chapter 75 skin disorders
How would the nurse classify the source of a sunburn? Thermal Radiation Electrical Chemical
Radiation
Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client knowing that which would indicate the presence of systemic toxicity from this medication? Constipation Tinnitus Decreased respirations Diarrhea
Tinnitus
Write the correct sequence order of actions to take in the ER for a client with a burn injury. -Assist to initiate an IV line and begin fluid replacement as prescribed -Administer oxygen as prescribed -Keep the client warm and place the client on NPO status -Assess for airway patency -Elevate the extremities -Obtain vital signs
4*-Assist to initiate an IV line and begin fluid replacement as prescribed 2*-Administer oxygen as prescribed 6*-Keep the client warm and place the client on NPO status 1*-Assess for airway patency 5*-Elevate the extremities 3*-Obtain vital signs
Deep partial thickness
damage to entire epidermis and deep into the dermis
Superficial thickness
damage to epidermis
Debridement
to remove loose skin, crusts, or denuded tissue
Cryosurgery
treatment of applying liquid nitrogen to remove warts
A client with a skin disorder is undergoing electrodesiccation. For which disorder is this a common treatment? Scabies Warts Impetigo Carbuncle
Warts
The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure ulcer in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure ulcer? -Apply a dressing that allows oxygen to pass through -Utilize a rubber ring -Clean with aclohol and water -Massage the area around the affected area
-Apply a dressing that allows oxygen to pass through
A nurse is reinforcing teaching with a client who has a history psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instruction should the nurse include in the teaching? -Administer psoralen medication before the treatment -Use the treatment every evening -Remove the sclaes gently following each treatment -Apply vitamin A cream before each treatment
-Administer psoralen medication before the treatment
A nurse is reinforcing discharge instructions with a client who had a skin biopsy with sutures. Which of the following client statements indicates that the teaching has been effective? "I will most likely have a fever for the first few days." "I can expect redness around the site 5 to 7 days." "I should apply an antibiotic ointment to the area." "I will make a return appointment in 3 days for removal of my sutures."
"I should apply an antibiotic ointment to the area."
A nurse is reinforcing teaching with a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include? -Cover affected area with snug fitting clothing. -Bathe daily with moisturizing soap. -Apply warm compresses to the affected areas. -Apply antibacterial topical medication to the crusted exudate.
-Apply warm compresses to the affected areas.Super
Which types of diet would be prescribed for a client with a third-degree, full thickness burn on 30% of the body? -Low calorie, high protein -High calorie, high protein -High calorie, high carbohydrate -Low calorie, high carbohydrate
-High calorie, high protein
An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage? 40.5% 22.5% 36% 31.5%
22.5%
Which would be the most likely candidate for a pedicle graft? A client with third-degree burns on his hand A client with severe eczema A client with a stage II decubitus ulcer A client with a keloid behind the ear
A client with third-degree burns on his hand
Indicate which are malignant (M) or benign (B) for the following neoplasms: (5 points) Angiomas
B
Indicate which are malignant (M) or benign (B) for the following neoplasms: (5 points) Keloids
B
Indicate which are malignant (M) or benign (B) for the following neoplasms: (5 points) Pigmented nevi
B
The American Cancer Society has developed a helpful ABCDE rule for evaluating a mole. Which is one of these guidelines? Border: edges are regular and defined Color: color is not uniform and has verying shades Asymmetry: one half the mole matches the other half. Diameter: size is smaller than that of a pencil eraser.
Color: color is not uniform and has verying shades
What term is used to identify a soft tissue cut caused by a serrated knife? Abrasion Laceration Desquamation Excoriation
Laceration
What makes the eyebrows a common site for seborrheic dermatitis to develop? Large concentration of sebaceous glands. Large number of hair follicles Thicker dermal tissue Increased number of pigment cells
Large concentration of sebaceous glands.
What is the priority observation of the nurse caring for a client diagnosed with psoriasis? Pigment chnages Low self-esteem Skin infections Difficulty breathing
Low self-esteem
Indicate which are malignant (M) or benign (B) for the following neoplasms: (5 points) Basal cell carcinoma
M
Indicate which are malignant (M) or benign (B) for the following neoplasms: (5 points) Squamous cell carcinoma
M
The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? Wear gloves only Avoid touching the client's clothes Wear a mask and gloves Wear a gown and gloves
Wear a gown and gloves
purulent
Yellow, gray or green drainage due to infection
Superficial partial thickness
damage to the entire epidermis and some parts of the dermis
Pruritus
itching
Neoplasm
means new growth
Serosanguineous
pink colored due to
sanguineous
red, leakage of fresh blood
Folliculitis
staphylococcal infection starting around the fair follicle
Which locations on the body would the nurse assess to confirm the presence of angioedema? (Select all that apply.) (1 point) Feet Eyes Lips Ear lobes Tongue
Feet Eyes Lips Tongue
The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication is being applied to which body area? Axilla Soles of the feet Back Palms of the hands
Axilla
The nurse is preparing a therapeutic bath for client recovering from third-degree burns. Which guideline is recommended for this procedure? -Give the bath in a standard tub, not a whirlpool tank -Use medicated bath oil instead of soap -Rub the client's skin dry after the therapeutic bath -Use water that is as hot as the client can tolerate
Use medicated bath oil instead of soap
Serous
clear or strawed colored
The nurse is applying a moist dressing on the arm of a client with acute dermatitis. Which nursing intervention would be appropriate? -Medicate with analgesics following the procedure -Follow standard precaution procedures -Use a bed cradle when applying the dressing -Premoisten the area with alcohol
-Follow standard precaution procedures
The nurse is caring for a client who has third-degree burns on 25% of her body. Which is a goal for this client when managing fluid and electrolyte balance? -Systolic blood pressure greater than 150 mm Hg -Heart rate less than 120 beats per minute -Decreased sodium levels -Urinary output of 1 to 1.5 mL/kg/hour
-Heart rate less than 120 beats per minute
The nurse is conducting a focused evaluation on a postoperative client's integumentary system. Which priority objective physical examination assessments are related to inspection? (Select all that apply.) (1 point) -Nails for shape, contour, color, thickness and cleanliness. -Biopsy results -Facial and body hair for distribution, color, quantity and hygiene. -Skin for color, integrity, scars, lesions, and signs of breakdown. -Palpate the skin for temperature, texture, moisture, thickness, turgor, and mobility.
-Nails for shape, contour, color, thickness and cleanliness. -Facial and body hair for distribution, color, quantity and hygiene. -Skin for color, integrity, scars, lesions, and signs of breakdown.
Which interventions should be introduced to a client for the treatment and prevention of rashes? (Select all that apply.) (1 point) -Rinse the clothes in clear water -Take hot baths or showers -Wear clothing made of wool -Lightly slap the itching area -Keep fingernails short.
-Rinse the clothes in clear water -Lightly slap the itching area -Keep fingernails short.
The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks.. The client suddenly becomes restless, and his color becoming dusky. The nurse should interpret this data as indicating which? -The client is hypotensive -The client is afraid and is having a panic attack as a result of the unfamiliar surroundings. -The burn has probably caused laryngeal edema, which has occluded the airway. -Pain is present from the burn injury.
-The burn has probably caused laryngeal edema, which has occluded the airway.
Deep full thickness
Damage to ALL layers of skin and extends to muscle, tendons, and bones
After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings? Ambulation three times daily Frequent comfort measures Pain management program Dressing change twice daily
Ambulation three times daily
Full thickness
Damage to the entire epidermis and dermis can extend into subQ tissue, nerve damage. Red, black, brown, yellow or white no blisters ***SEVERE edema, eschar hard and inelastic*** sensation minimal or absent heals within weeks to months scarring grafting ex. scalds, grease tar chemical or electrical burns, prolonged exposure to hot objects
A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Most of the burns are full thickness burns on the arms, face, neck, and 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? Carbon monoxide poisoning Bacterial pneumonia Inhalation injury Pulmonary edema
Inhalation injury
A nurse is assisting with the care of a client who sustained deep partial- thickness and full-thickness burns over 60% of his body 24 hr ago and is requesting pain medication. The nurse should ensure the medication is administered using which of the following routes to administer medication? Transdermal Subcutaneous Intravenous Oral
Intravenous
What is the priority nursing intervention for a client with minor burns on 20% of his head and neck? Monitor the client's respiratory status. Dress the burns with salve Insert a feeding tube before edema sets in. Wrap the burns with sterile bandages
Monitor the client's respiratory status.
A nurse is reinforcing teaching with the parent of a child who has contact dermatitis. Which of the following information should the nurse include? -Apply a warm, dry compress to the rash area. -Place the child in a bath with with colloidal oatmeal. -Leave the child's hands undercovered during the night. -Use fabric softener dryer sheets when drying the child's clothing.
Place the child in a bath with with colloidal oatmeal.
Isotretinon (Amenesteem, Clavaris.) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? Platelet count Triglyceride level White blood cell count Complete blood count
Triglyceride level
A nurse is 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? Elevated blood glucose levels Urinary retention Insomnia Hyperpigmentation of the skin
Urinary retention
