NCLEX 10000 Integumentary Disorders
A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? a) The client's urinary output has fallen below 30 ml/hour. b) The client's serum sodium levels are elevated. c) The client exhibits metabolic alkalosis. d) The client's complete blood count readings reflect a reduced hematocrit.
The client's complete blood count readings reflect a reduced hematocrit. Explanation: During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits.
The client phones the outpatient surgery center following skin biopsy on the left shoulder. The client states that the site continues to drain pinkish drainage and is uncomfortable. Which triage questions are appropriate to evaluate the client's concern? Select all that apply. a) "What is your pain level on a 0-10 pain scale?" b) "Did you have any other skin biopsies that day?" c) "How are you cleaning the area?" d) "On which day did you have the biopsy completed?" e) "When is your follow-up appointment?" f) "Can you describe the drainage that you see."
• "What is your pain level on a 0-10 pain scale?" • "Can you describe the drainage that you see." • "On which day did you have the biopsy completed?" • "How are you cleaning the area?" Correct Explanation: When triaging a client's concern following a surgical biopsy, it is most important for the nurse to obtain information about the site and post-operative care. Knowing the date of the surgery allows for the nurse to determine the amount and type of drainage which is normal for that stage of healing. Understanding the characteristics of the drainage helps the nurse assess if the drainage is from a healing process or from a potential infection. Assessing the pain level provides information of the inflammatory and infectious process. The nurse compares the client's pain rating with the rating scale typically noted for this procedure. Lastly, the nurse assesses how the wound is being cleaned. The nurse wants to assess understanding regarding the cleaning process.
A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage? a) "Apply sunscreen even on overcast days." b) "Use a sunscreen with a sun protection factor of 6 or higher." c) "When at the beach, sit in the shade to prevent sunburn." d) "Minimize sun exposure from 1 to 4 p.m., when the sun is strongest."
"Apply sunscreen even on overcast days." Correct Explanation: Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days.
Which of the following would provide the most effective emergency care for a burn victim at the accident site? a) Pouring cool water over the burned area. b) Applying clean, dry dressings to the area. c) Applying a mild antiseptic ointment to the area. d) Rinsing the area with a warm, mild soap solution.
Applying clean, dry dressings to the area. Incorrect Correct response: Pouring cool water over the burned area. Explanation: The recommended emergency treatment for a heat burn is immersion in cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue. The burn should be kept moist to prevent the dressing adhering to the wound.
A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that: a) some melanomas have a familial component and she should seek medical advice. b) she should not worry, because she did not experience severe sunburn as a child. c) her personal risk is low because most melanomas occur at age 60 or later. d) her personal risk is low because melanoma does not have a familial component.
some melanomas have a familial component and she should seek medical advice. Correct Explanation: Malignant melanoma may have a familial basis, especially in families with dysplastic nevi syndrome. First-degree relatives should be monitored closely. Malignant melanoma occurs most often in the 20- to 45-year-old age-group
Which client is at greatest risk for inadequate nutrition? a) the client who is breastfeeding b) the client recovering from a femur fracture c) the client with diabetetic peripheral neuropathy d) the client with burns to 45% of the body
the client with burns to 45% of the body Correct Explanation: With illness or injury, there is a need to heal or recover. To accomplish this, the client must consistently consume adequate nutrition (and protein) to maintain a positive nitrogen balance, and to experience necessary growth and/or healing. The client with burns has the greatest nutritional needs, due to the extent of the injury
During the emergent stage of burn management for a client with burns of 30 percent of the body the nurse should assess the client for which of the following? Select all that apply. a) Hypoglycemia. b) Increased hematocrit. c) Hyponatremia. d) Hyperkalemia. e) "Fever spikes."
• Hyperkalemia. • Increased hematocrit. • "Fever spikes." Explanation: In the emergent phase of burn management, hyperkalemia develops as a result of the destruction of red blood cells. The hematocrit is increased in response to the plasma loss that has occurred and the resulting hemoconcentration. Initially, hyponatremia may occur as sodium shifts into the interstitial spaces. "Fever spikes" of 102 to 103 degrees F (38.9 to 39.4 degrees C) are common during this stage. The client will have hyperglycemia due to decreased levels of insulin production.
At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress notes above and begins planning client care based on which nursing diagnosis? a) Readiness for enhanced knowledge of skin care precautions related to benign mole. b) Fear related to potential diagnosis of malignant melanoma. c) Deficient knowledge related to potential diagnosis of basal cell carcinoma. d) Risk for impaired skin integrity related to potential squamous cell carcinoma.
Fear related to potential diagnosis of malignant melanoma. Correct Explanation: Documentation reveals that the client is anxious about the symptoms. These symptoms most closely resemble malignant melanoma. Therefore, fear related to potential diagnosis of malignant melanoma is the most appropriate nursing diagnosis.
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? a) Complaints of intense thirst b) Moderate to severe pain c) Hoarseness of the voice d) Urine output of 70 ml the first hour
Hoarseness of the voice Correct Explanation: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation
What is the primary goal of nursing care during the emergent phase after a burn injury? a) Promote wound healing. b) Replace lost fluids. c) Control pain. d) Prevent infection.
Replace lost fluids. Correct Explanation: During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock.
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: a) basal cell carcinoma. b) squamous cell carcinoma. c) actinic keratoses. d) melanoma.
melanoma. Correct Explanation: The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma.
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? a) hourly urine output of 60 mL b) serum albumin level of 3.8 g/dL (38 g/L) c) serum creatinine level of 2.5 mg/dL (221 µmol/L) d) little fluctuation in daily weight
serum creatinine level of 2.5 mg/dL (221 µmol/L) Correct Explanation: Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinin
A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering IV fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse? a) Carefully monitor the client for signs of fluid overload. b) Confirm that a large-bore catheter was inserted. c) Assess patency of the IV site every 4 hours. d) Ensure a fluid volume sufficient to prevent shock.
Ensure a fluid volume sufficient to prevent shock. Correct Explanation: Fluid management is fundamental when treating burn clients during the immediate post-trauma period. Adequate volumes of IV fluids are required to prevent shock in those with extensive burn injuries. Significantly higher volumes of IV fluids are used with burn clients than with other clients. The aim of fluid resuscitation is to restore and maintain adequate oxygen delivery to all tissues of the body following the loss of sodium, water, and proteins. There are several formulas that can be applied to determine fluid resuscitation needs. One example is the Parkland formula. The Parkland formula for the total fluid requirement in 24 hours is as follows: • 4 mL x TBSA (%) x body weight (kg) • 50% given in first 8 hours • 50% given in next 16 hours Children receive maintenance fluid, in addition, at an hourly rate of: A. 4 mL/kg for the first 10 kg of body weight, plus B. 2 mL/kg for the second 10 kg of body weight, plus C. 1 mL/kg for > 20 kg of body weight End point • Urine - adults: 0.5-1.0 mL/kg/hour • Urine - children: 1.0-1.5 mL/kg/hou
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? a) Impaired physical mobility related to the disease process b) Risk for infection related to breaks in the skin c) Impaired skin integrity related to disease process d) Ineffective airway clearance related to edema of the respiratory passages
Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority.
