health care provider for an appointment and have the rash looked at."

4. "You should call your primary health care provider for an appointment and have the rash looked at." Rationale: Hydrocortisone is the topical treatment of choice for cutaneous inflammation and pruritus associated with contact dermatitis. If a rash does not respond to this over-the-counter medication, it should be evaluated by a primary health care provider. Remaining options are incorrect nursing responses. A pharmacist cannot assess, diagnose, or treat any potential complications the client may be experiencing. Waiting more than 7 days is not advisable if the client has not yet been evaluated by a licensed provider. The nurse should not recommend further treatment until the client has been evaluated by a provider.

A client presented to the health care clinic with a linear rash with vesicles that are seen across two dermatomes on the back. The nurse gathering the items needed to perform the diagnostic test to confirm this diagnosis will include what equipment? 1. A biopsy kit 2. A Wood's light 3. A patch test kit 4. A culture swab and tube

4. A culture swab and tube Rationale: The client's assessment findings are consistent with herpes zoster. Herpes zoster is caused by a reactivation of the varicella-zoster virus, the cause of the virus for chickenpox. With classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. A biopsy will determine tissue type. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. A patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies.

A client with dry skin is in need of a moisturizing agent. Which product should the nurse choose in order to be most effective? 1. An oil-based cream 2. A lotion moisturizer 3. Oil for the bath water 4. A petrolatum-based ointment

4. A petrolatum-based ointment Rationale: Petrolatum provides the most effective moisturizing by forming an occlusive barrier on the skin and reducing water loss. Creams and lotions are mostly water based, less occlusive, and less likely to reduce skin dryness than petrolatum-based products. Bath oils are not as effective as a petrolatum-based product.

The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding should the nurse expect to note in this condition? 1. A pink edematous hand 2. Red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white appearance to the skin that is insensitive to touch

4. A white appearance to the skin that is insensitive to touch Rationale: Assessment findings in frostbite include a white or blue appearance, and the skin will be hard, cold, and insensitive to touch. As thawing occurs, the skin becomes flushed, blisters or blebs develop, or tissue edema appears. Gangrene develops in 9 to 15 days.

The nurse performing a skin assessment on an older adult client notes the presence of lesions that are red-tan scaly plaques. What is the most likely cause of this finding? 1. Xerosis 2. Pruritus 3. Seborrhea 4. Actinic keratoses

4. Actinic keratoses Rationale: Actinic keratoses refer to lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Dry skin is called xerosis. In this condition, the epidermis lacks moisture or sebum and is often characterized by a pattern of fine lines, scaling, and itching. Causes include bathing too frequently, low humidity, and decreased production of sebum in aging skin. Pruritus refers to the symptom of itching, an uncomfortable sensation that leads to the urge to scratch the skin. Seborrhea relates to any of several common skin conditions in which an overproduction of sebum results in excessive oiliness or dry scales.

After 7 days of wound care, a client who has a well-granulated pressure injury reports "feeling better overall" to the nurse. Which nursing intervention most likely contributes to the client feelings? 1. Pain management program 2. Frequent comfort measures 3. Dressing change twice daily 4. Ambulation three times daily

4. Ambulation three times daily Rationale: The effects of exercise include client reports of feeling better generally, because the benefits of exercise are wide-ranging. Ambulation can decrease the need for pain medication and comfort measures in addition to providing enhanced tissue oxygenation and other cardiovascular, pulmonary, metabolic, integumentary, neuromuscular, and conditioning benefits. Therefore, the wide-ranging benefits of exercise are more likely to promote an overall sense of feeling better versus benefiting from pain control, less discomfort, or a well-granulated wound. The benefits of pain management, comfort measures, and dressing changes are more limited.

The nurse is monitoring the client who had been prescribed amphotericin B. Which laboratory value would be of most concern to the nurse? 1. Uric acid 5.0 mg/dL (0.29 mmol/L) 2. Glomerular filtration rate 125 mL/hr 3. Serum creatinine 0.7 mg/dL (61.6 mcmol/L) 4. Blood urea nitrogen 30 mg/dL (10.8 mmol/L)

4. Blood urea nitrogen 30 mg/dL (10.8 mmol/L) Rationale: Amphotericin B is classified as an antifungal medication. This medication should be used with caution in clients with renal impairment. A blood urea nitrogen level of 30 is elevated (normal level is 10 to 20 mg/dL [3.6 to 7.1 mmol/L]). The normal uric acid level for a female is 2.7 to 7.3 mg/dL (0.16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). The normal serum creatinine level for a female is 0.5 to 1.1 mg/dL (44 to 97 mcmol/L) and for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L). The normal glomerular filtration rate is 125 mL/hr.

An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats per minute, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths per minute. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats per minute, BP 130/80 mm Hg, and respirations 20 breaths per minute. Which factor likely accounts for the change in vital signs? 1. Cooling effects of the cleansing agent 2. Client's adaptation to the air conditioning 3. Early clinical indicators of cardiogenic shock 4. Decline in sympathetic nervous system discharge

4. Decline in sympathetic nervous system discharge Rationale: Physical or emotional stress triggers sympathetic nervous system stimulation. Increased epinephrine and norepinephrine cause tachycardia, high blood pressure, and tachypnea. Stress reduction then returns these parameters to baseline as the sympathetic discharge falls. Options 1 and 2 are unrelated to the changes in vital signs. Because the client's vital signs remain within normal limits, the client exhibits no indication of cardiogenic shock.

A client has sustained second-degree burns over 45% of his body. The burn unit nurse anticipates that which most likely affected areas require treatment? 1. Entire right and left legs 2. Entire right leg and right arm 3. Entire right and left arms and anterior thorax 4. Entire right leg and right arm and anterior thorax

4. Entire right leg and right arm and anterior thorax Rationale: According to the rule of nines, the right arm is equal to 9%, and the left arm is equal to 9%. The right leg is equal to 18%, and the left leg is equal to 18%. The anterior thorax is equal to 18%, and the posterior thorax is equal to 18%. The head is equal to 9%, and the perineum is 1%. If the anterior thorax (18%), entire right leg (18%), and entire right arm (9%) were burned, according to the rule of nines, this would equal 45%. "Entire right and left legs" equals 36%, "Entire right leg and right arm" equals 27%, and "Entire right and left arms and anterior thorax" equals 36%.

A client who sustained an inhalation burn injury arrives in the emergency department. On assessment of the client, the nurse notes that the client is very confused and combative. The nurse should be most alert to which priority reaction to the injury? 1. Fear 2. Pain 3. Anxiety 4. Hypoxia

4. Hypoxia Rationale: After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. Although the client may experience fear, pain, and anxiety, these are not the priority cause of the client's confusion and combativeness. The effects of hypoxia will result in a much greater physical decline in the client's status than will either fear, pain, or anxiety.

A client has experienced a superficial skin tear on the arm. Which dressing material should the nurse use to cover the wound? 1. Enzyme dressing 2. Nonstick dressing 3. Dry, sterile dressing 4. Semipermeable film dressing

4. Semipermeable film dressing Rationale: Semipermeable film dressings are used on superficial skin tears or ulcers. These dressings have the advantage of staying in place for several days, allowing tissues to heal underneath. Nonstick dressings do not adhere to a wound, but they are not as helpful as the semipermeable film dressing for healing. Dry, sterile dressings would stick to the wound and are inappropriate. An enzyme dressing is used in the treatment of necrotic tissue.

A client is seeking treatment for an infection that extends into the subcutaneous fat of the foot with diffuse, deep red erythema. After the client is diagnosed by the primary health care provider, what is the nurse's best response when asked to explain the diagnosis? 1. It is an acute superficial infection caused by burns. 2. It is an inflammation of the epidermis caused by allergies. 3. It is an epidermal infection caused by Staphylococcus, a type of bacteria. 4. It is a skin infection into the deep layer of skin and subcutaneous fat.

4. It is a skin infection into the deep layer of skin and subcutaneous fat. Rationale: The client's findings are consistent with cellulitis. Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red erythema without sharp borders, and that spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute superficial and rapidly spreading inflammation of the dermis and lymphatic tissue.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious scaly, wart-like lesion. The primary health care provider suspects a squamous cell carcinoma and recommends surgical excision. The nurse plans care, knowing that which describes the characteristic of this type of lesion? 1. It is encapsulated. 2. It is highly metastatic. 3. It does not metastasize. 4. It is characterized by local invasion.

4. It is characterized by local invasion. Rationale: Differentiating signs of squamous cell carcinomas are scaly, wart-like appearing lesions that do not heal or go away. Squamous cell carcinomas are malignant neoplasms of the epidermis that are not encapsulated. They are characterized by local invasion and the potential for metastasis, though not highly likely. Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas are highly metastatic, and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and, although metastasis is rare, underlying tissue destruction can progress to include vital structures.

The infection control nurse provides an educational session to the nursing staff regarding the assessment findings associated with scabies. Which description should the infection control nurse provide? 1. The appearance is of vesicles or pustules. 2. White patches are scattered about the trunk. 3. There is patchy hair loss and round, red macules with scales. 4. Multiple straight or wavy threadlike lines are visible beneath the skin.

4. Multiple straight or wavy threadlike lines are visible beneath the skin. Rationale: Scabies can be identified by the multiple straight or wavy threadlike lines noted beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the skin and lays its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle.

A hospitalized client is prescribed 5% permethrin cream. Which finding should the nurse expect to note on inspection of the client's skin? 1. The appearance of vesicles or pustules 2. Patchy hair loss and round, red macules with scales 3. The presence of white patches scattered about the trunk 4. Multiple straight or wavy threadlike lines beneath the skin

4. Multiple straight or wavy threadlike lines beneath the skin Rationale: Permethrin is the most common treatment for scabies. Scabies can be identified by the presence of multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by a female mite that burrows beneath the skin and lays its eggs. Vesicles, hair loss, and white patches are not characteristics of scabies.

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 at risk for which problem? 1. Anxiety 2. Feeling helpless 3. Low self-esteem 4. Negative self-image

4. Negative self-image Rationale: The client with a burn injury experiences structural and functional changes of the integumentary system as a result of this injury. The client problem of negative self-image refers to a disruption in the way one perceives one's body image. A verbal or nonverbal response to an actual or perceived change in structure or function of the body must be present to justify this problem. Anxiety, helplessness, and low self-esteem do not relate to the client's statement.

A client has been brought to the emergency department by emergency medical technicians (EMTs). The EMT reports that the client has experienced thermal burns. On assessment, the nurse should expect to note which manifestations? 1. Headache and dizziness 2. Nausea and dehydration 3. Cardiac fibrillation and chest pain 4. Singed eyebrows and nasal hairs

4. Singed eyebrows and nasal hairs Rationale: Exposure to or contact with flames, hot liquids, or hot objects causes thermal burns. Thermal burns are those sustained in residential fires, explosive accidents, scald injuries, or ignition of clothing or liquids. If the nurse notes facial burns or singed eyebrow or nasal hairs, the victim likely experienced the burn in an enclosed smoke-filled space, such as in a residential fire. Electrical burns are caused by heat that is generated by the electrical energy as it passes through the body, and cardiac fibrillation is a potential complication. Chemical burns are caused by tissue contact with strong acids, alkalis, or organic compounds. Headache and dizziness may be related to a chemical burn. Radiation burns are caused by exposure to a radioactive source. The radioactive source may be radiation therapy or the ultraviolet rays of the sun. Radiation burns related to the sun may be manifested by nausea and dehydration.

The nurse is assigned to care for a client recently diagnosed with a melanoma of the skin. The client's family asks about their loved one's prognosis. What is the nurse's best response? 1. This form of cancer is rarely treatable. 2. This cancer rarely causes metastasis throughout the body. 3. Survival will depend solely on a successful bone marrow transplant. 4. Treatment will be started right away to increase the survival rate.

4. Treatment will be started right away to increase the survival rate. Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis, not the bone marrow. This skin cancer is highly metastatic, and survival depends on early diagnosis and implementation of the treatment plan. It is not contagious.

The nurse reviews the record of a client who is receiving external radiation therapy and notes documentation of a skin finding as moist desquamation. Which finding on assessment of the client should the nurse expect to observe? 1. A rash 2. Dermatitis 3. Reddened skin 4. Weeping of the skin

4. Weeping of the skin Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. A rash, dermatitis, and reddened skin may occur with external radiation, but these conditions are not described as moist desquamation.