Evolve integumentary

Which finding would the nurse identify as normal inflammation versus an infection when assessing a client wound that was sutured 72 hours ago?

A slight red border around the wound

Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster?

Acyclovir, Silvadene, gabapentin, wet compresses, Contact isolation

Two days after a severely burned client is admitted to the hospital the client begins to exhibit restlessness. Which condition with the nurse determine the client is most likely developing?

Cerebral hypoxia. Rationale: restlessness is the main early sign of hypoxia.

Which key feature is a characteristic of a skin infection shown in the image?

A small, erYTHEMATOUS, pus filled nodule that becomes tender.

Which statement is correct regarding negative pressure room therapy

A suction pump is used and chronic ulcers are reduced by removing fluid from the world

Which medication can cause chemical burns?

Anthralin

Which interventions can be performed by an unlicensed assistive personnel in skin care?

Assist the client in bathing, apply with dressings to the skin, report changes in skin appearance

Which life-threatening ones are treated with hyperbaric oxygen therapy?

Burns, osteomyelitis, and diabetic ulcers

Which action would the nurse take when caring for a client with a deep soft tissue injury that is open and oozing blood?

Change the dressing each time the blood uses through the outside layer

Which lesions are considered primary lesions?

Erosions

A client with a skin infection in the axilla reports a small red lesion filled with pus upon assessment the nurse notices the area to be erythematous and tinder on palpation with noticeable pass the nurse would anticipate teaching a client about which condition?

Furuncle

Which clinical manifestation is associated with hypernatremia in Burns?

Seizures

Which description describes the coalesced type of skin lesion configuration?

Lesions merge together and appear confluent.

Which disorder is a cause of systemic altered inflammatory response and impaired wound healing?

Leukemia

Which lesion may alter skin turgor?

Lichenification

A client who is to receive external radiation for cancer says to the nurse my family and friends say that I will get a radiation burn. Which response by the nurse is most appropriate?

Localized skin reaction usually occurs.

Which assessment finding indicates that a client has had a stroke? select all that apply.

Lopsided smile, unilateral vision, incoherent speech, unable to raise right arm, and symptoms start it two hours ago.

A client develop sepsis after severe burn injuries for which complication is the client at risk?

Paralytic ileus

A client has bright-red erythematosus macules and papules on the skin. The nurse would expect to teach the client about which condition?

Medication irruption

Which integrmentary changes can be anticipated in a client with a platelet count of 60,000?

Petechiae, ecchymosis, hematoma. Rationale: the normal blood platelet counts range between 150 and 400,000. Account of less than 100,000 is referred to as thrombocytopenia which results in prolong bleeding time. Petechiae ecchymosis and the formation of hematoma are the results of bleeding disorders.

Which clinical manifestation is associated with cellulitis?

lymphadenopathy

What feature is associated with the maturation phase of normal wound healing?

The scar is firm and inelastic on palpation

A client with a skin infection reports an itching sensation associated with pain at the side of infection. The assessment findings shows erythematous blisters and interdigital scaling and maceration the nurse would expect to teach the client about which condition?

Tinea pedis

Which information with the nurse include in a community education session on decreasing the risk for musculoskeletal injuries.

Use of seatbelts, obeying the speed limits, wearing safety equipment, avoiding impaired vehicle use, and refraining from distracted driving.

The nurse teaches a client about strategies to reduce burn injuries. Which statement made by the client indicates the need for further teaching?

I should never leave burning candles near open curtains unattended

Your burn victim has waxie white areas int first with pink and red areas on the anterior trunk And all of both arms. Which percentage of body surface area with the nurse calculate

36%

Which type of allergic skin condition is associated with immunological irregularity asthma and allergic rhinitis?

A topic dermatitis - An allergic skin condition that is a genetically influenced chronic relapsing disease

A client is diagnosed with an eczema tacious eruption with well-defined and geometric margins on the scalp. Which conditions would the nurse anticipate teaching the client about?

Contact dermatitis. Rationale: the diagnostic feature of contact dermatitis is the presence of localized eczematous eruptions with well defined and geometric margins.

Which term would the nurse used to document a 1 cm elevated solid lesions noted on a client skin?

Nodule

Which clinical finding occurs due to thinning of the subcutaneous layer?

Increased risk for hypothermia

Which test is used in the diagnosis of systemic lupus erythematosus?

Direct immunofluorescence test

Which functions are related to the subcutaneous layer of skin?

It provides insulation, acts as an energy reservoir, and acts as a mechanical shock absorber.

Which action would the nurse take when preparing to change a client's dressing using surgical Asepsis?

Keep the area free of microorganisms

How would the nurse arrange the orders of steps in normal wound healing in the proliferative phase?

1. Formation of scaffold or frameworks. 2. Migration of mitotic fibroblast cells into the wound. 3. Buildup of Inflexible scar tissue. 4. Formation of capillaries in areas surrounding the wound. 5. Contraction of capillary buds and ecology and deposit from the granulation tissue. 6. Growth of epithelial cells over the granulation tissue bed.

Which passive warming measures with the nurse used to promote the warmth and comfort of a client experiencing hypo thermia?

Warm socks and reflective blanket

Which teaching point would the nurse include when teaching a client about how to care for the skin around a colostomy stoma?

Wash with soap and water

A client is noted to have thicken toenails that overhang the toes and crumble at the edge which actions with the nurse take? Select all that apply

Cut the clients toenails straight across, use the clients fingernails for assessing Capillary refill, inspect the client skin next to the toenail for irritation, and instruct the client to wear clean an absorbent socks.

Which instruction with the nurse include in the teaching plan for a client with scleroderma skin care?

Keep the hands warm

What physical changes may cause longitudinal nail ridges?

Decreased blood flow

Which action will the nurse take to prevent skin breakdown for a client who is on bed rest?

Encourage the client to move in the bed as much as possible

Which integumentary changes associated with the late wound healing in a client

Decreased cell division

Which image indicates atrophy?

Image number two that is sunken in

Which factors put a client at risk for bacterial infections?

A topic dermatitis, diabetes mellitus, and systemic antibiotics

Which side effects are related to oral psoralen in phototherapy

Sunburn and persistent pruritus

A client rescued from a burning building has partial and full thickness burns over 40% of the body which initial physiological change will the nurse expect?

An increase in serum potassium. Rationale: because of tissue destruction potassium ions are liberated from the injured cells. The result is hyperkalemia.

Which type of laser is used in the treatment of vascular and other pigmented lesions?

Argon - And argon laser is used in the treatment of vascular and other pigmented lesions.

Which example is associated with third spacing in a burn injury

Blister formation

A client has visited the primary healthcare provider complaining of inflammatory lesions on the phase and is diagnosed with an inflammatory disorder of the civilacious glands. Which medications would the nurse anticipate being prescribed by this client? Select all that apply

Clindamycin and erythromycin. Rationale: clindamycin and erythromycin or topical antibiotics used in the treatment of acne vulgaris which occurs due to inflammation of the sebaceous glands.

Which nursing intervention would be included in the plan of care for a client who has a disturbed body image as a result of a burn injury?

Conveying a positive attitude toward the client

Which information with the nurse provide to a client who reports the skin seem soft and has turned white were wet compresses have been applied to an irritated insect bite?

Discontinue the wet compresses for 2 to 3 days.

Which instruction with the nurse include in the teaching plan for a client who has a new colostomy and he's learning how to care for the skin around the stoma?

Empty the pouch before it is one third full

How would the nurse arrange the order of steps in normal wound healing in the proliferative phase?

Formation of scaffold or frameworks. Migration of my ptotic fibroblast cells in the wound. Buildup of inflexible scar tissue. Formation of capillaries in areas surrounding the wound. Contraction of capillary buds and a collagen deposit from the granulation tissue. Growth of epithelial cells over the granulation tissue bed.

When reestabishing a Jackson Pratt drain after emptying its contents the nurse squeezes the collection container and recaps the drain. Which rationale for this action is accurate?

To Restore suction

When providing care for a client with quadriplegia which nursing intervention assists in decreasing the potential occurrence of pressure ulcers?

Frequently reposition the client on a schedule basis

The nurse is teaching a client about the caretaking after topical therapy. Which statement made by the client indicates the need for further learning?

I should apply high potency anthralin to each lesion for more than two hours. Rationale: the client who has undergone topical therapy should take care when applying high potency enthralling because it causes chemical burns. The medication should be applied by suspending it in a stiff paste to each legion for short periods not exceeding two hours.

Which functions does the nurse associate with the epidermis?

Inhibit proliferation of micro organisms and allows the photo conversion of seven dehydro cholesterol to vitamin D

Arrange the steps of applying negative pressure wound therapy in order of implementation.

Clean the wound. Cut the foam dressing in the dimensions of the wound. Apply a large occlusive dressing. Make a small hole in the occlusive dressing over the foam dressing near the tubing attachment. Connected tubing to a pump.

The nurse is providing care for a client who has a permanent biliary drainage tube inserted to provide palliative care. Which action would the nurse take post operatively?

Cleanse the area around the insertion site to prevent skin breakdown

Which clinical manifestation is characterized by eczematous eruption with well defined geometric margins?

Contact dermatitis Rationale: In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins.

Which type of biopsy is required for removal of entire lesions on the skin?

Excisional biopsy

Which form is a source of the dermal regeneration template graph?

Glycosaminoglycan bonded to silicone membrane

The nurse is teaching a student nurse about the interventions to be followed by a client to prevent spread of infection. Which statement made by the student nurse indicates a need for further learning?

I will advise the client to squeeze the pustules. Rationale: the client should not squeeze the pustule because it contains pass in squeezing because the spread of bacterial infections

The nurse is teaching the nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply

I will elevate the head of the clients bed to know more than 30°, I will ensure that the client is turned on repositioned at least every two hours, I will ensure that the clients fluid intake is 2000 to 3000 mL per day.

When teaching a client with pruritus about personal care interventions which client statement indicates an understanding of the interventions?

I will trim my fingernails regularly

A client with a diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irritated. Which client statement indicates the nurse needs to follow up?

I will use an oatmeal-based lotion after each treatment

When teaching a client self care measures to prevent dry skin which client statement indicates Misunderstanding of the content?

I will use deodorant soap in place of alkaline soap

Which figure would the nurse identify as a primary skin lesion?

Image number three that is yellowish and round

Which image shows wound healing by secondary intention?

Image number two with the round mauve color wound bed.

Which bacterial skin functions are caused by group a beta hemolytic streptococci?

Impetigo and ERYSIPELAS

Which intervention would be included in the plan of care for the prevention of a pressure injury

Keeping the client skin directly off plastic surfaces

Which predisposing conditions may be present in a client with pitting Adema?

Kidney disease

A client who is being treated for pruritus complains of sedation which medication would the nurse anticipate being prescribed by the primary healthcare provider to treat this side effect?

Loratadine. Rationale: loratadine is a non-sedative medication used in treating sedation caused by antihistamine medication

Which skin damage is caused by chronic exposure to ultraviolet rays?

Photo aging, wrinkling of skin

Which mechanism of action for wet to damn sailing moistened guards for wound debridement is correct

Removing the necrotic tissue mechanically