Subtopic integumentary system

Which practice would be suitable in the prevention of a pressure ulcer? 1 Positioning a client directly on the trochanter 2 Keeping the client's skin directly off plastic surfaces 3 Keeping the head of the bed elevated above 30 degrees 4 Placing a rubber ring or donut under the client's sacral area

2 Keeping the client's skin directly off plastic surfaces For the prevention of a pressure ulcer, the client's skin should be kept directly off plastic surfaces. While the client is positioned on his or her side, direct positioning on the trochanter should be avoided. The head of the bed should not be kept elevated above 30 degrees. This is to prevent shearing. A rubber ring or donut under the client's sacral area should be avoided.

What is the color of a client's wound caused by skin tears? 1 Red 2 Gray 3 Black 4 Yellow

1 Red A wound that is caused by skin tears is red in color. A wound caused by a full-thickness or third-degree burn is gray or black in color. Wounds with nonviable necrotic tissue that create an ideal situation for bacterial growth are yellow in color.

A client visited the nurse with a complaint of chalk white patches on the skin. What could be the condition of the client? 1 Vitiligo 2 Jaundice 3 Cyanosis 4 Erythema

1 Vitiligo Vitiligo is the abnormal condition in which chalky white patches appear on the skin. This is due to a complete absence of melanin. Jaundice is an abnormal condition in which the skin appears yellow or yellow-brownish in color due to increased bilirubin in the blood. Cyanosis is the condition in which the skin is slightly bluish or purple in color due to excessive or reduced hemoglobin in capillaries. Erythema is the condition in which red-colored patches appear on the skin in variable sizes and shapes.

Which skin changes due to aging are caused by chronic exposure to ultraviolet rays? Select all that apply. 1 Reduced circulation 2 Actinic keratosis 3 Capillary fragility 4 Senile lentigines 5 Facial hirsutism

2 Actinic keratosis 4 Senile lentigines The skin changes due to aging caused by chronic exposure to ultraviolet rays are actinic keratosis and senile lentigines (or lentigo). Reduced circulation, capillary fragility, and facial hirsutism are considered normal skin changes related to aging.

What could be the possible cause of a scald injury? 1 Contact with grease 2 Contact with hot liquids or steam 3 Contact with alkali in oven cleaners 4 Contact with open flame in house fires

2 Contact with hot liquids or steam Scalding injuries usually result from contact with hot liquids or steam. Contact with grease and the alkali in oven cleaners may cause chemical injuries. An open flame in house fires may cause thermal injuries.

The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance? 1 T-tube movement increases. 2 Pain at the incision site increases. 3 The nasogastric tube gets irritating. 4 The bandage on the abdomen is constricting.

2 Pain at the incision site increases. The incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations.

A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? 1 Provide low-sodium milk. 2 Provide high-protein drinks. 3 Provide foods that are low in potassium. 4 Provide 10% more calories in the form of fats.

2 Provide high-protein drinks. High-protein drinks have twice the calories per volume of other fluids and provide protein for wound healing. Low-sodium milk does not contain adequate calories to help meet the high metabolic rate associated with burns. Potassium is restricted during the first 48 to 72 hours after a burn injury, not 2 weeks after the injury. Increased calories in the form of protein and carbohydrates, not fats, are needed.

Which fungal infection does the client refer to as jock itch? 1 Tinea pedis 2 Tinea cruris 3 Tinea corporis 4 Tinea unguium

2 Tinea cruris Tinea cruris is a fungal infection commonly referred to as jock itch. It clinically manifests with well-defined scaly plaque in the groin area. Tinea pedis is a fungal infection commonly referred to as athlete's foot. It is clinically manifested as interdigital scaling and maceration, scaly plantar surfaces, erythema, and blistering. Tinea corporis is a fungal infection commonly referred to as ringworm. It is clinically manifested as an erythematous annular, ringlike, scaly lesion with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? 1 Utricaria 2 A drug reaction 3 Atopic dermatitis 4 Allergic contact dermatitis

4 Allergic contact dermatitis Allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens. Utricaria is an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis. A drug reaction may be caused by any drug such as penicillin that acts as antigen causing hypersensitivity reactions. Atopic dermatitis is a genetically influenced, chronic, relapsing disease associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? 1 Equal 2 Unrelated 3 Inversely related 4 Directly proportional

4 Directly proportional There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

Which client has a primary lesion? 1 One with scales 2 One with ulcers 3 One with fissures 4 One with erosions

4 One with erosions Erosions are considered primary lesions. Scales, ulcers, and fissures are secondary lesions, which are modifications of primary lesions.

While assessing the skin of a client, the nurse observes a lesion that has a wavy border. Which type of lesion is present in the client? 1 Annular 2 Circinate 3 Coalesced 4 Serpiginous

4 Serpiginous A lesion with a wavy border indicates a serpiginous lesion. A lesion that is ringlike with raised borders around a flat, clear center indicates an annular lesion. A circular lesion indicates a circinate lesion. A lesion that merges with another and appears confluent indicates a coalesced lesion.