EAQ 10- Tissue Integrity
Which virus is responsible for causing infectious mononucleosis in the clients?
esptein-barr virus- and possibly Burkitt lymphoma; parvovirus and rotavirus cause gastroenteritis; coronavirus causes upper respiratory tract infections
Which skin infection is caused by bacteria?
folliculitis; candidiasis and dermatophytosis caused by fungus, herpes caused by virus
Which factors put a client at risk for bacterial infections?
atopic dermatitis, diabetes mellitus, systemic antibiotics
Which condition would the nurse expect when performing a physical assessment on a client with a history of hypothyroidism?
dry- caused by decreased function of sebaceous glands
Which symptoms are common during the fulminant stage of inhalation of anthrax?
dyspnea, diaphoresis, high temperature
Which type of hepatitis virus spreads through contaminated food and water?
hepatitis A; Hepatitis B,C,D spread through contaminated needles, syringes, and blood products
Which physical skin finding indicated opioid abuse?
need marks
Which organs can be affected by Candida albicans?
vagina, mouth, intestines
systemic lupus erythematosus
a chronic, progressive, inflammatory connective tissue diroser that causes major body organs and systems to fail, manifests as "butterfly" rash
Which medication can cause chemical burns?
anthralin- a strong irritant that has an action similar to tar
An adolescent displaying low self-esteem complains of inflamed, red, and painful lesions on his forehead. Which condition is likely?
acne vulgaris
Which interventions can be performed by an unlicensed assistive personnel in skin care?
assist the client in bathing, apply wet dressings to the skin, report changes in the skin appearance
Which type of continuing care would a client expect if discharge home with an infusion device to continue treatment for a leg wound?
home care
Which bacterial skin infections are caused by A beta- hemolytic streptococci?
impetigo and erysipelas; furnucle is a deep infection with staphylococci; cellulitis caused by staphylococcus aureus and streptococci; folliculitis caused by staphylococci
When performing a physical assessment on a client, which term would the nurse use to describe a flat, poorly mass on the sole over a bony prominency and caused by pressure?
callus; plantar wart is a painful papillomatous growth caused by a virus; a silver of toenail penetrating the skin and causing inflammation results in ingrown nail; a hypertrophic ungual labium is a chronic hypertrophy of the nail lip caused by improper nail trimming
The nurse recognizes which statement as true regarding transdermal estradiol?
estradiol is slowly absorbed from the skin- administered to increase the level of estrogen in postmenopausal women to ease hot flashes, available as emulsion that is typically applied to the thighs or calves; transdermal films are changed once or twice a week, gel is applied daily; sunscreen products should not be used with because reduces absorption
Which sexually transmitted infection is caused by a virus?
genital warts- strain of the human papillomavirus (HPV); bacteria causes syphilis, gonorrhea, and chlamydial infections
The nurse is caring for a client who had a hip replacement 2 days prior. Which nursing intervention would the nurse perform next?
provide perineal care
Which benign condition shows silver scaly plaques on the skin?
psoriasis- commonly seen on elbows and scalp; hyperpigmented areas that vary in form and color are due to nevi; spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to urticaria; noninflammatory lesion, including open comedones and closed comedones are due to acne vulgaris
For which circumstance would the nurse use the Z-track technique to administer a medication?
the medication is irritating to eh subcutaneous tissue and skin- Ztrack method seals the puncture at the intramuscular level, preventing seepage of irritating medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin
Which test is used in the diagnosis of systemic lupus erythematosus?
direct immunofluorescence test; the patch test and photo patch test are used to evaluate allergic dermatitis and photo allergic reactions; an indirect immunofluorescence test is performed on a blood sample
Which medication can be administered via the intramuscular route to treat anaphylaxis?
epinephrine; methdilazine administered to treat allergic reactions and pruritus; phenylephrine is administered orally to treat anaphylaxis; mycophenolate mofetil is administered intravenously as an immunosuppressant agent
Which sexually transmitted infection receives antiviral medications as the treatment of choice?
genital herpes; bacteria cause syphilis, gonorrhea, and chlamydial infections
Which autoimmune disease affects the central nervous system?
multiple sclerosis; uveitis is affects the eyes; celiac disease affects the GI system; goodpasture syndrome affects the kidneys
Which integumentary finding is related to skin texture?
surface character
Which fungal infection does the client refer to as jock itch?
tinea cruris- clinically manifests with a well-defined scaly plaque in the groin area; tinea pedis is a fungal infection commonly referred to as athlete's foot; tinea corporis is a fungal infection referred to as a ringworm; tinea unguium or onychomycosis is manifested as scaliness under the distal nail plate
Which assessment finding of the skin refers to elasticity?
turgor
Which skin color in a client indicates an increased urochrome level?
yellow-orange; red color indicated increased blood flow to the skin; blue color indicates increase in deoxygenated blood in the body; reddish-blue color of the distal extremities indicates decreased peripheral circulation
Which foot disorder is caused by continual pressure over bony prominences?
corn; plantar wart caused by virus; hammertoes is caused by flexion and deformity in the joints; hallux rigidus caused by osteoarthritis
Which fungal infection is commonly referred to as athlete's foot?
tinea pedis
Which changes to the client's skin are caused by the atrophy of eccrine sweat glands?
dry skin and decreased body odor; increased capillary fragility and permeability will result in ecchymosis; decreased subcutaneous fat, degeneration of elastic fibers, and stiffening of the collagen fibers will result in wrinkles; decreased subcutaneous fat will result in shearing of the skin
Which nursing interventions would the nurse implement when providing a postoperative care for a client who had a below the knee amputation?
elevate residual leg slightly while keeping the knee joint straight for the first 24 hours- must be slight, because continued elevation may lead to hip contractures
Which physiological changes should be noticed in an adolescent during puberty?
increase in number of neural connections, decrease in the basal body temperature gradually, increase in serum iron, hemoglobin, and hematocrit
Which medication is a newer treatment option for treating metastatic melanoma?
ipilimumad- type of immunotherapy and is a monoclonal antibody
Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins?
contact dermatitis; medication eruption are bright red erythematosus macule and papules are seen; atopic dermatitis is lichenification with scaling and excoriation is observed; eczematous dermatitis is lichenification with weeping papules and macules
Which synovial joint movement is described as turning the sole away from the midline of the body?
eversion
Which client's report indicates AIDS?
diagnosis of AIDS requires that the person should be HIV positive and have either a CD4+ T-cell count of less than 200cells/mm3; a healthy client usually has a least 800-1000 CD4+ T-cell cells/mm3
Which functions are related to the subcutaneous layer of the skin?
provides insulation, acts an energy reservoir, acts as a mechanical shock absorber; epidermal layer prevents systemic dehydration; dermal layer provides cells for wound healing
The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. Which is the nurse assessing for?
skin turgor
Which disorder is a cause of systemic altered inflammatory response in impaired wound?
Leukemia; uremia, cirrhosis, and hypovolemia are systemic impaired cellular proliferation responses in impaired wound healing
How would the nurse describe the exudate characteristic of a serosanguineous wound?
blood tinged amber fluid
Which change in the epidermis causes increased risk of sunburn?
decreased melanocyte activity; decreased cell division causes delayed wound healing; decreased vitamin D production leads to increased risk for osteomalacia; decreased immune system cells results in a decreased skin inflammatory response
Which organ specific autoimmune disorder would the nurse associated with a client's kidney?
goodpasture syndrome; Graves disease and Addison disease are autoimmune disorders associated with the endocrine system; Guillain-Barre syndrome is an autoimmune disorder associated with CNS
Which clinical finding occurs due to thinning of the subcutaneous layer?
increased risk for hypothermia; degeneration of elastic fibers in the dermis results in decreased tone and elasticity; in dermis reduced number and function of nerve endings leads to decreased sensory perception; a decrease in dermal blood flow results in increased susceptibility to dry skin
Which component of skin maintains optimal barrier function?
keratin- a protein produced by keratinocytes; melanin pigment is produced by melanocytes that gives color to the skin; collagen is a protein produced by fibroblasts, production is increased during tissue injury and helps form scar tissue; adipose tissue is the subcutaneous fat that insulates the body and absorbs shock
Which functional level of trauma center is involved in providing a full continuum of trauma services?
level I; level II trauma centers provide care for most injured clients; level III centers are able to stabilize clients with major injuries, but must transport clients if need exceed resource capabilities; level IV trauma centers are usually involved in providing basic trauma client stabilization and advanced life support within the resource capabilities
Identify the mediators of the injury in IgE-mediated hypersensitivity reactions?
mast cells, histamines, leukotrienes; cytokines are the mediators of injury in the delayed type of hypersensitivity reaction (Type IV); neutrophils are the mediators of injury in the immune-complex type of hypersensitivity reaction (type III)
A client sustained minor injuries after an accident. Which event occurs close to the time of injury?
migration of leukocytes to the site of injury- beginning at the time of injury and lasting 3 to 5 days is the inflammatory phase in which migration of leucocytes takes place; scar tissue formed in the maturation phase; formation of granulation tissue and migration of fibroblasts occurs in the proliferative phase
Which condition is characterized by infection of a client's bone or bone marrow?
osteomyelitis; osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency
Which goal is the nurse trying to achieve when placing a client with severe burns on a circulating air bed?
preventing pressure on peripheral blood vessels
Which function of the dermis is accurate?
provides cells for wound healing- dermis is present between the epidermis and subcutaneous laters and has functions such as giving skin its flexibility and strength and providing cells for wound healing; subcutaenous tissue is the innermost layer of the skin that helps in retention of body heat and acts as a mechanical shock absorber; epidermis is the outermost layer of skin that inhibits the proliferation of microorganisms
The nurse observes elevated superficial lesions filled with purulent fluid on a client's skin. Which type of lesion would the nurse document in the health record?
pustule (ex. are acne and impetigo); a wheal is a firm, edematous, irregularly shaped lesion (insect bites and urticaria); plaque consists of circumscribed, elevated superficial solid lesions less than 0.5cm in diameter (psoriasis and seborrheic); a vesicle is a circumscribed, superficial collection of serous fluid (varicella and second degree burns)
Which color would the nurse anticipate when assessing a client's skin tears?
red; a wound caused by 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 3 year old child is admitted with partial and full thickness burns over 30% of the body. Which significant adverse outcome during the first 48 hours would the nurse attempt to prevent?
shock
While examining the client, the nurse finds a 0.6cm circumscribed elevation of the skin filled with serous fluid on the cheek. Which would the nurse suspect the finding to be?
vesicle- skin filled with serous fluid and a lesion size of less than 1cm; papule is a palpable, circumscribed, has a solid elevation, and a size smaller than 1cm; nodule is an elevated solid mass, deeper and firmer than a papule and 1 to 2cm in diameter; pustule is a circumscribed elevation of the skin similar to a vesicle but filled with pus and varies in size
Which instruction would the nurse provide a client with leukopenia secondary to chemotherapy?
you should avoid large crowds and people with infections- leukopenia consists of low levels of white blood cells and client may contract an infection as a result of compromised immunity; suggestion of sun screen beneficial for a client with chemotherapy induced skin changes; suggestion of eating high fiber foods and increasing fluid intake would be beneficial for a client with constipation after chemotherapy; consuming iron supplements and erythropoietin would be required for a client who developed anemia after chemotherapy
Which type of skin lesion has a wavy border?
serpiginous; annular lesion= ringlike with raised borders around a flat, clear center; coalesced lesion- merges with another and appears confluent; circinate lesion= circular lesion
Which side effects are related to oral psoralen in phototherapy?
sunburn and persistent pruritus
Which condition can be identified in a client using Phalen's test?
carpal tunnel syndrome; muscle biopsy is done for the diagnosis of atrophy, a computed tomography scan is done to diagnose a bone tumor; the drop arm test is performed to detect rotator cuff injuries
which sexually transmitted infection is caused by Chlamydia trachomatis?
cervicitis; Gonorrhea caused by Neisseria gonorrhoeae; genital warts caused by human papillomavirus; genital herpes caused by herpes simplex virus
The nurse is providing care for a client who has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action would the nurse take postoperatively?
cleanse the area around the insertion side to prevent skin breakdown- bile is irritating to skin so cleanse area around t-tube to prevent skin breakdown; T-tube attached to a bad for straight drainage via gravity, not suction; reposition the client to prevent venous pulmonary stasis
While assessing the skin of a client, the nurse identifies an elevated, solid lesion measuring 4mm x 4mm in size. Which type of lesion does the client have?
papule- an elevated, solid skin lesion of less than 0.5 to 1cm in diameter; a macule is circumscribed, flat area with a change in skin color; the vesicle is a circumscribed, superficial collection of serous fluid; a pustule is an elevates, superficial lesion filled with purulent fluid
Which is the priority nursing action for a child with severe burns on the arms and who is scheduled for therapeutic escharotomy?
monitoring radial pulses- eschar is rigid and may restrict circulation and lead to loss of limb perfusion, associated with full thickness burns; blisters are associated with partial thickness burns, not removed because they protect underlying skin
Which procedure id preferred to find out the composition of a thyroid nodule and ascertain the need for further surgical intervention?
needle biopsy- fine needle used to aspirate the contents of the thyroid nodule; mass spectrometry is an assay in which several different hormone concentrations can be simultaneously analyzed; compute tomography scans are useful for evaluation of ovaries, adrenal glands, and the pancreas; the average blood glucose level over 2 to3 months is revealed by a glycosylated hemoglobin test
Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocytelike precursor cells?
nevi (moles)- hyperpigmented areas that vary in form and size; psoriasis is an autoimmune chronic dermatitis that involved excessively rapid turnover of epidermal cells; acne vulgaris is an inflammatory disorder of sebaceous glands; plantar warts are formed due to a viral infection and appear on the bottom surface of the feet and grow inward because of pressure
Which benign tumor forms on the surface of the client's epithelium?
papilloma; fibroma forms on fibrous tissue; an adenoma forms on the glandular epithelium; a chondroma forms on the cartilage
A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full thickness burns. Which information did the nurse recall?
partial thickness burns are often painful, reddened, and have blisters- grafting not needed unless becomes infected, involve only the epidermis and only part of the dermis, recovery with no infection occurs in 2 to 6 weeks
Which organism is responsible for causing dermatitis related to sexually transmitted infection?
phthirus pubis; candida albicans may lead to vulvovaginitis; campylobacter jejuni may cause proctits; ureaplasma urealyticum may cause salpingitis, infertility, reproductive loss, and ectopic pregnancies
Which structure is removed during circumcision?
prepuce (foreskin); the glans is the tip of the penis; epididymis is the internal structure that helps the transportation and maturation of sperm; the vas deferens carries sperm from the epididymis to the ejaculatory duct
Which surgery is used to treat excessive wrinkling or sagging of facial skin?
rhytidectomy- the removal of excess skin and tissue from the face; rhinoplasty= nose; dermabrasion is the process of removing the facial epidermis or a portion of the dermis to treat acne scars; blepharoplasty is the removal of bulging fat in the periorbital area used to treat bags under the eyes
A newborn receiving medication therapy for an infection has developed jaundice. The newborn has poor sucking and extreme sleepiness. Which medication would the nurse suspect as responsible for the newborn's condition?
sulfonamide- jaundice, poor sucking, and extreme sleepiness are the clinical manifestations of kernicterus- condition seen in newborns due to deposition of bilirubin in the brain and is caused by sulfonamides; tetracycline can cause staining of developing teeth in pediatric clients; phenothiazine may cause sudden infant death syndrome; chloramphenicol may cause Gray syndrome in pediatric clients
Which type of bone tumor occurs most commonly is elderly clients?
chondrosarcoma- occurs in the arm, leg, and pelvic bones; endochroma occurs in client's in the age group of 10 to 20 years old; osteosarcoma and osteochondroma occur in the age group of 10 to 25 years old
Which type of biopsy is required for removal of entire lesions on the skin?
excisional biopsy; punch biopsy provides full thickness skin for diagnostic purposes; shave biopsy provides a thin specimen for diagnostic purposes; an incisional biopsy is used along with shave and punch biopsies
Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite?
fingers and ear lobes
Which type of surgery involves opening the skull with a drill?
burr hole; craniotomy involves opening the cranium with the removal of the bone flap and opening the dura to remove the lesion; craniectomy is an excision into the cranium to cut away a bone flap; cranioplasty is the repair of a cranial defect caused by trauma
Which medication would be used as a nursing priority to treat the client bitten by a snake that belongs to the class of North American pit vipers?
crotalidae polyvalent immune fab (CroFab); diazepam is a muscle relaxant used for the treatment of black widow spider bite; epinephrine is used as a nursing priority for bees and wasps sting; acetaminophen is used for the treatment of fever related to scorpion bite
Which integumentary change is associated with delayed wound healing in a client?
decreased cell division; decreased thickness of the epidermis may cause skin transparency and fragility; decreased cells of the immune system are the reason for a decreased skin inflammatory response; increased epidermal and permeability increases the risk for irritation
Which hormonal deficiency would increase the client's risk for fractures?
growth hormone- causes decrease in bone density; follicle-stimulating hormone deficiency causes amenorrhea, decreased libido, and infertility in women and impotence in men; thyroid-stimulating hormone deficiency causes menstrual abnormalities and hirsutism; adrenocorticotropic hormone deficiency causes hypoglycemia and hyponatremia
Which surgery will a client undergo if pituitary glands must be removed?
hypophysectomy
Which clinical manifestations are associated with a diagnosis of tuberculosis?
persistent cough, anorexia, hemoptysis, night sweats, SOB, and high body temperature
Which skin damage is caused by chronic exposure to ultraviolet rays?
photaging and wrinkling of the skin
Which diagnostic study would the health care provider use to investigate the cause of an inflamed joint and determine a client's response to anti-inflammatory medication therapy?
thermography- uses an infrared detector that measures the degree of heat radiating form the skin's surface; plethysmography is to record variations in volume and pressure of blood passing through tissues; duplex venous doppler records blood flow abnormalities to the lower extremities, which help detect DVT; somatosensory evoked potential use identifies subtle dysfunction of lower motor neuron and primary muscle disease
When teaching a client self care measures to prevent dry skin, which client statement indicates misunderstanding of the content?
use of deodorant soap in place of alkaline soap; do avoid caffeine and alcohol, wear splints at night to prevent scratching in deep sleep due to pruritus, keep environment cooler when sleeping
Which condition is likely in a client who has an interruption of venous return?
varicosity- will cause a bulge and prominence of superficial veins; petechiae are flat, pinpoint , discrete deposits of blood found on the extravascular tissues that result from decreased platelet count in blood; ecchymosis is a small, bruiselike lesion caused by the collection of extravascular blood in the dermis and subcutaneous tissue that occurs as a result of trauma and bleeding disorders
Which information about skin care would the nurse include in the teaching plan for a client who is receiving radiation therapy?
avoid applying lotions and powders over the area
A client with jaundice is associate with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this skin color change?
inability of the liver to remove normal amounts of bilirubin from the blood
Which medication might damage the cartilage of children?
quinolone antibiotics- they can cause permanent destructive arthropathy
Which sexually transmitted infection (STI) is caused by treponema pallidum?
syphilis; haemophilus ducreyi and Klebsiella granulomatis cause genital warts; herpes simplex virus, trichomonas vaginalis, and candida albicans may cause vulvoganitis
Which description is associated with a hematoma?
the visible swelling due to extravasation of blood of sufficient size
Which type of allergic skin condition is associated with immunological irregularity, asthma, and allergic rhinitis?
atopic dermatitis- allergic skin condition that is genetically influences, chronic, relapsing disease, associated with immunological irregularity involving inflammatory mediators associated with allergic rhinitis and asthma; urticaria is an allergic skin condition that results in a local increase in permeability of capillaries, causing erythema and edema in upper dermis; psoriasis is an autoimmune chronic dermatitis but not an allergic skin condition, acne vulgaris is an inflammatory disorder of sebaceous glands
Which medication is the first line treatment for acne in adolescents?
benzoyl peroxide; tretinoin, doxycycline, and clindamycin are used to treat acne, but they are not first line agents
Which example is associated with third spacing in a burn injury?
blister formation; edema formation and fluid mobilization generally happen in every burn injury; fluid accumulation is formed in a second spacing in a burn injury
Which organism is responsible for causing Lyme disease in clients?
borrelia burgdorferi; phthirus pubis is caused by pediculosis; scabies is caused by sarcoptes scabiei; pediculus humanus var. corporis also causes pediculosis
Which life threatening wounds are treated with hyperbaric oxygen therapy?
burns, osteomyelitis; diabetic ulcers
Which diagnostic study is used to detect DVT in the client's lower extremities?
duplex venous doppler; thermography measure the heat radiating from the skin surface to determine client response to anti=inflammatory meds; plethysmography is used to record variations in volume and pressure of blood passing through tissues, test is nonspecific; somatosensory evoked potential is used to identify subtle dysfunction of lower motor neurons and primary muscle disease
Which finding would the nurse document as normal for a second, postabdominoperineal resection stoma?
moist, red, and raised above the skin surface
While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent which complication?
pressure injuries
Which type of laser is used in the treatment of vascular and other pigmented lesions?
Argon; gold vapors and neodymium are types of lasers used in the treatment of skin disorders; a carbon dioxide laser is also a type of laster used in the treatment of skin disorders
The client reports crumbly, discolored, and thickened toenails. Which reason could be a possible cause for this condition?
fungal infection; dermatological problems associated with allergies and hypersensitivity reactions may include only skin and may not include nails and hair; insect bites may cause allergic reactions; bacteria may cause scalp infections to hair and skin but do not usually cause nail infections
Which prescribed medication with the nurse administer to the client with pertussis?
antibiotic (usually macrolides)- pertussis is a highly contagious infection of the respiratory tract caused by Bordetella pertussis; antihistamines should not be used because they are ineffective and may induce coughing episodes; corticosteroids and bronchodilators are not useful
Which skin color alteration may be observed in a client diagnosed with methemoglobinemia?
blue- indicates deoxygenated blood; erythema associated with generalized inflammation; pallor indicate a deceased level of hemoglobin or it may signify a risk of anemia and shock; a yellow-orange skin discoloration may indicate jaundice associated with liver disorders
Which age related skin change occurs in older adult clients and increases their potential for developing pressure ulcers?
decrease subcutaneous fat- leads to skin shearing; atrophy of the sweat glands will cause dry skin and decreased body odor; stiffening of the collagen fibers and degeneration of the elastic fibers will result in the development of wrinkles
Which changes with a client's hair would be responsible developing white hair at the age of 23?
decreased melanocytes; decrease in oils= dry, coarse hair; decreased hair density= thinning and hair loss; decrease in estrogen= facial hirsutism
Which complication is associated with Pott disease?
destruction of intervertebral discs; abdominal TB can cause peritonitis; central nervous system TB can cause severe bacterial meningitis; generalized lymphadenopathy can be caused by miliary tuberculosis
Which organism infestation is diagnosed with the help of the mineral oil test?
mites- causative organism of scabies; lice leave excrement and eggs on skin and hair, live in seams of clothing and in hair as nits; diagnosis of Lyme disease caused by ticks is often based on clinical manifestations in particular the erythema migrans lesions and a history of exposure in an endemic area; potassium hydroxide is a diagnostic measure to determine the presence of a fungus
A client arrives at the emergency department after being bitten by a dog. The bite involved tearing of skin and deep soft tissue injury. Which action would the nurse take first?
assess the client's injury, vital signs, and past history
A client who was involved in a motor vehicle crash reports seeing flashes of light. Which condition would the nurse be prepared to address?
detached retina- caused by vitreous traction; glaucoma causes individual to see halos around lights; scleroderma is a disease of the connective tissue, not eye; cerebral concussions do not result in this ocular symptom
Which type of emergency assessment is the nurse performing when the nurse uses the "AVPU" mnemonic to assess a group of clients admitted with neurological injury after hiking at high altitude?
disability- assessment is part of the primary survey that is done to assess the LOC that may occur due to a neurological injury; AVPU, A indicates alert, V indicates response to voice, P stands for response to pain, and U indicates unresponsive; exposure assessment is one of the priorities of a primary survey which involves removing clothing for a complete assessment and preventing hypothermia using heat devices; breathing assessment involves checking breath sounds and respiratory effort, circulation assessment is performed in a primary survey to monitor blood pressure and pulse
While palpating the skin of a client, the nurse observes pitting edema on the dorsum of the foot. Which condition could be a possible cause of this?
fluid and electrolyte imbalance; endocrine imbalance may result in nonpitting edema; excessive collagen production leads to increased skin thickness; stimulation of the autonomic nervous system may result in an increase in skin moisture
Which skin infection would cause facial paralysis?
herpes zoster- facial paralysis is the clinical sign of Bell Palsy, a complication of herpes zoster virus, seen when the trigeminal nerve is infected by the varicella zoster virus
A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey colored crust and surrounded by erythema. Which infection is suspected by the primary health care provider?
impetigo- primary bacteria infection most common on the face; shingles or herpes zoster is a viral infection that usually occurs unilaterally on the trunk, face, or lumbosacral areas; folliculities is a bacterial infection seen most commonly on the scalp, beard, and extremities in men; verruca vulgaris is a virla infection that is clinically manifested as circumscribed, hypertrophic, flesh-colored papule limited to the epidermis
Which functions does the nurse associate with the epidermis?
inhibits proliferation of microorganisms, allows the photoconversion of 7-dehydrocholesterol to vitamin D; subcutaneous tissue serves as an every reserve; the dermis helps in providing cells for wound healing; subcutaneous tissue acts as a mechanical shock absorber
The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches fire. The nurse teaches the most effective method for putting out the flames. Which information from the group members indicates successful learning?
instruct victim to roll on the ground- STOP, DROP, and ROLL
Which medication is used to treat acne vulgaris in adolescents but is contraindicated in pregnancy?
isotretinoin- passes through the placental barrier and exhibits teratogenic affects
Which medication would be prescribed for the client to treat severe nodulocystic acne?
isotretinoin; imiquimod is a topical immunomodulator used to treat plantar warts; clindamycin is a topical antibitotic used to treat acne vulgaris to suppress new lesions and minimize scarring; corticosteroids may cause flare ups in clients with acne
Which intervention would be included in the plan of care for the prevention of a pressure injury?
keeping the client's skin directly off plastic surfaces
Which clinical manifestation is associated with cellulitis?
lymphadenopathy; occasional papules are present in folliculitis; herpes simplex viral infections evolve the vesicles into pustules; isolated erythematous pustules occur in folliculitis bacterial infections
A client has a bright-red erythematosus macules and papules on the skin. The nurse would expect to teach the client about which condition?
medication eruption-occurs because of an adverse reaction to a medication; atopic dermatitis is characterized by scaling and excoriation, which occurs due to food allergies, chemicals, or stress; contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens; nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques