LPNC 103: integumentary disorders and burn questions

A nurse is assisting with the care of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? a. Hemoglobin 10 g/dL b. Sodium 132 mEq/L c. Albumin 3.6 g/dL d. Potassium 4.0 mEq/dL

b. Sodium 132 mEq/dL Rationale: The nurse should anticipate a client who is in the resuscitation phase of a burn injury to have a low sodium level because sodium is trapped in interstitial space.

A nurse is reinforcing teaching with the parent of a child who has contact dermatitis. Which of the following information should the nurse include? a. Use fabric softener dryer sheets when drying the child's clothing b. Apply a warm, dry compress to the rash area c. Place the child in a bath with colloidal oatmeal d. Leave the child's hands uncovered during the night

Correct answer: C Rationale: a colloidal oatmeal bath will relieve th child's itching

A nurse is reinforcing teaching with a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include in the teaching? a. Apply vitamin A cream before each treatment b. Administer a psoralen medication before the treatment c. Use the treatment every evening d.Remove the scales gently following each treatment

Correct answer: b Rationale: PUVA treatment involves the administration of a medication, such as a psoralen, to enhance photosensitivity

A nurse caring for a client who has contact dermatitis and a new prescription for diphenhydramine. For which of the following adverse effects should the nurse monitor? a. Elevated blood glucose levels b. Urinary retention c. Hyperpigmentation of the skin d. Insomnia

Correct answer: b Rationale:the nurse should monitor the client's urinary output, as retention is a possible adverse effect of diphenhydramine

A nurse is assisting with the care of a client with sustained deep partial-thickness and full-thickness burns over 60% of his body 24 hr ago and requesting pain medication. The nurse should ensure the medication is administered using which of the following routes to administer the medication? a. Subcutaneous b. Oral c. Intravenous d. Transdermal

Correct answer: c Rationale: the nurse should ensure the use of the IV route for the administration of pain medication for rapid absorption and fast pain relief during the resuscitation phase

A nurse is reviewing information about a new prescription for corticosteroid cream with a client who has mild psoriasis. Which of the following instructions should the nurse include? (select all that apply.) a. Apply an occlusive dressing after application b. Apply three to four times a day c. Wear gloves after application to lesions on the hands d. Avoid applying in skin folds e. Use medication continuously over a period of several months

Correct answers: a, c, d. Rationale: an occlusive dressing can enhance the efficacy of the topical corticosteroid on the exposed lesions. Wearing gloves after applying the medication can enhance the efficacy of the topical corticosteroid on the exposed lesions on the hands. Applying corticosteroid cream to lesions in the skin folds increased the risk of yeast infections.

A nurse is assisting with the plan of care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a. limit visitors in the clients room b. encourage fresh vegetables in the diet c. increase protein intake d. instruct client to consume 2,000 calories/day e. Restrict fresh flowers in the room

Correct answers: a, c, e Rationale: the nurse should limit the number of visitors and the amount of time they can visit to decrease the risk of infection. The client should increase protein consumption, which promotes wound healing and prevents tissue breakdown. Flowers should not be in the client's room due to the bacteria they carry, which increase the risk for infection

a nurse is reinforcing teaching with a female client on the use of calcipotriene topical medication for psoriasis. Which of the following information should the nurse include? (select all that supply.) a. Recommended for facial lesions b. Expect a stinging sensation upon application c. Apply to the scalp d. Obtain a pregnancy test e. Limit application to skin folds

Correct answers: b, c, d, e Rationales: Calcipotriene causes stinging and burning sensations when applied to the lesions. Calcipotriene solution is applied to the scalp lesions. Calcipotriene can cause birth defects. Clients should obtain a pregnancy test before using the medication. Applying calciportriene to skin folds can cause a possible local reaction of itching, irritation, and erythema.

A nurse is reinforcing teaching with a client who has burn injuries to his trunk about what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? a. "I will be on a special shower table." b. "The water temperature will be very cool to ease my pain." c. "The nurse will use a firm-bristled brush to remove loose skin." d. "The nurse will use scissors to open small blisters."

a. "I will be on a special shower table." Rationale: Hydrotherapy is a special shower table that facilitates examination and debridement of the wound. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature and there is a lower risk of wound infection.

a nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? a. "May I go with my family to the visitor's lounge?" b. "I'll see my friends one day when I feel better." c. "My dad is coming to visit. Can you fix my hair for me?" d. "I told my cousins I'm in protective isolation."

a. "May I go with my family to the visitors lounge?" Rationale: This statement demonstrates a positive self-image. The client is asking to visit with her family in a public setting.

A nurse in an urgent care clinic is caring for a client who has a snakebite on her arm. Which of the following actions should the nurse take? a. Immobilize the limb at the level of the heart b. Apply a tourniquet to the affected limb. c. Use a sterile scapula to incise the wound. d. Apply ice to the skin over the snakebite wound.

a. Immobilize the limb at the level of the heart. Rationale: The emergency management of a client who has a snakebite focuses on limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart.

A nurse in a provider's office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which of the following skin lesions? a. Papules b. Macules c. Wheals d. Vesicles

a. Papules Rationale: A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Warts and elevated moles are examples of papules.

A nurse is reinforcing discharge teaching with a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of malignancy of a mole? a. Ulceration b. Blanching of surrounding skin c. Dimpling d. Fading of color

a. Ulceration Rationale: Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.

A nurse is assisting with the development of an education session about malignant melanoma for a group of clients. The nurse should include that which of the following clients has an increased risk for developing malignant melanoma? a. A client who has brown eyes b. A client who has a light complexion c. A client who has black hair d. A client who is 20 years of age

b. A client who has a light complexion Rationale: A light complexion and less pigmentation place a client at an increased risk for developing malignant melanoma.

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? a. Zoster Vaccine b. Acyclovir c. Amoxicillin d. Infliximab

b. Acyclovir Rationale: The nurse should anticipate a prescription for acyclovir, an antiviral medication, because it inhibits replication of the virus that causes herpes zoster.

A nurse is caring for a client who has been applying silver sulfadiazine cream to a deep partial-thickness arm burn for the past 2 weeks. The nurse should monitor the client for which of the following adverse effects? a. Hyponatremia b. Leukopenia c. Hyperchloremia d. Elevated BUN

b. Leukopenia Rationale: Transient leukopenia is an adverse effect of silver sulfadiazine; therefore, the nurse should monitor the client for an allergic reaction causing a decrease in the client's WBC count.

A nurse is caring for a client whose wounds are covered with the heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? a. Cadaver skin b. Pig skin c. Amniotic membranes d. beef collagen

b. Pig skin Rationale: Heterografts are obtained from an animal, usually a pig.

a nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses should the nurse make? a. Basal cell carcinomas b. Melanomas c. Actinic keratoses d. Squamous cell Carcinomas

b. melanomas Rationale: Melanomas are malignant neoplasms with atypical melanocytes in both the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases in the bone, liver, lungs, spleen, the CNS, and lymph nodes.

A nurse is assisting with the development of a program to educate clients about measures to reduce the risk of skin cancer. Which of the following instructions should the nurse include? a. Re-apply sunscreen every 4 hr during sun exposure b. Wear a sun visor instead of a hat when outside in the sun c. Avoid exposure to the midday sun d. Use a tanning booth instead of sunbathing outdoors.

c. Avoid exposure to the midday sun. Rationale: The nurse should instruct clients to avoid skin exposure to the sun between 1100 and 1500 because sun rays are the strongest during that time.

A nurse is observing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? a. First-degree frostbite b. Second-degree frostbite c. Third-degree frostbite d. Fourth-degree frostbite

c. Third-degree frostbite. Rationale: When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled and the skin does not blanch.

A nurse is reinforcing teaching with a client who has a large would healing by second intention. The nurse should instruct the client that which of the following nutrients promotes wound healing? a. Vitamin B1 b. Calcium c. Vitamin C d. Potassium

c. Vitamin C Rationale: Rationale: A diet high in protein and vitamin C is recommended because these nutrients promote wound healing.

A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? a. partial-thickness burn b. Stage 3 pressure ulcer c. surgical incision d. Dehisced sternal wound

c. surgical incision rationale: With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention.

A nurse in a provider's office is collecting data from a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? a. superficial thickness b. superficial partial thickness c. deep partial thickness d. full thickness

correct answer: a Rationale: a sunburn is a superficial thickness burn. Superficial burns damage the top layer of the skin

A nurse is caring for a client who has sustained burns over 35% of his total body surface are. Most of the burns are full-thickness burns on the arms, face, neck, shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. These findings are indications of which of the following? a. pulmonary edema b. bacterial pneumonia c. inhalation injury d. carbon monoxide poisoning

correct answer: c Rationale: wheezing and hoarseness indicate inhalation injury with impeding loss of the airway. These require immediate reporting to the provider

A nurse is assisting with the care of a client who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hr ago. Which of the following findings should the nurse expect? (select all that apply) a. Dyspnea b. Bradycardia c. Hyperkalemia d. Hyponatremia e. Decreased Hematocrit

correct answers: a, c, d Rationales: Dyspnea can occur during the initial phase following a burn due to airway injury and fluid shifts. Hyperkalemia occurs during the the initial phase following a burn as a result of leakage of fluid from the intracellular space space. Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space

A nurse is reinforcing teaching with a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? a. "Move between the bed and the wheelchair once every 2 hours." b. "Make sure that your caregiver massages your skin daily." c. "Use a rubber ring when sitting in the wheelchair." d. "Shift your weight in the wheelchair every 15 minutes."

d. "Shift your weight in the wheelchair every 15 minutes." Rationale: This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure.

A nurse is assisting with the admission of a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? a. 4 b. 1 c. 3 d. 2

d. 2 Rationale: With a stage II pressure ulcer, there is a partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage.

A nurse is collecting data from a client who has an arm lesion. Which of the following characteristics is a clinical manifestation of a malignant melanoma? a. rough, dry, and scaly b. firm nodule with crust c. pearly papule with an ulcerated center d. irregularly shaped with blue tones

d. irregularly shaped with blue tones Rationale: Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client's upper back and lower legs.

A nurse is contributing to the plan of care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should expect the provider to perform which of the following procedures? a. curettage b. External radiation therapy c. regional chemotherapy d. surgical excision

d. surgical excision rationale: The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting.

a nurse is collecting data from a client who sustained superficial partial -thickness and partial-thickness burns 72 hrs ago. Which of the following findings should the nurse report to the provider? a. edema in the affected extremities b. severe pain at the burn sites c. urine output of 30 mL/hr d. Temp of 102.4 degrees F (39.1 degrees C)

d. temp of 102.4 degrees F (39.1 degrees C) Rationale: An elevated temperature is an indication of infection and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms.