HESI: Med-Surg Integumentary System
Folliculitis is the condition that forms a small pustule at the hair follicle opening; it has minimal erythema and is most commonly seen on the scalp, beard, and extremities. A furuncle is a condition in which there is a tender erythematous area around the hair follicle. Cellulitis is the condition in which there is a hot, tender, erythematous, and edematous area on the skin with diffuse borders. A carbuncle is the condition in which many pustules appear in an erythematous area, most commonly at the nape of the neck.
A client has a small pustule at a hair follicle opening with minimal erythema on the scalp. Which condition would the nurse suspect? 1 Furuncle 2 Cellulitis 3 Folliculitis 4 Carbuncle
Dysphagia The proximity of the parotid gland to the esophagus necessitates assessment of swallowing, because dysphagia may be a result of damage to surrounding tissue. Ataxia, an impairment in muscle coordination, is not a typical side effect of radiation therapy to the neck region. Hypoxia, an oxygen deficiency in body tissues, should not occur, because the lungs are not being irradiated. Arthralgia, or pain in a joint, is not a side effect of radiation therapy for this client.
A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. Which condition will the nurse assess the client for during the return visit to the radiology department? 1 Ataxia 2 Hypoxia 3 Arthralgia 4 Dysphagia
Fungal infection Exposure to the pathological fungal varieties may cause infections to the nails along with hair and skin. Dermatological problems associated with allergies and hypersensitivity reactions may include only skin and may not include nails and hair. Insect bites may cause life-threatening allergic reactions due to the venom of the insect. Bacteria may cause scalp infections to hair and skin but do not usually cause nail infections.
The client reports crumbly, discolored, and thickened toenails. Which reason could be a possible cause for this condition? 1 Allergy 2 Insect bite 3 Fungal infection 4 Bacterial infection
Client with epilepsy A client with epilepsy does not have any circulatory inadequacy. The capillary refill time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-positive result). A client with shock has decreased oxygen saturation levels that further prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood circulation for clients with anemia, peripheral vascular disease, or diabetes.
The nurse assesses the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? 1 Client with shock 2 Client with anemia 3 Client with epilepsy 4 Client with peripheral vascular disease
"The epidermis of the skin will protect from trauma by providing a cushioning effect." Cushioning effect of the skin that aids in protection from trauma is provided by the fat depositions in the subcutaneous layer of the body. The client needs more teaching. All the other statements are correct. The fat deposits in the subcutaneous layer insulate the body and provide protection from trauma. Sweat produced by the sweat glands helps maintain homeostasis through fluid and electrolyte balance. Sebum produced by the sebaceous glands will rejuvenate the hair and prevents it from drying.
The nurse teaches a client about the functions of the integumentary system. Which statement made by the client indicates the need for further teaching? 1 "The subcutaneous layer insulates the body." 2 "Sweat glands in the skin aid in homeostasis in the body." 3 "Sebaceous glands in the skin will prevent the hair from drying." 4 "The epidermis of the skin will protect from trauma by providing a cushioning effect.
Fissure An example of a fissure-type secondary lesion is athlete's foot. Surgical incisions and healed wounds are examples of scar-type secondary lesions. A scale-type secondary lesion would include flaking of the skin after a medication reaction or sunburn. Ulcer-type lesions may include pressure ulcers or chancres. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
Which secondary skin lesion may include athlete's foot as an example? 1 Scar 2 Scale 3 Ulcer 4 Fissure
Meat provides protein, and fruit provides vitamin C; both promote wound healing. Although meatloaf provides protein, tea does not provide vitamin C. Chicken soup and a baked apple or buttered bread do not meet the client's need for protein or vitamin C. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain period, can provide a clue to the most appropriate response or, in some cases, responses.
A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. Which food items would the nurse recommend the client to select for the upcoming meals? 1 Meatloaf and tea 2 Meatloaf and strawberries 3 Chicken soup and baked apple 4 Chicken soup and buttered bread
A procedure performed at the hospital is the cause. An iatrogenic infection is one caused by health care providers or therapy. Poor personal hygiene, inadequate dietary intake, and the client's developmental level are not the causes of an iatrogenic infection. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.
A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection. Which rationale explains the nurse's comment? 1 Poor personal hygiene is the cause. 2 Inadequate dietary intake is the cause. 3 The client's developmental level is the cause. 4 A procedure performed at the hospital is the cause
Seeking professional treatment for any minor injuries to the extremities Because diminished circulation leads to inadequate healing, early treatment of injuries is essential. Toenails should not be too short and should be trimmed straight across. Bathwater should be checked with a bath thermometer; toes of persons with peripheral artery disease (PAD) may be less sensitive to temperature change, and a burn may occur. These clients develop trophic skin changes; the drying action of alcohol will contribute to dryness and skin breakdown. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.
The nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which directions will the nurse include in the teaching plan? 1 Trimming toenails so that they are short and rounded 2 Checking bathwater temperature by putting the toes in first 3 Using alcohol to rub hands, feet, legs, and arms at least two times a day 4 Seeking professional treatment for any minor injuries to the extremities
Deep partial-thickness In deep partial-thickness burns, upper layers of the dermis, and injury to deeper portions of the dermis occur. Eschar, a dry, leathery covering of denatured protein, occurs with full-thickness burns. In full-thickness burns, total destruction of the epidermis, dermis, and some underlying tissue occurs. In superficial partial-thickness burns, the epidermis is injured, but there are no weeping vesicles or blisters.
Which classification would the nurse use to describe burns that are painful, mottled red, weeping, and edematous? 1 Eschar 2 Full-thickness 3 Deep partial-thickness 4 Superficial partial-thickness
Seizures Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.
Which clinical manifestation is associated with hypernatremia in burns? 1 Fatigue 2 Seizures 3 Paresthesias 4 Cardiac dysrhythmias
"I will trim my fingernails regularly." Regular trimming of the nails, wearing of splints at night, and application of moisturizing lotion after (not before) bath are some interventions the client may implement to protect the skin when experiencing pruritus. When the client stated that he or she would not file the fingernail edges, the client was revealing a misconception that does not reflect understanding. The client should regularly file rough edges of fingernails to prevent skin damage and secondary infection. Clients should not use baby powder or talc in the groin areas because the product cakes and holds moisture in the area potentially leading to yeast infections or fungal infections.
When teaching a client with pruritus about personal care interventions, which client statement indicates understanding of the interventions? 1 "I will trim my fingernails regularly." 2 "I will apply moisturizing before my bath." 3 "I will avoid filing the edges of fingernails into oval shapes." 4 "I will use baby powder or talc in my groin areas."
Intertrigo Intertrigo is dermatitis of overlying layers of the skin. Moles are the benign overgrowth of melanocytes. Vitiligo is the complete absence of melanin, resulting in chalky white patches. Tenting is the failure of skin to return immediately to a normal position after gentle pinching.
Which abnormal finding does the nurse identify in this image? 1 Mole 2 Vitiligo 3 Tenting 4 Intertrigo
Maintain compression of the drainage system Self-contained suction devices for wound drainage must be compressed for suction to work. Drainage tubes generally are not irrigated by nurses. Application of heat may increase inflammatory edema. These drains work via negative pressure, not gravity.
Which action would the nurse implement for a client who has a portable wound drainage system in place after surgery? 1 Irrigate the drainage tube with saline. 2 Apply warm compresses to the involved site. 3 Maintain compression of the drainage system. 4 Keep the involved area in a dependent position
1 Apply the medication every 2 to 8 hours Polymyxin should be applied every 2 to 8 hours to keep the affected area moist. Nonadhesive antimicrobial dressing, which is a material containing silver granules, should be left in place for 7 days. Collagenase with polysporin powder can be applied once a day and can be used with barrier dressing such as occlusive petrolatum gauze. Silver-coated antimicrobial dressings should not be used with oil-based products.
Which action would the nurse implement when caring for a client with burns who is prescribed polymyxin? 1 Apply the medication every 2 to 8 hours. 2 Leave in place for 7 days. 3 Use the medication with barrier dressing. 4 Refrain from using with oil-based products
Keratin Keratin is a protein produced by keratinocytes that helps maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its 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 component of skin maintains optimal barrier function? 1 Keratin 2 Melanin 3 Collagen 4 Adipose tissue
Linear cracks in the epidermis that extend into the dermis Fissures are linear cracks in the epidermis that extend into the dermis. Ulcers may be described as deep erosions extending beneath the epidermis. Atrophy is the thinning of the surface of the skin with a loss of skin markings. Lichenifications are characterized by thick areas of epidermis with accentuated skin markings.
Which description is associated with fissures? 1 Deep erosions that extend beneath the epidermis 2 Thinning of the skin surface with a loss of skin markings 3 Linear cracks in the epidermis that extend into the dermis 4 Thickened areas of epidermis with accentuated skin markings
3 Primary lesions are superficial lesions with a diameter of less than or greater than 0.5 cm. Pustules, papules, vesicles, and plaque are examples of primary lesions. Option 3 shows a pustule, which is a primary lesion of the skin. Options 1, 2, and 4 are secondary lesions of the skin.
Which figure would the nurse identify as a primary skin lesion?
Telangiectasia Telangiectasia is a permanent condition characterized by cutaneous blood vessels that are superficial and visibly dilated. Tenting is the failure of the skin to immediately return to the normal position after a gentle pinch. Angioma is a tumor that consists of blood and lymph vessels. Varicosity is the increased prominence of superficial veins.
Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? 1 Tenting 2 Angioma 3 Varicosity 4 Telangiectasia
Provides cells for wound healing The dermis is present between the epidermis and subcutaneous layers and has such functions as giving the skin its flexibility and strength and providing cells for wound healing. Subcutaneous 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.
Which function of the dermis is accurate? 1 Provides cells for wound healing 2 Assists in retention of body heat 3 Acts as mechanical shock absorber 4 Inhibits proliferation of microorganisms
All of the above According to the Rule of Nines, the client has full-thickness burns to 22.5% of the body (18% chest and 4.5% right arm). The nurse would monitor vital signs (including oxygen saturation), remove the client's clothing and jewelry, insert a urinary catheter to maintain intake and output, and insert an intravenous line to administer fluids. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the exam quickly can cause you to misread or misinterpret the real intent of the question.
Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. 1 Monitoring vital signs 2 Cutting off the clothing 3 Inserting a urinary catheter 4 Removing the client's jewelry 5 Establishing an intravenous line
2, 4, 5 The eccrine gland is a sweat gland, the main functions of which are to moisturize the surface cells, cool the body by evaporation, and excrete waste products through the pores of the skin. Dysfunction of the eccrine gland may result in drying of surface cells, decreased efficiency to cool the body, and decreased excretion of waste products through the skin. The sebaceous gland secretes sebum, which prevents drying of hair and skin. Dysfunction of the sebaceous gland may lead to drying of hair and skin. Endogenous synthesis of vitamin D occurs by the action of ultraviolet (UV) light on vitamin D precursors in epidermal cells. Dysfunction of the eccrine gland may not be associated with decreased vitamin D synthesis.
Which physiological abnormality might occur in the client diagnosed with a dysfunction of the eccrine glands? Select all that apply. One, some, or all responses may be correct. 1 Drying of hair 2 Drying of surface cells 3 Decreased synthesis of vitamin D 4 Decreased efficiency to cool the body 5 Decreased excretion of waste through the skin
Deep breathing exercises Deep breathing exercises are an effective intervention in controlling pain; this is a positive coping skill. Muscle relaxation techniques generally include muscle contraction and then relaxation, which may increase the pain. Active range-of-motion exercises may increase the pain. Understanding important aspects of wound care will not reduce pain; health teaching should be initiated before, not during, a procedure. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.
Which point would the nurse include in a teaching plan to help manage pain during dressing changes if a client has burns over 18% of body surface? 1 Deep breathing exercises 2 Progressive muscle relaxation 3 Active range-of-motion exercises 4 Important elements of wound care
1, 5 In negative pressure wound therapy, a suction pump is used to treat the wounds. This therapy can reduce chronic ulcers by removing fluids from the wound. Necrotizing infections are treated by hyperbaric oxygen therapy. Hyperbaric oxygen therapy is the administration of oxygen under high pressure. Electrical stimulation is the application of a low-voltage current to a wound area.
Which statement is correct regarding negative pressure wound therapy? Select all that apply. One, some, or all responses may be correct. 1 A suction pump is used. 2 Necrotizing infections are treated. 3 Oxygen is administered under high pressure. 4 A low-voltage current is applied to a wound area. 5 Chronic ulcers are reduced by removing fluids from the wound