Med Surg (summer) Exam 2
A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which statement by the client indicates that she has adapted to her changed body image?
"May I go with my family to the visitor's lounge?"
Papule
a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter; common lesions of warts and elevated moles.
6 functions of the skin
protection (3 layers) sensation (feel pain, pressure, temp) fluid balance (sweat and diaphoresis) temperature regulation (98.6 F or 37 C) vitamin production (converts sunlight to vitamin D) immune response function
Erythema
redness of skin
Secondary lesion
result of initial injury
How to reveal jaundice for a colored person
sclera is yellow
Herpes zoster
shingles
Stage 1 pressure ulcer
skin is intact with an area of persistent, nonblanchable redness, usually over a bony prominence, that might feel warm or cool when touched the tissue is swollen and congested, and the client might report discomfort at the site with darker skin tones, the ulcer can appear blue or purple and different from other skin areas
A nurse is assesing 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 stage?
stage 2
First degree burn
superficial and limited to the outer layer of dermis
A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which procedure?
surgical excision
Treatment for melanoma
surgical removal and chemotherapy
s/s Cellulitis
swelling, edema, erythema, acutely spread, warmth, tenderness
s/s of peripheral arterial disease
uneven pulses, shiny skin, circular unleration, ischemia
Nursing management of peripheral arterial disease
vasodilators, smoking cessation, avoiding trauma, avoid long periods of standing, use Doppler to detect pulses
Juandice
yellow/orange skin color revealing hepatic problem
Basal cell carcinoma
A tumor of the skin that rarely metastasizes but has the potential for local invasion and damage
A nurse is caring for a client with burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which statement indicates understanding of the teaching?
"I will be on a special shower table."
A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which instructions should the nurse include?
"Shift your weight in the wheelchair every 15 minutes."
Malignancy
A tendency to advance in strength
Silver sulfadiazine cream
A topical medication used in preventing and treating wound infections associated with burns of the skin
Candidiasis
(oral thrush) normal flora of the oral cavity depleted d/t ATB or chemotherapy
high risk Braden score
12 or less
moderate risk Braden score
13-14
low risk Braden score
15-16
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 medication?
Acyclovir
Herpes Zoster
An acute viral disorder characterized by inflammation of the nerve branch and by eruption of blisters The pain may be burning, sharply cutting, stabbing or aching and typically radiates over the entire region supplied by the nerve with accompanying lesions Complication in the eye results in ulceration and blindness
ABCDE method for detecting melanoma
Asymmetry: The mole has an irregular shape. Border: The edge is not smooth, but irregular or notched. Color: The mole has uneven shading or dark spots. Diameter: The spot is larger than the size of a pencil eraser. Evolving or Elevation: The spot is changing in size, shape or texture.
A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which instructions should the nurse include?
Avoid exposure to midday sun
Labs for pressure ulcers
CBC, wound culture
Cancer
Characterized by the excessive growth of malignant cells that invade healthy tissue
A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which trait places a client at risk for developing malignant melanoma?
Light skin
Frostbite
Damage to the skin and underlying tissues caused by extreme cold Distinguishable by the hard, pale, and cold quality of the skin that has been exposed to the cold for a length of time. The area is likely to lack sensitivity to touch, although there may be an aching pain or tingling. As the area thaws, the flesh becomes red and very painful. Hands, feet, nose and ears are the most vulnerable.
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which laboratory finding?
Leukopenia
A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which intervention should the nurse implement?
Immobilize the limb at the level of the heart
A nurse is assessing a client who has a lesion. Which is a clinical manifestation of a malignant Melanoma?
Irregularly shaped lesion with blue tones
Melanoma
Malignant neoplasms in which atypical melanocytes are present in both epidermis and the dermis and sometimes the subcutaneous cells
Most lethal of all skin cancers
Melanoma
A nurse is caring for a client who has a lesion on the back of his hand. The client asks the nurse which type of skin cancer is the most serious. Which response is appropriate?
Melanomas
A nurse in a provider's office is assessing a client's 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 skin lesions?
Papules
A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which source?
Pig skin
Stasis ulcer
Skin breakdown from inadequate circulation, usually on lower extremities toward ankle marked by irregular borders
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?
Sodium 132 mEq/L
A nurse on a surgical unit is caring for four clients who have healing wounds. Which wounds should the nurse expect to heal by primary intention?
Surgical incision
A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider?
Temperature 39.1 C (102.4 F)
Pressure ulcer
The formation of a wound due to prolonged pressure on a particular point on the body
Metastases
The spread of cancerous cells from one location in the body to another site, where additional tumors may also develop
Hydrotherapy
The use of externally applied water in the treatment of disease
Burn
Thermal injury to the skin
A nurse is assessing 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?
Third-degree frostbite
Blanch
To become pale or lose color (usually in the face), usually suddenly and in the context of being saddened or frightened.
A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which finding should the nurse include as an indication of a potential malignancy of a mole?
Ulceration
Peripheral venous disorders
Virchow's triad: Endothelial damage Venous stasis Altered coagulation
A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which nutrient promotes wound healing?
Vitamin C
Diagnostic tests for cellulitis
WBC
Secondary intention
Wounds that are left to heal without approximating the edges, often done with bowel surgeries where feces may have contaminated the wound, such as with a ruptured appendix. The wound fills in with granulation tissue from the bottom up. The epithelium (skin) then fills in over the top of the granulation tissue and the result is a large, wide, scar.
Stage 2 pressure ulcer
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.
Secondary skin infection
affects broken skin
Primary skin infection
affects healthy skin
How are chicken pox spread?
airborne
Lesion
an abnormal change in structure of an organ or body part due to injury or disease
Treatment of impetigo
antibiotics (topical or systemic)
Patch testing
applies allergens to skin to detect pruritus or rash
Tinea pedis
athlete's foot
Impetigo
bacterial infection
Cellulitis
bacterial skin infection; inflammatory response
What is hydrotherapy used for?
baths, showers, sits baths, foot baths, debridement and blood flow of wounds
Peripheral arterial disease
blockage of arteries carrying blood to the legs, arms, kidneys and other organs
Cyanosis
bluish discoloration of the skin reveals poor circulation or deoxygenation
Where does metastases from melanoma tend to occur?
bone, liver, lungs, spleen, CNS, and lymph node
Third degree burn
both the epidermis and dermis are destroyed with damage extending into the underlying tissues
Patients with stasis ulcers can develop
cellulitis
Arterial ulcers
circular, well defined, "punched out", usually on toes, foot, ankle covered in slough and necrotic tissue, associated with pain
How is shingles spread?
contact
Treatment for scabies
corticosteroids, oral antihistamines
Cause of peripheral arterial disease
nicotine, high blood pressure, diabetes
Treatment for tine pedis
ointment or cream
Treatment for shingles
pain meds, antiviral meds, Neurontin
Nursing interventions for pressure ulcers
daily assessment, manage moisture, optimize nutrition and hydration, minimize pressure
Second degree burn
damage extends into the dermis
Immunoflourescence
detect antibodies
Biopsy
diagnostic examination of a piece of tissue from the living body to establish malignant cancer cells
How is impetigo transmitted?
direct contact
Nursing management of cellulitis
dressing changes, IV ATB
Normal aging of skin
dryness, wrinkles, thinning, loss of subQ tissue
Nursing management for stasis ulcers
elevate legs, encourage ambulation and use of compression stockings
Nursing management of venous disorders
encourage patient not to use tobacco, wear shoes, stay out of hot tubs, ambulate, elevate extremities, check souls of feet
3 layers of skin
epidermis, dermis, subcutaneous
Stage 3 pressure ulcer
full-thickness tissue loss with damage to or necrosis of subcutaneous tissue the ulcer might extend down to, but not through, underlying fascia the ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone drainage and infection are common
Stage 4 pressure ulcer
full-thickness tissue loss, with destruction, tissue necrosis, and visible damage to muscle, bone, or supporting structures sinus tracts, deep pockets of infection, tunneling, and undermining can occur
Integumentary assessment
health history, onset, signs, symptoms, location, duration, pain, itching, changes in lotions, shampoos, soaps, etc.
Risk factors for venous disorders
heart disease, varicose veins, obesity
s/s venous disorders
heaviness, pain, tenderness, swelling, redness, warmth
Clubbing of the nails is caused by
hypoxemia
Scrapings
identify fungi and paracites
Primary lesion
initial injury
Venous ulcers
irregular bordered, toward ankle, covered with slough, large, minimally painful
Pruritus
itching
Scabies
mites that burrow under skin
Staphylococcus aureus
most common host of impetigo