Iggy Study Guide Integumentary

Which client does the nurse consider to be at highest risk for development of skin cancer? A. Dark-skinned male who works as a lab technician B. Light-skinned female who works as a lifeguard every summer C. Older adult who enjoys gardening and wears a large hat D. Younger adult who works as a home health assistant

B Overexposure to sunlight is the major cause of skin cancer. Because sun damage is an age-related skin finding, screening for suspicious lesions is an important part of physical assessment.

Which response during sponging of a client with a high fever indicates to the nurse that cooling may be occurring too quickly? A. Increased temperature B. Decreased urine output C. Acute confusion D. Shivering

D Shivering during any form of external cooling usually indicates that the client is being cooled too quickly. A rising temperature indicates the cooling method is not effective. Neither acute confusion nor chaining urine output indicate excessive or too rapid cooling.

What is the priority action for the nurse and other inter professional team members when caring for a client with Stevens-Johnson syndrome? A. Treat the subjective symptoms of pain and itching. B. Closely observe for signs of renal failure. C. Protect against localized skin infection. D. Identify the offending drug and discontinue it.

D Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening cutaneous reactions most commonly triggered by drugs. Drugs most commonly associated with SJS/TEN include allopurinol, carbamazepine, lamotrigine, phenobarbital, phenytoin, and sulfasalazine. The response will continue and worsen if exposure to the drug continues.

What is the most accurate method for the nurse to use when assessing cyanosis in a dark-skinned client admitted for pneumonia? A. Check the conjunctivae and nail beds for a bluish tinge color. B. Observe for asymmetrical skin color changes. C. Auscultate for decreased breath sounds the lung fields. D. Inspect the palms and soles for a yellow-tinged color.

A In a dark-skinned client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge. To support these findings, assess for other indicators of hypoxia, including tachycardia, hypotension, changes in respiratory rate, decreased breath sounds, and changes in cognition. These secondary findings are supportive but do not indicate cyanosis. Yellow-colored soles and palms are associated with jaundice.

How will the nurse document assessment findings on a client's coccyx region that is reddened, is intact, and does not blanch when pressure is applied? A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Unstageable pressure injury

A Stage 1 pressure injuries are non-blanchable erythema of intact skin. Characteristics include: intact skin with localized area of non-blanchable erythema (may appear differently in skin with darker pigmentation); may be preceded by changes in sensation, temperature or firmness; and color changes are not purple or maroon. See Key Features of Pressure Injuries in your text.

Which assessment findings would the emergency department (ED) nurse expect when a client has a smoke-related inhalation injury? Select all that apply. A. Soot around the nose or mouth B. Singed nasal hairs C. Hoarseness of speech D. Shortness of breath E. Cherry red skin F. Cough

A, B, C, D, F With a suspected inhalation injury, the nurse would assess the mouth, throat, and nose for signs of soot. He or she would also listen for coughing, shortness of breath, or hoarseness of the voice which may indicate smoke inhalation. Cherry red skin is a sign of carbon monoxide poisoning, not inhalation injury.

Which is the best action for the nurse to take priority to changing the dressing of a client with a burn injury? A. Allow the client to rest and nap for an hour. B. Give pain medication 30 minutes prior to dressing change. C. Instruct the AP to give the client a complete bath. D. Leave the wound open to air for 30 minutes.

B Because dressing changes can be uncomfortable, giving pain medication at least 30 minutes ahead of time can make the procedure less painful and more comfortable.

Which actions will the nurse take when a client is placed on Droplet Precautions? Select all that apply. A. Using chlorhexidine for handwashing B. Wearing a disposable gown whenever entering the client's room C. Using a mask when within 6 feet of the client D. Putting a mask on the client whenever transport is necessary E. Double gloving before entering the client's room F. Prohibiting all visitors

C, D Infections spread by droplet transmission are heavy and released when the client sneezes or coughs. These droplets travel short distances, usually only 3 feet or less, and do not remain in the air. Wearing a mask within 6 feet of the client and having the client wear a mask whenever he or she is out of the room is all that is needed. Visitors are permitted but must remain at least 3 feet away from the client or wear a mask. Soap and water for hand washing is sufficient and gowns are not needed.

Which preprocedural teaching will the nurse provide for a client suspected of a bacterial cellulitis? A. The primary health care provider will inject bacteriostatic saline, withdraw it, and send the aspirate to the lab for culture. B. The crusts will be removed with normal saline, then the underlying exudate will be swabbed for a specimen. C. A smear will be obtained from the base of the lesion and examined in the lab under a microscope. D. A cotton-tipped applicator will be used to obtain vesicle fluid from intact lesions.

A A biopsy of deep bacterial infections may be needed to obtain a specimen for culture. If bacterial cellulitis is suspected, the primary health care provider can inject nonbacteriostatic saline deep into the tissue and then aspirate it back; the aspirant is sent for culture.

For which client will the nurse instruct the assistive personnel (AP) to use a lift sheet when assisting with movement in bed? A. Older adult client on steroids with thin, fragile skin. B. Client with type 2 diabetes and delayed wound healing. C. Obese client with moisture in skin folds. D. Client with a substance use problem.

A A client with decreased dermal thickness has very thin, transparent skin that is at risk for trauma. Steroids are known to induce skin thinning also. This client would be most at risk and in most need of use of a lift sheet when assisting him or her to move in bed to avoid shearing. All clients should be assessed regularly for risks to skin.

What is the priority focus on prehospital care for client with a chemical injury burn? A. Decontamination B. Fluid balance C. Airway control D. Preventing infection

A Acids and alkaline are the most common chemical substances that can inflict burn. Decontamination is the focus for prehospital emergency responders. Contaminated clothing is removed and chemicals in powder form are brushed off.

Which health behavior does the nurse teach a client who is immunocompromised to prevent infection from normal flora? A. Wiping perineal area from front to back after toileting for females. B. Wearing insect repellent or long sleeves to avoid mosquito bites. C. Washing fruit and vegetables first before eating them raw. D. Receiving an annual influenza vaccination.

A Although all behaviors are appropriate actions for the client to take to reduce infection risk, only the action of option A helps reduce the risk of infection caused by normal flora of the intestinal tract from improperly entering the urinary tract (which should be a sterile site).

Which is the nurse's best response when a client diagnosed with bedbug bites states he or she is embarrassed, showers, every day, and lives in a clean environment? A. "Have you been traveling or staying in a hotel?" B. "No need for embarrassment, these things happen." C. "Showering will not kill bedbugs." D. "Have you seen bedbugs on your clothing?"

A Bedbug infestations are increasingly common as a result of travel and resistance to pesticides. Clients are taught to: examine hotel rooms and sleeping quarters, especially in crevices of box springs; place luggage on a rack away from the bed when traveling; place used/worn clothing into a sealed plastic bad when traveling; and carefully examine used items from garage sales before bringing them home. Bedbugs often liven mattresses and fabric upholstery, and in cracks and crevices of furniture. The most common mode of infestation is carrying the bug home from an infested environment such as a hotel room. Options B, C, and D do not respond to the client's concerns.

Which specimen would the nurse instruct the assistive personnel (AP) to immediately place on ice and transport to the lab as soon as possible? A. Vesicle fluid taken by sterile technique and placed in a viral culture tube B. Punch biopsy performed with sterile technique for collection of a tissue piece C. Exudate taken by sterile technique and swabbed on a bacterial culture medium D. Aspirate taken by sterile technique and placed in a bacterial culture tube

A Cultures for viral infection are indicated if a herpes virus infection is suspected. A cotton-tipped applicator is used to obtain visible fluid from intact lesions. Viral culture specimen tubes must be placed on ice immediately after specimens are obtained and are transported to the laboratory as soon as possible. None of the other specimens must be placed on ice.

What does the nurse suspect when a client has skin that is tight and skin over the lower extremities? A. Fluid retention and edema B. Early stage of infection C. Early signs of poor circulation D. Bleeding into the skin

A Edema causes the skin to appear shiny, taut (tightly stretched), and paler than uninvolved surrounding skin. During skin inspection, the nurse documents the location, distribution, and color of areas of edema. Redness and swelling would be signs of infection. Decreased pulses and dry skin with flaking and scaling are typical of decreased circulation. Bleeding into the skin is abnormal and results in Purpura (bleeding under the skin that m ay progress from red to purple to brownish-yellow), petechiae, and ecchymosis.

Which technique would the nurse use to check for tunneling when assessing a large pressure injury on a client's hip with a small opening in the skin draining purulent material? A. Use a sterile cotton-tipped applicator to probe gently for the tunnel. B. Using gloves, palpate the surface of the wound for spongy areas. C. Flush the wound with sterile saline and watch the flow of the fluid. D. Press around the edges of the wound and observe for erythema.

A If the nurse suspects that tunneling is present ("hidden" wounds that extend from the primary wound into surrounding tissue), he or she uses a cotton-tipped applicator to probe gently for a much larger tunnel or pocket of necrotic tissue beneath the opening, estimates the size and location of any tunneled ares, and documents the findings.

What would the help-line nurse advise a client who states that a skin lesion's color has changed, its size has increased, and its border is irregular? A. "Contact your primary health care provider immediately." B. "Continue to monitor the changes and take pictures to show your primary health care provider." C. "You should go to the nearest emergency department and have the lesion evaluated." D. "It may not be anything to worry about, but make an appointment within the next month."

A It is essential that the client contact the primary health care provider if any of these findings are noted: a change in the color of a lesion, especially it if darkens or shows evidence of spreading; a change in the size of a lesion, especially rapid growth; a change in the shape of a lesion, such as a sharp border becoming irregular or a flat lesion becomes raised; redness or swelling of the skin around a lesion; a change in sensation, especially itching or increased tenderness of a lesion; or a change in the character of a lesion, such as oozing, crusting, bleeding, or scaling.

Which client is most likely to be a candidate of Mohs surgery? A. Client with squamous cell carcinoma on the nose B. Client with joint contractures from burn injuries to the elbows C. Client with infected pressure injury in deep tissues over the coccyx D. Client with the need to have excessive breast tissue removed

A Mohs surgery is a specialized form of excision usually for basal and squamous cell carcinomas when they occur on the face, nose, or other area of thin skin that may affect the cosmetic outcome.

What would the nurse direct the home assistive personnel (AP) to do for an older client who wants to avoid dry skin? A. Assist with a complete bath or shower only every other day (wash face, axillae, perineum, and any soiled areas with soap daily). B. Generously apply oil and leave it on for 20 minutes; then bathe the client, especially the genital and axillary areas. C. Use an antimicrobial skin soap and wash the client carefully; then apply alcohol-based astringent, especially to the legs and arms. D. Use hot water with a deodorant soap; then gently pat the client dry and apply oil and cream to the skin.

A To assist an older adult in prevention of dry skin, the nurse would teach the AP to help the client take a complete bath or shower every other day (wash face, axillae, perineum, and any soiled areas with soap daily), using tepid water. See Patient and Family Education: Preparing for Self-Management- Preventing of Dry Skin in your text for additional interventions to prevent dry skin.

What would the nurse suspect when a client is admitted with a rash of white or red edematous papule or plaques that developed after the client ate seafood? A. Urticaria B. Pruritus C. Eczema D. Psoriasis

A Urticaria (hives) is a rash of white or red edematous papules or plaques of various sizes. This problem is usually caused by exposure to allergens, which releases histamine into the skin. Blood vessels dilation and plasma protein leakage lead to formation of lesions or wheals.

What is best method for the nurse to complete a client's skin assessment while effectively using time management? A. Examine the client's skin while bathing or assisting with hygiene B. Perform the examination when the client willingly consents and agrees C. Question the assistive personnel (AP) who has completed the client's bath D. Check the skin assessment from the previous shift and look for changes

A A thorough assessment of the skin is best performed with the client undressed. Incorporate skin examination as a routine part of daily care during the bath or when assisting with hygiene. The nurse should not depend on infaomrtioin from the previous shift or the assistive personnel. while it is preferable that the client be willing and agreeable, this may not help with time management, which is the focus of this question.

Which conditions will the nurse consider to be contributing factors for a client with chronic pressure injuries? Select all that apply. A. Malnutrition B. Peripheral vascular disease C. Incontinence D. Immobility E. Pressure relief mattresses F. Prolonged bedrest

A, B, C, D, F Contributing factors for chronic pressure injuries include: prolonged bedrest and/or immobility; incontinence; diabetes mellitus and/or peripheral vascular disease; malnutrition; and decreased sensory perception or cognitive problems. A pressure relieving mattress would prevent pressure injuries.

Age-related changes in the integumentary system include decreases in which factors? Select all that apply. A. Rate of nail growth B. Thickness of epidermis C. Dermal blood flow D. Thickening of the nail E. Vitamin D production F. Epidermal permeability

A, B, C, E Changes in the integumentary system related to aging include decreases in vitamin D production, thickness of epidermis, dermal blood flow, and rate of nail growth. There are increases in nail thickening and epidermal permeability.

Which interventions would the nurse use to prevent harm from development of a pressure injury in a client with a prolonged coma? Select all that apply. A. Use pillows or padding devices to keep the client's heels free from pressure. B. When positioning a client on his or her side, position at a 30-degree tilt. C. Use donut-shaped pillows under the coccyx when elevating the head of the bed 90 degrees. D. Turn and reposition the client at least every 2 hours during all shifts. E. Place pillows or foam wedges between two bony surfaces or between body surfaces and the bed. F. Massage reddened areas to improve blood return and assist with healing.

A, B, D, E See Best Practice for Patient Safety & Quality Care (QSEN) Prevents Pressure Injuries in your text book. All of the responses except two are appropriate interventions. Donut-shaped pillows are not used because these can damage capillary beds and increase tissue necrosis. Reddened areas are not massaged because this increases the risk for skin breakdown.

Which roles of a client's intact skin will the nurse consider most important? Select all that apply. A. Body temperature regulation B. Protection against infection C. Providing nutrition to underlying cells D. Maintaining fluid and electrolyte balance E. Sensory function to provide comfort F. Aid in elimination fo excess CO2

A, B, D, E Skin tissue integrity plays a major role in protection by protecting the body against invasion of pathogenic organisms. Intact skin helps regulate body temperature and maintains fluid and electrolyte balance. The skin's sensory function allows the use of touch as an intervention to provide comfort, relieve pain, and communicate caring. The vascular system provides nutrients to cells and the lungs eliminate excess carbon dioxide (CO2).

Which priority nursing interventions focus on increasing client comfort and preventing skin injury when the client has pruritus? Select all that apply. A. Administering prescribed antihistamines or topical drugs B. Keeping client's fingernails trimmed short C. Instructing assistive personnel (AP) to trim toenails D. Applying mittens or gloves to client's hands at night E. Maintaining daily fluid intake of 3000 mL unless contraindicated F. After bathing, patting skin dry rather than rubbing

A, B, D, E, F All of these interventions are appropriate except that a podiatrist should trim the client's toenails, not an AP or a family member.

For which infectious diseases will the nurse recommend immunizations for older adult clients? Select all that apply. A. Influenza B. Pneumonia C. Human papilloma virus D. Herpes zoster (shingles) E. Measles, mumps, and rubella F. Tetanus, diphtheria, and pertussis

A, B, D, F The recommended immunizations for older adults include the following: Pneumococcal 13-valent conjugate vaccine (Prevnar 13) to prevent pneumonia. Pneumococcal vaccine polyvalent vaccine (Pneumovax) to prevent pneumonia. Yearly influenza vaccine (trivalent or quadrivalent) to prevent influenza (flu). Zoster vaccine recombinant (Shingrix) to prevent shingles (herpes zoster). Adult Tap vaccine to prevent tetanus, diphtheria, and pertussis (whooping cough) (and Td booster every 10 years after Tdap). Immunization against the human papilloma virus or against the childhood disorders of measles, mumps, and rubella are not recommended.

Which client factors does the nurse identify as increasing the risk for infection? Select all that apply. A. Drinking four to five alcoholic beverages daily. B. Smoking two packs of cigarettes daily. C. Using hormone-based contraceptives. D. Eating a balanced vegetarian diet. E. Serving a 5-year prison term. F. Walking 2 miles daily.

A, B, E Client factors that increase infection risk include cigarette smoking and drinking substantial amounts of alcohol daily. Living in crowded conditions, especially in institutions, also increases the risk for infection transmission. Hormone-based contraceptives, eating a balanced vegetarian diet, and regular participation in low-impact exercise do not increase a client's susceptibility to infection.

When the nurse takes a client's medication history after noting the presence of ecchymoses, which types of drugs are of concern? Select all that apply. A. Aspirin products B. Oral antidiabetic agents C. Anticoagulants D. Long-term corticosteroids E. Histamine blockers F. Short-term loop diuretics

A, C, D Certain drugs (e.g., aspirin, warfarin, corticosteroids) and low platelet counts lead to easy or excessive bruising. Anticoagulants and decreased numbers of platelets disrupt clotting action, resulting in ecchymosis. Anticoagulants, aspirin products, and long-term corticosteroids increase a client's risk for bleeding and ecchymoses (bruising). Oral antidiabetic agents are prescribed mainly for type 2 diabetes; short-term loop diuretics for excess fluid; and histamine blockers to decrease the production of acid in the stomach. None of these drugs are known to reduce blood clotting.

Which clients would the nurse understand are at risk for pressure injuries? Select all that apply. A. A middle-aged quadriplegic client who is alert and conversant B. An ambulatory client who has occasional urinary incontinence C. A very thin client who sits for long periods in a chair and refuses meals D. An obese client who must be assisted to move and turn in the bed E. An older adult who is bedridden and in late stage of Alzheimer's disease F. A client who is slightly confused but can use the bathroom with assistance

A, C, D, E Factors that increase the risk for development of pressure injuries include lack of mobility, exposure of skin to excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. Clients with cognitive decline or impairment are at risk if they are unable to fully participate in care. Individuals with peripheral vascular disease and/or diabetes mellitus are at risk, as they may experience impaired sensory perception as well as delay would healing. The client who is ambulatory with occasional urinary incontinence is not at increased risk, nor is the confused client who can use the bathroom with assistance as long as they receive the care necessary to use the bathroom and keep their skin clean and dry.

Which are priorities of care when providing care for a client with a burn injury during the emergent phase? Select all that apply. A. Securing the airway B. Maintaining nutrition status C. Supporting circulation and perfusion D. Maintaining body temperature E. Keeping client comfortable with analgesics F. Psychosocial adjustment

A, C, D, E The priorities of care during the emergent phase include (1) securing the airway, (2) supporting circulation and perfusion, (3) maintaining body temperature, (4) keeping the client comfortable with analgesics, and (5) providing emotional support.

Which assessment techniques would the nurse use when checking a client with dark skin for inflammation? Select all that apply. A. Compare affected area with non affected area for increased warmth. B. Examine the nail beds, palms, and soles for blue tinge. C. Compare the skin color of affected area with the same area on the opposite side. D. Examine the sclera nearest to the iris rather than the corners of the eye. E. Check the oral mucosa or conjunctive for petechiae. F. Examine the skin of the affected area to see if it is shiny, taut, or pits with pressure.

A, C, F To examine a dark-skinned client for inflammation, these techniques are used: compare the affected area with non-affected area for increased warmth; examine the skin of the affected area to determine whether it is shiny or taut or pits with pressure; compare the skin color of the affected area with the same area on the opposite side of the body; and palpate the affected area and compare it with the unaffected area to determine whether texture is different (affected area may feel hard). Checking for bleeding includes if a client has thrombocytopenia, petechiae may be present on the oral mucosa or conjunctiva. Examining the nails, soles, and palms is used to assess for cyanosis. Assessing for jaundice includes examination of the sclera nearest to the iris rather than the corners of the eye.

Which situations are examples of an animate reservoir? Select all that apply. A. Coronavirus (COVID-19) influenza was first transmitted to humans from infected bats and snakes. B. Escherichia coliform (E. Coli) bacteremia has been contracted from eating contaminated romaine lettuce. C. An immunocompromised client with HIV-III develops toxoplasmosis from changing a cat litter box daily. D. A 48-year-old man living in the tropics develops malaria after being extensively bitten by a swarm of mosquitoes. E. Health care personnel can transmit skin infections from one client to another by not cleaning stethoscope surfaces between clients. F. A 38-year-old client who is immunosuppressed from receiving chemotherapy develops aspergillum pneumonia while his 100-year-old house is renovated.

A, D Animate reservoirs include people, animals, and insects. COVID-19 influenza and mosquito-borne malaria are the examples in this list that meet the criteria. Romaine lettuce, kitty litter, stethoscopes, and aspergillum mold are inanimate reservoirs. Aspergillum is a newly designated inanimate reservoir of mold spores that becomes environmental particulate matter when released into the atmosphere such as during extensive renovation of older buildings.

Which action will the nurse take first to prevent harm when an assistive personnel (AP) reports that an 88-year-old client has a temperature of 100.2 degree F? A. Administer prescribed acetaminophen. B. Assess the client for other indications of infection. C. Instruct the AP to recheck the temperature in 4 hours. D. Report the temperature elevation to the primary health care provider.

B Although the client's temperature is not greatly above normal, older adults usually do not have high fevers even when infection is present. The most appropriate action is the nurse to assess the client for other indications of infection before notifying the primary health care provider. Because this low-grade fever could represent a serious infection in an older client, administering acetaminophen is not performed before assessment to prevent masking the infection. Rechecking the temperature in 4 hours is not the first or priority action. the nurse will report the temperature elevation to the primary health care provider after gathering other pertinent assessment data.

What priority complication would the nurse suspect when assessing a client with an electrical burn that has an entrance wound on the right shoulder and an exit wound through the left side ribs? A. Kidney failure B. Cardiac dysrhythmias C. Gastrointestinal ileus D. Fractured ribs

B An electrical injury occurs when an electrical current enters the body. Tissue injury occurs when electrical energy converts to heat energy as it travels through the body. Once the current penetrates the skin causing the entry wound, it flows through the body damaging tissues in its path until leaving the body at the exit wound. The path of this client's electrical injury flows across the chest through the myocardium causing damage to the heart, which can lead to dysrhythmias.

Which question would the nurse ask a client, who has nonspecific eczematous dermatitis, to determine if avoidance therapy is an appropriate intervention? A. "Have you noticed a change in the appearance of a mole?" B. "Have you used any new soaps, detergents, or personal care products?" C. "Does anyone residing in your household have a similar skin problem?" D. "Do you have a history of surgery for removal of skin growths?"

B Avoidance therapy is used to reverse the reaction and clear the rash when the initiating cause is known. For example, if a new soap for hand washing causes contact dermatitis of the hands, the client is taught to avoid that substance.

What diagnostic test does the nurse prepare a client for when the PHCP prescribes a test to determine if the client has a fungal infection of the skin? A. Punch biopsy B. KOH test C. Shave biopsy D. Wood's light exam

B Cultures for fungal infection are obtained by using a tongue blade and gently scraping scales from skin lesions into a clean container. The specimen is also treated with a potassium hydroxide (KOH) solution and examined microscopically. A positive fungal infection shows branched hyphae when viewed under a microscope after treatment with KOH and may eliminate the need for a culture. For a punch biopsy, a small circular cutting instrument, a small circular cutting instrument, or "punch", ranging in diameter from 2 to 6 mm, is used. After the site is injected with a local anesthetic, a small plug of tissue is cut and removed. Shave biopsies remove only the part of the skin that rises about the surrounding tissue when injected with a local anesthetic. A scalpel or razor blade is moved parallel to the skin surface to remove the tissue specimen. For a Wood's lamp examination, a handheld, long-wavelength ultraviolet (black) light may be used during examination. Exposure of certain skin infections with this light produces a specific color, such as blue-green or red, that can be used to identify the infection.

Which areas would the nurse give special attention to when assessing an obese older adult? A. Mucous membranes B. Skinfolds C. Scalp D. Nails

B Depending on a client's degree of ability to perform ADL's, hard-to-reach areas (e.g., perirectal and inguinal skinfolds, axillae, feet) may be less clean than other skin surface areas. Clients are positioned to promote air circulation to skinfolds. Increased moisture is commonly found in skinfolds, especially for an obese client.

What priority instruction would the nurse provide the assistive personnel (AP) who is to bathe a client with skin that is not intact and is draining? A. Save any fingernail clippings or hair samples for testing. B. Wear clean gloves and use Standard Precautions. C. Have a second AP assist you to get the client out of bed. D. Let the client load in the tub for 15 minutes before rinsing.

B For a client with non intact and draining skin, use of clean gloves and Standard Precautions is the standard of care. Gloves should be used to examine the skin, as well as to bathe the client and perform any dressing changes. Soaking in a bathtub would increase the risk of spreading infection from draining skin. Nail and hair samples would not be saved unless prescribed by the PHCP. The client would not be gotten out of bed without PHCP orders and when this is done, a lift would be used.

Which finding, when assessing a client's wound for signs of healing or infection, indicates to the nurse that healing is progressing as expected? A. Wound surface is excessively moist with a deep reddish-purple color B. Area appears pale pink, progressing to a spongy texture with a beefy red color C. Eschar starts to lift and separate from the tissue beneath, which appears dry and pale D. Tissue is soft and more yellow with substantially increased exudates.

B Granulation tissue is a sign of healing tissue It may be pale pink (early granulation) to beefy red; healthy tissue is moist and slightly spongy. Eschar is an indicator of necrotic tissue, increased exudate often indicates infection, and deep red, maroon, or purple indicates a suspected deep-tissue injury.

Which is the most important action for the nurse to teach visitors to avoid acquiring influenza when visiting a client with the disease? A. Keeping windows open in the rooms where the client spends the most time. B. Remaining at least 6 feet away from the client. C. Washing hands after touching the client. D. Not sharing a toilet with the client.

B Influenza is spread by droplets, which are heavy and do not travel far in the air. The CDC recommends prevention by remaining at least 6 feet away from the client, which is farther than the droplets trail when the client sneezes or coughs. Influenza is not spread from toilets. Keeping windows open would be helpful for airborne disease but is of no value for preventing infections spread by droplets.

In addition to Standard Precautions, which type of transmission-based precautions will the nurse use to prevent infection transmission when caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA)? A. Airborne Precautions B. Contact Precautions C. Cutaneous Precautions D. Droplet Precautions

B MRSA is an organism that is spread by direct and indirect transmission, not by the airborne or droplet route. The most appropriate type of precautions in addition to Standard Precautions are Contact Precautions. Cutaneous Precautions are not a designated category for protection.

What collaborative action would the nurse take to promote wound healing for a thin, malnourished client who had emergency abdominal surgery? A. Encourage the client to be out of bed as soon as possible. B. Consult with the registered dietitian nutritionist (RDN) about a high-protein diet. C. Instruct the client and his or her caretaker about appropriate dressing changes. D. Delegate complete morning care including a bed bath to the assistive personnel (AP).

B Malnutrition increases the risk for skin breakdown and delayed wound healing. The nurse collaborates with the registered dietitian nutritionist (RDN) to help the client eat a well-balanced diet, especially emphasizing protein.

When will the nurse draw blood from a client who has been ordered to have a serum trough level of the prescribed antibiotic measured? A. At the halfway interval between two scheduled doses B. 30 minute before the next ordered dose C. 60 minutes after the next ordered dose D. Immediately after giving a scheduled dose

B Peak and trough levels may be measured to determine the consistent blood levels of a prescribed antibiotic. A specimen for a trough level (lowest serum drug concentration) is drawn about 30 minutes before the next scheduled dose. Specimens for peak levels are drawn about 60 minutes after a dose is given.

Which information would the nurse teach a client about treatment of pediculosis pubis? A. Pubic lice are found only in the genital region of the body. B. Abstain from sexual intercourse with any infected person. C. Treatment of this condition involves shaving genital hair. D. Over-the-counter lindane is a topical drug used to kill the lice.

B Pediculosis pubis causes intense itching of the vulvar or perirectal region. Pubic lice can be contracted from infested bed linens or during sexual intercourse with an infected individual, so it is essential to avoid infected individuals. Although these lice are usually found in the genital region, they can also infect the axillae, the eyelashes, and the chest. The treatment of pediculosis involves using chemicals to kill the parasites (e.g., topical sprays, creams, and shampoos). Topical agents include permethrin cream or malathion lotion. Oral agents such as ivermectin may also be used. Over-the-counter lindane, a topical drug, has been used in the past as a pediculocide. It is no longer recommended as the first line of treatment for pediculosis because of possible neurology adverse effects.

Which technique does the nurse use to assess the "...health of the nails of a client with very dark skin." A. Obtain a color chart to identify the normal color of nails for dark-skinned clients. B. Gently squeeze the end of the finger exerting downward pressure, then release it. C. Observe the nail bed for a pale pink color and a shiny, smooth surface. D. Soak the fingertips in warm water, then gently push back cuticles.

B Regardless of skin color, the healthy nail blanches (lightens) with pressure. Blanch the nail bed to see whether the color changes with pressure. The nurse gently squeezes the end of the finger or toe, exerting downward pressure on the nail bed, and then releases the pressure. Color changes caused by blood flow changes as pressure is applied and returns to the original state when pressure is released. Color caused by pigment deposits remain unchanged.

Which assessment findings does the nurse use as the best indication of a client's healthy nails? A. Nail bed color is normal for the client. B. Nail bed blanches with gentle pressure. C. Nails are well groomed and nicely shaped. D. Nail surface is smooth and transparent.

B Regardless of skin color, the healthy nail blanches (lightens) with pressure. During examination, the client's fingers and toes should be free of any surface pressure that interferes with local blood flow or alters the appearance of the digits. To differentiate between color changes from the underlying blood supply and those from pigment deposits, the nurse blanches the nail bed to see whether the color changes with pressure. The end of the finger or toe is gently squeezed, exerting downward pressure on the nail bed, and then the pressure is released. Color changes caused by blood flow changes as pressure applied and returns to the original state when pressure is released.

What is the priority action for the nurse to take for a client who has just been diagnosed with scabies? A. Provide meticulous mouth care. B. Place the client on Contact Precautions. C. Give the client an antipyretic medication. D. Perform precise measurement of intake and output.

B Scabies is an infectious mite infestations of the skin that can be transmitted by both direct and indirect contact. This infection is not oral and does not cause fever. In addition, it has no deleterious effect on kidney function.

How does the nurse determine which dressing is best for a client with a stage 3 pressure injury over the left trochanter area that has a thick exudate? A. Select a dressing that helps remove debris by mechanical debridement. B. Obtain a prescription to consult with the certified wound care specialist. C. Expect the primary health care provider to prescribe a drug for topical debridement. D. Obtain a prescription for the type of dressing from primary health care provider.

B Specific dressings, because there are so many and recommendations are so specialized based on the individual client's needs, are often recommended by the wound nurse. The unit nurse will collaborate closely with this member of the interprofessional team to determine themes appropriate dressing.

Which assessment technique would the nurse use to check the skin turgor of a client who is at risk for hypovolemia? A. Push on the skin with thumbs and observe for blanching. B. Gently pinch the skin on the back of the hand and observe for tenting. C. Brush the skin surface back and forth while observing for flaking. D. Push on the skin over the tibia and observe for depth of indentation.

B Turgor indicates the amount of skin elasticity. Gently pinch the client's skin between your thumb and forefinger and then release. If skin turgor is normal, the skin immediately returns to its original state when released. Poor skin turgor is seen as "tenting" of the skin, with a slower and more gradual return assess for dry skin; blanching for perfusion; and indentation for edema.

Which action performed during hand hygiene by an assistive personnel does the nurse need to correct? A. Wetting hands before applying soap B. Using hot water and a scrub brush C. Using friction under running water D. Washing for at least 15 seconds

B Using hot water and scrub brushes can injure the skin surface and may cause open areas in which microorganisms can enter. Although friction is required for good hand hygiene, abrading the skin with a brush is not.

For which client would the nurse notify the primary health care provider when a Zostavax vaccine for shingles is prescribed? A. Client with diabetes B. Client with immunosuppression C. Client with Raynaud's disease D. Client with hypertension

B Zostavax (zoster vaccine live) should not be given to clients with severe immunosuppression, those who are taking drugs that reduce immunity, individuals who are undergoing radiation or chemotherapy, or those with cancer affecting the bone marrow or lymphatic system.

Which teaching strategies would the nurse include when instructing clients about how to prevent burn injuries? Select all that apply. A. Hot water heaters should be set below 150 degree F. B. Never add a flammable substance to an open flame. C. Use sunscreen and protective clothes to avoid sunburn. D. Avoid smoking when drinking alcohol or taking drugs that induce sleep. E. When space heaters are used, keep flammable objects away from them. F. If using home oxygen, do not smoke in the room where oxygen is in use.

B, C, D, E, F All of the options presented are appropriate teaching points for prevention of burn injuries except A. Water heaters should be set below 120 degree F.

Which clients with pressure injuries would the nurse assess as at high risk for development of infection? Select all that apply. A. Client with rotator cuff injury awaiting surgery. B. Older client with a low white blood cell (WBC) count. C. Client with type 1 diabetes mellitus D. Older client with high cholesterol who walks a mile every day E. Client with chronic obstructive pulmonary disease (COPD) on steroids F. Older client with large abdominal incision who needs help with repositioning

B, C, E, F Clients with diabetes are slow to heal and the longer the incision is open the greater the risk for infection. Low WBC count leaves the client unable to fight infection. Steroid therapy interferes with the actions of the immune system. The client with the large abdominal incision is at risk because of difficulty with healing. The client awaiting surgery and the client with high cholesterol who walks daily are not increased risk for infection from a pressure injury.

Which physical factors does the nurse assess for in an older adult client that are likely to increase the risk for infection? Select all that apply. A. Increased antibody production B. Thin, delicate skin C. Decreased gag reflex D. Increased gastrointestinal motility E. Decreased mobility F. Higher incidence of chronic disease

B, C, E, F Thin, delicate skin is easily injured, reducing the barrier function and increasing the risk for infection. A decreased gag reflex increases the risk for aspiration and respiratory infection. Decreased mobility contributes to infection risk in many ways including venous stasis and loss of skin integrity. Increased age is associated with many chronic illnesses such as diabetes, chronic obstructive pulmonary disease, and neurologic impairment that also increase infection risk.

What changes in color does the nurse expect when assessing a client with polycythemia vera? Select all that apply. A. Brown localized skin area B. Reddish blue generalized skin color C. Red color localized to area of involvement D. Dark red nail beds E. Diffuse blue discoloration of nails F. Yellow to brown nail beds

B, D With polycythemia vera, the skin has a generalized reddish-blue tinge and the nail beds are dark red. Skin that is blue is related to increased deoxygenated blood and localized brown is associated with increased melanin. Blue nails (cyanosis) are commonly related to respiratory problems and yellow to brown nails to jaundice (see Table 22.2 and 22.5) for more information about alterations in skin and nail bed colors.

Which circumstances are examples of colonization? Select all that apply. A. Health care provider contracts the Centers for Disease Control and Prevention because client has symptoms of smallpox. B. A nurse has a nasal swab that cultures out methicillin-resistant Staphylococcus aureus (MRSA) and remains asymptomatic. C. An 86-year-old client who is immunocompromised because of multiple chronic health problems lives in a long-term care facility. D. An assistive personnel chooses to use an alcohol-based hand rub rather than washing with soap and water after caring for a client with Clostridium difficile. E. A 55-year-old client with severe and a productive cough has a sputum culture that is positive for Streptococcus pneumonae. F. A 64-year-old woman's urine culture is positive for Escherichia coli although the urine is clear and no symptoms of cystitis are present.

B, F Colonization is the presence of microorganisms (often pathogenic in the tissues of the host) that do not cause symptomatic disease because of normal flora. Options B and F are consistent with this definition. Option A is incorrect because the client has disease symptoms although the organism remains unknown, and option E is incorrect because the client has infectious symptoms consistent with the organisms in the culture. In option C, the client is at increased risk for infection development but is not known to be harboring any pathogenic organisms. For option D, the client has an actual known infection and the assistive personnel is not using the recommended precautions to prevent spread.

Which essential teaching would the nurse provide for a client who is prescribed diphenhydramine to treat urticaria (hives)? A. Warm environments and warm showers will accelerate metabolism and recovery. B. Use an emollient cream or lotion after bathing to reduce the itching. C. Avoid alcohol consumption, which can potentiate the sedative effects of this drug. D. Use an antibacterial soap when bathing and apply topical antibiotic cream after.

C Antihistamines provide some relief from itching but may not keep the client totally comfortable. The sedative effects of these drugs may be better tolerated if most of the daily dose is taken near bedtime. The client is taught about daily dose is taken near bedtime. The client is taught about possible side effects like drowsiness, and reminded to avoid driving, use of machinery, concurrent use of alcohol or other drugs, and making decisions that require clarity of thought.

Which laboratory test would the nurse be sure to check when finding a large area of ecchymoses while assessing a client? A. Hemoglobin level B. White blood cell count C. Platelet count D. International normalized ration (INR)

C Ecchymoses (bruises) are larger areas of hemorrhage. In older adults, bruising is common after minor trauma to the skin. Certain drugs (e.g., aspirin, warfarin, corticosteroids) and low platelet counts lead to easy or excessive bruising. Anticoagulants and decreased numbers of platelets disrupt clotting action, resulting in ecchymosis.

For a decrease in which integumentary factor would the nurse avoid taping the skin on an older adult client? A. Vitamin D production B. Dermal blood flow C. Thickness of epidermis D. Melanocyte activity

C For an older adult with decreased epidermal thickness, the nurse would avoid taping the client's skin; handle clients carefully to reduce skin friction and shear; and assess for excessive dryness or moisture. For decreased vitamin D production, the client would be encouraged to take a multiple vitamin or a calcium supplement with vitamin D. For decreased blood flow, the client is taught to apply moisturizers when the skin is still moist and to avoid agents that promote skin dryness. For decreased epidermal permeability, the client is instructed to avoid exposure to skin irritants.

For which client care situation will the nurse teach assistive personnel to perform hand washing, rather than using alcohol-based hand rubs (ABHRs)? A. After removing gloves used when emptying a Foley catheter bag B. After setting up a basin and towels for a client's morning care C. After contact with a client who has had diarrhea for 3 days D. Before having direct contact with any clients

C Handwashing is recommended instead of ABHRs when hands are visibly dirty or soiled or feel sticky and after toileting (including toileting clients). ABHRs are ineffective against spore-forming organisms such as Clostridium difficile, a common cause of health care-associated diarrhea, especially in older adults. A client with diarrhea may have spores in the fecal matter or on his or her body.

Which action does the nurse take to prevent indirect contact transmission of microorganisms to a susceptible client? A. Wearing a high-efficiency particulate air filter mask when providing direct care to a client with a respiratory infection. B. Placing the client on Airborne Precautions until a negative tuberculosis test is verified. C. Cleaning the glucometer with disinfectant between testing clients. D. Wearing gloves when obtaining blood from glucose testing.

C Indirect contact transmission occurs when microorganisms are transmitted from a source to a host by passive transfer from a contaminated object. A commonly used object that can be contaminated is a glucose testing device such as a glucometer. Even if blood is not seen on the device, it should be disinfected appropriately between clients to prevent indirect contact transmission of infection. The use of Airborne Precautions, wearing of filter masks, and wearing gloves are examples of preventing direct transmission, not indirect transmission of infection.

What is the best site for the nurse to assess skin for dehydration in an older adult client? A. Forearm B. Mid-thigh C. Forehead D. Lower abdomen

C Older adult clients experience degeneration of elastic fibers the skin which results in decreased tone (firmness) and elasticity. The best places to check skin turgor for older adults is the forehead or the chest. To avoid mistaking dehydration for dry skin in an older adult, assess skin turgor on the forehead or chest. Use of other sites may provide inaccurate findings.

What area of a dark-skinned client would the nurse assess for petechiae when the client is at risk for thrombocytopenia? A. Palmar surface B. Anterior chest C. Oral mucosa D. Periorbital area

C Petechiae are pinpoint, red spots on the mucous membranes, palate, conjunctivae, or skin. If a client has dark skin and thrombocytopenia, petechiae may be present on the oral mucosa or conjunctiva. Petechiae are rarely visible in dark skin.

Which condition would the nurse suspect when observing linear ridges on the inner aspects of the wrists and the client reports intense itching especially at night? A. Dermatitis B. Body lice C. Scabies D. Head lice

C Scabies is a contagious skin infection caused by mite infestations. It is transmitted by close contact with an infested person or infested bedding. Curved linear ridges in the skin are characteristic of scabies. The itching is very intense, and clients often report that is become unbearable at night. The webs of the fingers and on the inner aspects of the wrists are where the linear ridges are most commonly found.

What would the nurse be sure to do before documenting a client's pressure injury changes with a series of photographs? A. Close the door and turn on the overhead light. B. Pull the bedside curtains for client privacy. C. Obtain informed consent from the client. D. Consult with the primary health care provider.

C Serial photographs of the wounds are very helpful in documenting changes in wound appearance and progress toward healing. Policies on photographic documentation vary between agencies but require informed consent from the client or durable power of attorney if the client is unable to provide consent.

What is the best method for the nurse to collect a superficial specimen from a raised lesion for a suspected fungal infection in a client's groin? A. Express exudate from a lesion and use a sterile swab to collect fluid. B. Obtain a small sample of tissue from the groin using needle biopsy. C. Use a scalpel or razor blade and move it parallel to the skin surface to remove the tissue specimen. D. Have the PHCP do a deep excision with a scalpel followed by closer with sutures.

C Shave biopsies remove only the part of the skin that rises above the surrounding tissue when injected with a local anesthetic. A scalpel or razor blade is moved parallel to the skin surface to remove the tissue specimen. Shave biopsies are usually indicated for superficial or raised lesions. Suturing is not needed.

Which precaution is most important for the nurse to teach a client prescribed to take oral delafloxacin to treat a skin lesion infected with methicillin-resistant Staphylococcus aureus (MRSA)? A. Report any burning on urination to your primary health care provider immediately. B. Remain in an upright position for at least 1 hour after taking this drug. C. Take this drug 2 hours before or 6 hours after taking an antacid. D. Drink at least 3 L of fluid daily while taking this drug.

C The drug can combine with any metal or divalent cation such as magnesium, reducing its effectiveness. Because many antacids contain magnesium, clients are taught not to take an antacid with or close to when delafloxacin is taken. There are no fluid requirements or position restrictions associated with the drug. Delafloxacin does not increase the risk for urinary tract infection.

What would be the nurse's best action when a client with a burn injury develops a brassy cough, increased difficulty swallowing, and progressive hoarseness? A. Place the client on continuous pulse oximetry. B. Instruct the AP to check vital signs every 30 minutes. C. Activate the Rapid Response Team. D. Establish a second IV access.

C The nurse would monitor a client's respiratory efforts closely to recognize possible airway involvement. For a burn client in the resuscitation phase who is hoarse, has a brassy cough, drools, has difficulty swallowing, or produces an audible breath sound on exhalation, the nurse responds by immediately positioning the client upright, applying oxygen, and notifying the Rapid Response Team.

What is the best place for the nurse to examine a fair-skinned client for yellow discoloration when jaundice is suspected? A. Palms B. Soles C. Sclera D. Nail beds

C To detect jaundice, the best place on the body to assess is: the sclera nearest to the iris rather than the corners of the eye; a second place to check for yellow tinge is the oral mucous membranes, especially the hard palate. The nail beds, palms, and soles would be examined for blue tinge if a client had cyanosis.

When would the nurse expect to culture a client's pressure injury wound? A. Routinely every other day with a sterile culture swab B. When there is any exudate from the wound C. When clinical or systemic signs of infection are present D. When the pressure injury wound first becomes apparent

C Wound culturing is not routinely performed, unless there is lack of healing and signs of persistent infection are present. If performed, a tissue culture is done. Clinical indicators of infection (e.g., cellulitis, exudate changes, increase in injury size or depth) and systemic signs of bacteremia (e.g., fever, elevated white blood cell [WBC] count) are used to diagnose an infection.

Which intervention would the nurse use to reduce shearing force for an obese client who is on bedrest for the next 3 days? A. Place the client in a high Fowler's position. B. Instruct the client to use arms and legs to push when moving in bed. C. Place the client in a side-lying position at a 30-degree tilt. D. Assist the client to get up three to four times daily to a recliner chair.

C Shearing forces are generated when the skin itself is stationary and the tissues below the skin (e.g., fat, muscle) shift or move. The movement of the deeper tissue layers reduces the blood supply to the skin, leading to skin hypoxia, anoxia, ischemia, inflammation, and necrosis. To reduce pressure, the head of the bed is NOT elevated about 30 degrees to prevent shearing. When a client is positioned on his or her side, the position is kept at a 30-degree tilt (avoiding 90-degree positions).

For which clients does the nurse ensure placement in a private room? Select all that apply. A. 28-year-old client with influenza B. 36-year-old after a cholecystectomy who is HIV positive C. 48-year-old severely immunosuppressed client receiving cancer chemotherapy D. 59-year-old with active tuberculosis E. 63-year-old client with hepatitis C F. 84-year-old with methicillin-resistant Staphylococcus aureus (MRSA)

C, D Although all types of infections that can be transmitted by the direct contact, droplet, or the airborne routes are recommended to be cared for in private rooms, those that require private rooms are those clients who have airborne transmitted infections and those who are severely immunosuppressed and need a protected environment. HIV infection and hepatitis C are blood borne infections and do not require seperate private rooms to prevent transmission. Those clients who have infections spread by droplets, such as influenza, and those who have infections spread by contact (MRSA) can cohort with another client who has the same infection.

Which personal protective equipment (PPE) does the nurse assemble for use when giving oral and parenteral drugs to a client who has diarrhea from Clostridium difficile overgrowth? Select all that apply. A. Air-purifying respirator B. Eye goggles C. Gloves D. Gown E. Hair cover F. Surgical mask

C, D When performing the action of giving either oral or parenteral drugs to any client with diarrhea, including those who have Clostridium difficile, only Contact Precautions are needed.

Which would the nurse use to document a client's rash that is red, raised, and itching over most of his or her body? A. Red, macular, lichenified B. Cyanotic, annual, popular C. Red, universal, circinate D. Erythematous diffuse, pruritic

D Erythematous refers to redness of the skin; diffuse is widespread over most the body; and pruritic refers to itching. (See Table 22.3 and key terms list).

Which finding indicating infection in a client would the nurse report to the health care provider immediately? A. Progressive decrease in injury size and depth B. Presence of granulation and re-epithelialization C. Beefy red color that grows and fill-in the wound D. Changes in the quantity, color, or odor of exudate

D In the presence of a pressure injury, the following changes are reported to the primary health care provider: sudden deterioration of the ulcer, with an increase in the size or depth of the lesion; changes in the color or texture of the granulation tissue; and changes in the quantity, color, or odor of exudate.

Which question would the nurse ask when assessing a female client who reports an unusual increase in facial hair? A. "Does your skin seem unusually dry and flakey?" B. "Have you noticed any bruising or unusual bleeding?" C. "Are you having trouble with urination or moving your bowels?" D. "Have you noticed any deepening of your voice quality?"

D Increased hair growth across the face and chest in women is a sign of hirsutism. It may occur on the face of a woman as part of aging, as a sign of hormonal imbalance, or as a side effect of drug therapy. If hirsutism is present, the nurse looks for changes in fat distribution and capillary fragility, which can occur in Cushing's disease, and for clitoral enlargement and deepening of the voice, which may indicate ovarian dysfunction.

Which essential teaching would the nurse provide for a younger female client with psoriasis who is prescribed tazarotene? A. This drug can reduce the effectiveness of hormone-based contraceptives. B. Tazarotene should be applied to each lesion for only a short period of time. C. This drug can help relieve chronic psoriasis but may cause acne. D. Tazarotene can cause birth defects even when applied topically.

D Tazarotene is a teratogenic substance (e.g., can cause birth defects). Women who are pregnant, or who plan to become pregnant, are instructed to avoid use of this drug, and to use effective contraception even if pregnancy is desired while using this drug. Corticosteroids provide anti-inflammatory effects. Anthralin is a hydrocarbon with action similar to tar which can help relieve chronic psoriasis. It should be applied to each lesion for a short period of time.

Which instruction would the nurse give the assistive personnel (AP) about how to perform skin care on a client at risk for pressure injury because of immobility and incontinence? A. Use an antibiotic soup and rinse with hot water to remove all soap residue. B. Scrub vigorously to ensure that all dried feces are removed. C. After cleaning, apply a light layer of powder or talc directly on the perineum. D. Clean the skin and moisturize with dimethazone, zinc oxide, lanolin, or petrolatum.

D The skin is cleaned as soon as possible after soiling occurs and at routine intervals, and is then moisturized with dimethazone, zinc oxide, lanolin, or petrolatum. Incontinence products are changed frequently and the skin is inspected at least every 2 hours, especially under these products. Skin is washed, not scrubbed, with clean, warm water and mild soap, using only the amount of pressure needed to clean. Skin is patted dry, not rubbed.

What is the priority medical/surgical concept when the nurse assess a client and finds reddened scratch marks on the right forearm? A. Infection B. Immunity C. Cellular regualtion D. Tissue integrity

D This client has a break in the skin, which is the largest organ of the body. Skin tissue integrity plays a major role in protection by protecting the body against invasion of pathogenic organisms as the first, second, and third lines of defense. The question does not give indications of infection or immunity, nor does it suggest a problem with cellular regulation (the genetic and physiologic processes that control cellular growth, replication, differentiation, and function to maintain homeostasis).

What skin manifestations does the nurse expect to observe in a client during impending shock? A. Dry, flushing appearance B. Poor turgor with rough texture C. Bluish color that blanches D. White, pale, cool skin

D When a client is going into shock from blood loss, the nurse would expect to assess skin that is pale, white, and cool. Skin temperature would be decreased. Nail beds would also be pale.

Which change in a client's white blood cell differential does the nurse interpret as associated with a severe or prolonged bacterial infection? A. Increased immature neutrophils B. Increased lymphocytes C. Increased eosinophils D. Increased monocytes

A A bacterial infection is usually associated with an increased total white blood cell count and an increase in the mature neutrophils. When a bacterial infection is severe or prolonged, the bone marrow increases the release of immature neutrophils, a phenomenon known as a "left shift". This change indicates that the body can no longer keep pace with the infection and the client is at increased risk for sepsis. An elevated lymphocyte count is associated with viral infections. An elevated eosinophil count is associated with allergic reactions. An elevated monocyte count is associated with mononucleosis.

Which actions would the nurse teach a client and family to use to stop the spread of methicillin-resistant Staphylococcus aureus (MRSA)? Select all that apply. A. Wash your hands with soap and warm water before and after touching the infected area or handling the bandages. B. Shower (rather than bathe) daily, using an antibacterial soap. C. Sleep in a seperate bed from others until the infection is cleared. D. Do not share clothing, washcloths, towels, athletic equipment, shavers or razors, or any other personal items. E. Avoid close contact with others, including participation in contact sports, until the infection has cleared. F. Wash all soiled clothing and linens with hot water and laundry detergent. Dry clothing either in a hot dryer or outside on a clothesline in the sun.

A, B, C, D, E, F Preventing skin infection, especially bacterial and fungal infections, involves avoiding the offending organism and practicing good hygiene to remove the organism before infection can occur. Handwashing and not sharing personal items with others are the best ways to avoid contact with these organisms, including MRSA. In your text, see Patient and Family Education: Preparing for Self-Management: Preventing the Spread of MRSA for a list of strategies to teach clients and family members to prevent infection spread to other body areas and to other people.

For which conditions, which could contribute to overall hygiene, would the nurse assess when a client presents with matted hair, body odor, and soiled clothes? Select all that apply. A. Intact sensory functions (e.g., sight, smell) B. Range of motion and strength C. Access to shower and laundry D. Client's currently prescribed drugs E. Perception of his or her appearance F. Knowledge (memory) of hygiene care

A, B, C, D, E, F The nurse asks about living conditions and bathing practices. Information is collected about drug and substance use. Prescribed drugs, over-the-counter (OTC) drugs, herbal preparations or remedies, and tobacco use can cause skin reactions or affect skin appearance or function. Weakness and poor range of motion can interfere with self-care as can reduced access to a shower or laundry. A client's cognitive state and non intact sensory functions can prevent recognition that there is a problem with his or her appearance to self or others.

With which clients will the nurse use extra precautions to prevent harm from infection development as a result of medical or surgical intervention? Select all that apply. A. 27-year-old taking anti rejection drugs after receiving a kidney transplant. B. 36-year-old being mechanically ventilated. C. 45-year-old with an indwelling urinary catheter. D. 58-year-old with type 2 diabetes mellitus. E. 60-year-old who had an artificial aortic value replacement 4 years ago. F. 65-year-old taking corticosteroids daily for chronic obstructive pulmonary disease (COPD). G. 80-year-old with mild chronic heart failure taking a diuretic daily.

A, B, C, E, F Drug therapies that cause any degree of immunosuppression, such as corticosteroids or anti rejection drugs, increase the risk for infection. Artificial (synthetic) medical devises also increase the risk for infection as do devices that provide a direct access to the client's internal environment and bypass normal protections, such as indwelling urinary catheters and endotracheal/tracheal tubes. Although diabetes mellitus increases a client's infection risk, this is not a medical or surgical intervention. Advancing age also increases a client's infection risk but is not a medical or surgical intervention. Diuretics do not increase infection risk.

Which preventive strategies for skin cancer would the nurse teach to clients and families? Select all that apply. A. Avoiding sun exposure between 11 a.m. and 3 p.m. B. Wearing a hat, opaque clothing, and sunglasses when you are in the sun C. Using tanning beds no more than 30 minutes twice a week D. Taking pictures of lesions and comparing them month by month E. Keeping a "body map" of your skin spots, scars, and lesions F. Using sunscreens if your sun exposure will be more than an hour

A, B, D, E All options are appropriate except C and F. Tanning bed should be completely avoided, and whenever a client's skin will be exposed to sunlight, a sunscreen should be used.

Which teaching points would the nurse be sure to share with a client schedule for a punch biopsy? Select all that apply. A. A local anesthetic will be injected into the site. B. A circular instrument will cut out a tissue sample. C. The site will always require suturing after the procedure. D. You will have a scar similar to a healed surgical incision. E. Antibiotic ointment may be prescribed to reduce the risk for infection. F. Keep a dry dressing on the site until your sutures are removed.

A, B, E For a punch biopsy, a small circular cutting instrument, or "punch," ranging in diameter from 2 to 6 mm, is used. After the site is injected with a local anesthetic, a small plug if tissue is cut and removed. The site may be closed with sutures or may be allowed to heal without suturing. After a punch, the client is taught that only a small amount of skin is removed and scarring is minimal. Antibiotic ointment may be prescribed to prevent infection. The dry dressing should be kept in place for at least 8 hours, and the site cleaned daily after the dressing is removed. Tap water or saline is used to remove any dried blood or crusts.

Which factors increase the risk of complications from a burn injury in an older adult client? Select all that apply. A. Slower healing time B. Thinner skin C. Increased inflammatory response D. Increased pulmonary compliance E. Medical conditions such as diabetes F. Increased immune response

A, B, E Thinner skin increases the depth of injury even when the exposure to the cause of injury is of shorter duration. Slower healing time leads to longer time with open areas, which results in a greater risk for infection. Pre-existing conditions such as diabetes can lead to slower healing time. Decreased (not increased) inflammatory and immune responses would increase risk for complications. Increased pulmonary compliance would not affect an older adult's risk for complications with burn injuries. See Patient-Centered Care: Older Adult Considerations Age-Related Changes Increasing Complications from Burn Injury in your text.

Which characteristics would the nurse expect to assess for a client with plaque psoriasis? Select all that apply. A. Raised, red patches covered with silvery white scales B. White pustules surrounded by reddened skin C. Affected areas usually include scalp, knees, elbows, lower back D. Usually starts after a streptococcal infection E. May be itchy, painful, or bleeding F. Affected areas usually include hands and feet

A, C, E Plaque psoriasis is the most common form of psoriasis. It is described as: raised, red patches covered with silvery white scales; usually found on scalp, knees, elbows, lower back; and may be itchy, painful, or bleeding. White pustules surrounded by reddened skin occurs with pustular psoriasis which usually occurs on hands and feet. Guttate psoriasis usually occurs after a streptococcal infection.

In addition to topical drugs for psoriasis, which therapies would the nurse teach a client to reduce symptoms? Select all that apply. A. Ultraviolet (UV) irradiation B. Oral antibiotics C. Photochemotherapy with psoralen D. Surgical excision E. Excimer lasers F. Systemic therapy

A, C, E, F Ultraviolet (UV) irradiation has been shown to be beneficial in controlling psoriatic lesions. Photochemotherapy can be given by administration of psoralen, a photosensitized, taken either orally or within a bath, followed by ultraviolet A (UVA) radiation. Excimer lasers emit UVB light and can be used for localized lesion treatment. Whether administered in a continuous or pulsed exposure, this modality allows for better focus on the lesions and reduces exposure to the surrounding normal skin. Oral systemic agents are often prescribed for clients with more than 5% body surface area affected by psoriasis (e.g., methotrexate, folic acid, and systemic retinoids). Oral antibiotics and surgical excision are not interventions of choice for this problem.

Which actions would the nurse take when a client has decreased eccrine and aprocine gland activity? Select all that apply. A. Instruct the client to use soap with a high fat content. B. Assess skin for size and shape of pores or comedones. C. Use the oral mucosa to assess for cyanosis. D. Teach the client to avoid frequent bathing with hot water. E. Suggest wearing hats to prevent heat loss in cold weather. F. Encourage the client to apply moisturizers after bathing.

A, D, F Decreased eccrine and apocrine gland activity leads to increased susceptibility to dry skin. The nurse will: urge clients to use soaps with a high fat content; teach clients to avoid frequent bathing with hot water; and teach clients to apply moisturizers after bathing while skin is moist. Assessment of pores and comedones is done for decreased sebum secretion. Using the oral mucous to assess for cyanosis is done for decreased nail bed blood flow, and suggesting a hat in cold weather would be done for decreased hair follicles and rate of hair growth.

Which factors are include in the ABCDE features associated with skin cancer? Select all that apply. A. Evolving or changing of any feature B. Diameter greater than 5 mm C. Crusting, bleeding, or itching D. Color variation within a lesion E. Border regularity F. Asymmetry of shape

A, D, F The nurse assesses each lesion on a client for these ABCDE features that are associated with skin cancer: Asymmetry of shape; Border irregularity; Color variation within one lesion; Diameter greater than 1/4 of an inch or 6 mm; and Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting). A client who has a lesion with one or more of the ABCDE features should be evaluated by the dermatologist or surgeon.

When caring for an older adult, what skin change would cause the nurse to keep the client's room warmer? A. Decreased number of active melanocytes B. Decreased layer of subcutaneous fat C. Decreased thickness or epidermis D. Decreased sebum production

B A client with a decreased subcutaneous fat layer is at increased risk for hypothermia and is taught to dress warmly, as well as may need a warmer temperature in his or her room. Decreased melanocytes increase the risk of sun sensitivity. Decreased melanocytes increase the risk of sun sensitivity. Decreased epidermal thickness causes skin transparency and fragility (these clients must be handled carefully and tape should be avoided). Decreased sebum production can lead to increased size of nasal pores.

Which is the best rationale for the nurse to use to encourage a client to seek treatment for dandruff? A. Dandruff is a cosmetic problem but appearance is important to self-esteem. B. Severe dandruff is caused by excessive oiliness and can cause hair loss. C. Dandruff flakes are caused by dry scalp and suggest possible dehydration. D. Brushing your hair everyday can prevent dandruff but may weaken hair follicles.

B The flaking that occurs with dandruff causes many adults to mistakenly think the scalp is too dry; however, it is actually a problem of excessive oil production. Dandruff by itself is a cosmetic problem, but a very oily scalp can induce inflammatory changes with redness and itching. Severe inflammatory dandruff can extend to the eyebrows and the skin of the face and neck. If severe dandruff is not treated, alopecia (hair loss) can occur. The client is taught that dandruff is not caused by dryness and should be treated to prevent hair loss.

Which client would the nurse monitor carefully when continuous negative-pressure wound therapy (NPWT) is used to facilitate healing? A. Client with diabetes mellitus B. Client receiving anticoagulation C. Client with severe pain D. Client hypertension

B The nurse would recognize that continuous negative-pressure wound therapy (NPWT) is used with caution with clients on anticoagulant therapy because NPWT increases the risk for bleeding at the application site. He or she would respond by consulting with members of the inter professional team, such as the primary health care provider and wound care nurse, to ensure that anticoagulant status was appropriately monitored.

Which client is the nurse most likely to recommend for directly observed therapy (DOT)? A. Older client with poor dentition who requires liquid medications B. Homeless man with tuberculosis (TB) prescribed four anti-TB drugs daily C. College student prescribed oral antibiotics for a sexually transmitted infection D. Athlete with methicillin-resistant Staphylococcus aureus (MRSA) infection on the hand

B Tuberculosis is a highly contagious pulmonary infection transmitted by the airborne route that most commonly requires at least 6 months of daily drug therapy with four drugs. Failure to adhere to the drug regimen can result in disease progression, development of resistant organisms, and transmission to others. A homeless person is less likely to be adherent to the regimen for many reasons and would benefit most from directly observed therapy.

Which expected outcomes are appropriate for a client with a pressure injury? Select all that apply. A. Client will rate pain at an acceptable level B. Client will remain free from local or systemic infections C. Client will re-establish skin tissue integrity and restore skin barrier function D. Client will verbalize that wound is smaller E. Client's wound will show granulation and decrease in size F. Client will consume a diet rich in carbohydrates

B, C, E The expected outcomes for a client with pressure injury include that the client will: experience progress toward wound healing by second intention as evidenced by granulation, epithelialization, contraction, and reduction or resolution of wound size; re-establish skin tissue integrity and restore skin barrier function; and remain free from local or systemic infections.

Which questions would the nurse ask to determine if a client with a rash is having a new allergic reaction? Select all that apply. A. "Is your skin usually flakey or dry?" B. "Are you taking any new medications?" C. "Have you been using any different soaps, cosmetics, or lotions?" D. "Have you noticed any bruises or brownish discolorations?" E. "Have you been exposed to any new cleaning solutions?" F. "Have you had any recent changes in your diet?"

B, C, E, F A new allergy would suggest that something has changed for the client such as new drugs, new products (soap, cosmetics, lotions, cleaning solutions), or changes in diet. Bruises or brownish discolorations suggest a bleeding problem. Flakey or dry skin suggests the need for something to moisturize the skin.

Which actions will the nurse take to prevent disease transmission when caring for a client who has an infection with a multi drug resistant organism? Select all that apply. A. Taking a prophylactic antibiotic daily B. Showering as soon as reaching home after work C. Remaining at least 6 feet away from infected clients D. Keeping work clothes separate from personal clothes E. Wearing scrubs and changing clothes before leaving work F. Wearing gloves while drawing blood for laboratory assessment

B, D, E To help prevent the transmission of an MDRO, nurses are expected to wear scrubs and change clothes before leaving work. Keeping work clothes separate from personal clothes, as well as taking a shower upon reaching home helps rid the body of any unwanted pathogens. Taking prophylactic antibiotics can contribute to the development of MDRO and is most definitely not recommended. Remaining 6 feet away from infected clients is not possible during client care. Wearing gloves during blood draws is part of Standard Precautions and does not specifically address infection prevention for MDROs.

Which medical-surgical concept would the nurse designate as the highest priority for a client with pressure injuries of both heels? A. Fluid and electrolyte balance B. Immunity C. Tissue integrity D. Cellular regulation

C A pressure injury (PI) is a loss of tissue integrity. It is caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface. This results in reduced tissue perfusion and gas exchange, which eventually leads to cell death. Most frequently these injuries are found on the sacrum, hips, and heels.

What type of healing does the nurse assess when a client's surgical wound edges are approximated, closed with sutures, and there is no inflammation? A. Healing by third intention B. Healing by granulation C. Healing by first intention D. Healing by second intention

C A wound without tissue loss, such as a clean laceration or a surgical incision, can be closed with sutures, staples, or adhesives. The wound edges are brought together with the skin layers lined up in correct anatomic position (approximated) and held in place until healing is complete. This type of wound represents healing by first intention, in which the closed wound eliminates dead space and shortens the phases of tissue repair.

Which skin disorder is most associated with a familial predisposition? A. Scabies B. Cellulitis C. Psoriasis D. Ringworm

C Some skin problems (e.g., psoriasis, keloid formation, eczema) have a familial predisposition. Others are transmittable disorders (e.g., ringworm, scabies). Clients are asked about immediate family members' current health with regard to skin problems. Cellulitis is a deep bacterial infection.

Which action will the nurse use during the client care to prevent infection by mechanically disrupting biofilms? A. Washing hands with chlorohexidine for 15 seconds. B. Cleaning the skin with alcohol prior to venipuncture. C. Using sterile technique when inserting a urinary catheter. D. Helping the client to floss and to brush teeth.

D A biofilm is a complex of microorganisms that group together and form a gel-like coating (glycocalyx) that supports continued growth of the microorganisms. Effective treatment or prevention starts with disruption of biofilm. Human biofilms include plaque on teeth and gums, a coating on and in the crypts of tonsils, and as a layer of exudate in wounds. They do not usually form on normal skin or mucous membrane.

Which skin assessment finding in an older adult client is most important for the nurse to report to the primary health care provider (PHCP) for follow-up? A. Presence of cherry hemangiomas B. Multiple brownish liver spots on the arms C. Dry and flakey skin on the lower extremities D. Irregular light-brown macule (6.5 cm) on the right scapula

D A client's lesion that is evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting) should be evaluated by a surgeon or dermatologist (remember ABCDE). Cherry hemangiomas are the result of proliferation of capillary and are benign. Dry skin may require application of a moisturizer. Multiple liver spots are normal changes that occur with aging.

Which equipment would the nurse obtain to assist the PHCP in examining a light-skinned client for evaluation of skin pigment changes? A. Glass slides B. Biopsy tray C. Bright nonfluorescent light D. Wood's lamp

D A handheld, long-wavelength ultraviolet (black) light or Wood's lamp may be used during examination. Exposure of certain skin infections with this light produces a specific color, such as blue-green or red, that can be used to identify the infection. Hypopigmented skin is more prominent when it is viewed under black light, making evaluation of pigment changes in lighter skin easier. This examination is carried out in a darkened room and does not cause discomfort.

Which term would the nurse use to document a client's skin lesions that are widespread involving most of the body? A. Circumscribed B. Universal C. Linear D. Diffuse

D Diffuse lesions are widespread, involving most of the body with intervening areas of normal skin. Circumscribed lesions are well-defined with sharp borders. Universal lesions involve the entire body, and linear lesions occur in a straight line.

When regulating body temperature, how much evaporative water can the eccrine sweat glands lose in one day? A. 500-600 mL/day B. 700-900 mL/day C. 2-4 L/day D. 10-12 L/day

D Eccrine sweat glands arise from the epithelial cells. They are found over the entire skin surface and are not associated with hair follicle. The odorless, colorless secretions of these glands are important in body temperature regulation. This sweat and the resultant water evaporation can cause the body to lose up to 10 to 12 L of fluid in a single day.

Which skin changes does the nurse expect to see in an older adult client as a result of a decreased number of active melanocytes? A. Increased skin transparency B. Decreased skin firmness and elasticity C. Slowed and decreased healing D. Increased sensitivity to sun exposure

D Melanocytes are pigment-producing cells found at the basement membrane. Melanin protects the skin from damage by UV light, which stimulates melanin production. For this reason, people with dark skin (and thus more melanin) are less likely to experience sunburn than people with light skin. When there is a decrease in melanocytes, the client is more sensitive to sun exposure and is taught to wear protective clothing and a wide-brimmed hat.

Which finding when the nurse assesses a nevus on a client's back would be of concern and warrant further investigation? A. Regular and well-defined borders B. Uniform dark brown color C. Rough surface D. Report of itching and bleeding

D Melanomas are pigmented cancers arising in the melanin-producing epidermal cells. Most often they start as the benign growth of a nevus (mole). Normal nevi have regular, well-defined borders and are uniform in color, ranging from light colors to dark brown. The lesion's surface may be rough or smooth. Those with irregular or spreading borders, and/or multiple colors, are abnormal. Other suspicious features include sudden changes in lesion size and reposts of itching or bleeding.

How long would the nurse expect a client's partial-thickness wound to heal by epithelialization? A. 24 hours B. 48 hours C. 2 to 3 days D. 5 to 7 days

D Partial-thickness wounds are superficial with minimal loss of tissue integrity from damage to the epidermis and upper dermal layers. These wounds heal by re-epithelialization, the production of new skin cells by undamaged epidermal cells in the basal layer of the dermis, which also lines the hair follicles and sweat glands. In a healthy adult, healing of a partial-thickness wound takes about 5 to 7 days.