Integumentary

A client sustains a burn injury to the entire right and left arms, right leg, and anterior thorax. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage?

54%

The nurse is caring for a client with a diagnosis of pemphigus vulgaris. The nurse understands that which is a characteristic of this condition?

Blistering skin

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which?

Characteristic of a thrush infection

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure ulcer in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure ulcer? Select all that apply.

Clean with mild soap and water. Encourage adequate nutritional intake. Apply a dressing that allows oxygen to pass through.

The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure?

Darken the room for the examination.

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition?

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection?

Red, shiny skin around the nail bed

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

"I need to avoid sun exposure before 10:00 am and after 4:00 am."

The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse should include on the poster instructions to avoid which activities?

Being in the sun for prolonged periods between 10:00 am and 3:00 pm

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching?

"I should never wear warm clothing over the newly healed skin area."

The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching?

"I should use a dehumidifier, especially during the winter months."

Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?

"I will apply the ointment once a day and cover it with a sterile dressing."

The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching?

"I will remove the dressing when I get home and wash the site with tap water."

The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching?

"If the patch comes off, I need to reapply it."

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?

"My clothes can be laundered with other household members' clothes."

A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client?

"The exact cause of acne is not known."

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client?

"The local anesthetic may cause a burning or stinging sensation."

The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client?

Administer an opioid analgesic last taken 6 hours ago.

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy?

Covering the application with a warm, moist dressing and an occlusive outer wrap

The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment?

Culture of the lesion

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

The return of distal pulses

A client comes to a health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick?

Bull's-eye rash

An African-American client has been admitted for a skin rash on his lower back. Which should the nurse rely on when assessing the skin rash? Select all that apply.

Palpation Induration

Which individuals is least likely at risk for the development of psoriasis?

A 32-year-old African American

A client arrives at the emergency department and has experienced frostbite to the right hand. Which should the nurse expect to find when inspecting the client's hand?

A white color of the skin, which is insensitive to touch

After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings?

Ambulation three times daily

A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem?

Appearance

The nurse is caring for a client on transmission-based precautions who has herpes zoster or shingles. Which are some of the most important skin issues associated with this condition? Select all that apply.

Full-thickness skin necrosis can result. Lesions are very contagious when they are fluid-filled blisters. Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. To reduce the risk of transmitting the virus to others, keep clients with lesions separated from other clients until lesions have crusted.

The nurse prepares to assist in instructing a client about prevention of Lyme disease. Which should the nurse include in the instructions?

It is caused by a tick carried by deer.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which describes a characteristic of this type of a lesion?

It is highly metastatic.

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present?

Silvery-white scaly lesions

The nurse is discussing skin biopsy with a client scheduled for the procedure. The nurse tells the client to expect which amount of discomfort during the procedure?

Slight because the local anesthetic may burn or sting

The nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse should document the ulcer as which category?

Stage II

An older client is complaining of chronic dry skin and occasional pruritus. The nurse reinforces instructions for the client to avoid which skin care regimen that will aggravate the condition?

Using astringents to clean the skin

The nurse is assigned to care for a client with herpes zoster. Which characteristics should the nurse expect to note when checking the lesions of this infection?

Clustered skin vesicles

Using the rule of nines, calculate the burn percentage for the client. Refer to the figure; the burned area is the darkly shaded area. Fill in the blank. Refer to figure. Chest and Stomach

19%

Which clients are at risk for developing skin breakdown? Select all that apply.

A client who is underweight A client diagnosed with heart failure A client diagnosed with spinal cord injury

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition?

White skin that is insensitive to touch

A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response should the nurse give to the client's question?

"It is a skin infection that involves the deeper skin layers and subcutaneous fat."

A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what "heterograft" means. Which is the most appropriate response to the client?

"It is skin from another species."

Which individual is least likely at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as malignant melanoma. The nurse should expect which characteristic of this type of lesion to be documented in the client's record?

An irregularly shaped lesion

The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription?

Apply cold compresses to the affected area.

The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client?

Elevating and immobilizing the affected leg

The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply.

Inflammatory or (lag) phase Maturation or (remodeling) phase Proliferative or (connective tissue repair) phase

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable.

During the inspection of a client's skin, the nurse notes redness and an abrasion type wound on the sacrum area. The nurse determines that this finding is indicative of which stage of pressure ulcer?

Stage 2 pressure ulcer

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action?

Use the edge of a sterile surgical tool to scrape out the stinger.

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which percentage?

36%

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?

22.5%

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.

36 %

The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder?

An outdoor construction worker

The nurse is preparing a client for skin grafting and identifies that the health care provider has documented that the client is scheduled for a heterograft. The nurse understands that a heterograft used for the burn client is skin from which source?

Another species

The nurse in a health care provider's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse should reinforce instructions to the client to do which action before the procedure?

Discontinue the prescribed antihistamine 2 days before the test.

The nurse is conducting a focused evaluation on a postoperative client's integumentary system. Which priority objective physical examination assessments are related to inspection? Select all that apply.

Dressing if present Nails for shape, contour, color, thickness and cleanliness Skin for color, integrity, scars, lesions, and signs of breakdown Facial and body hair for distribution, color, quantity and hygiene

The nurse is assisting in caring for a client with a severe burn who has just received an autograft to the knee area of the right leg. The nurse plans to keep the right leg in which position?

Elevated and immobilized

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury?

Elevated hematocrit levels

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Elevation above the level of the heart

Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan?

Ensure that the solution is freshly prepared before use.

The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action?

Monitor the client for signs of infection.

Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which is most indicative of this stage?

Neurological deficits

A client has a non-infected pressure ulcer on the left heel. The nurse should use which sterile solutions to cleanse the wound as part of a dressing change procedure?

Normal saline

The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information?

Palms of the hands

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which should the nurse expect to find when checking the client's sacral area?

Partial-thickness skin loss of the epidermis

A client with jaundice is complaining of pruritus. Which strategy should the nurse institute to help control the problem and prevent injury?

Pat the skin dry after bathing.

A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion?

Venous circulation is being impaired.

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet to see if which therapy has been prescribed for site care?

Warm compresses

The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client?

Warm compresses to the affected area

The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which?

Weeping of the skin

A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client?

"Take a shower immediately, and lather and rinse several times."

The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown?

A client with a lowered mental awareness status

A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. How should the nurse interpret this data?

A superficial injury to tissue from the radiation

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?

Can stain the skin and hair

An older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing?

Chicken breast, broccoli, strawberries, milk

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which?

Punch biopsy of the cutaneous lesions

A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure?

"I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply.

Wound from repair of a perforated appendix Gunshot wound that punctured the small intestine Traumatic wound to the abdomen and intentionally left open for several days Wound related to debridement of a chronic pressure ulcer resulting in a cavity-like defect