Integumentary Disorders (Prep U) Spring '18

The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply. Elevate the head of the bed to 50 degrees. Obtain daily cultures. (X) Cover with protective dressing. (x) Reposition the client every 2 hours. (x) Request an alternating-pressure mattress. The nurse is bathing a client and discovers a pressure ulcer on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first? (x) Position the client off of the ulcer. Massage the ulcerated area vigorous Place antibiotic cream over the ulcerated area Notify the physician and await orders Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized? (x) The client's skin is intact with non-blanchable redness of a localized area over a bony prominence. The client's skin has partial loss of dermis presenting as a shallow open ulcer with a red pink wound bed. The client's skin is a shiny, dry ulceration with bruising noted. The client's subcutaneous tissue is visible with a blood blistered wound bed. A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to: Apply a moist-to-moist dressing, being careful to pack just the wound bed. Consult with a wound-ostomy-continence nurse specialist. (x) Reposition the client off the reddened skin and reassess in a few hours. Complete and document a Braden skin breakdown risk score for the client. A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? Pulse rate of 112 bpm blood pressure of 94/64 mm Hg (X) urine output of 30 mL/h serum sodium level of 136 mEq/L (136 mmol/L) A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp? Temporal area Top of the head (x) Behind the ears Middle area A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? Strict (x) Contact Respiratory Enteric A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect? Impetigo (x) Scabies Contact dermatitis Dermatophytosis The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do first? Instruct the home health aide to reposition the client every 2 hours while the client is awake. Ask the client's daughter to purchase a foam mattress. (x) Contact the health care practitioner (HCP) to request a hydrocolloid dressing. Make a home visit to verify the changes in the ulcer.

LvL 1 to 2

When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch? pasta salad, carrots, and milk (x) roast beef sandwich, milkshake, and cottage cheese chicken breast, salad, and iced tea hamburger, orange, and coffee An autograft is taken from the client's left leg. The nurse should care for the donor site by: applying a pressure dressing. wrapping the extremity with an elastic bandage. covering it with an occlusive dry dressing. (x) keeping the site clean and dry. A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? Bullae Pustules (x) Vesicles Cysts Sudoriferous glands secrete which type of substance? (x) Sweat Oil Hormones Cerumen Which intervention has the highest priority when providing skin care to a bedridden client? Rubbing moisturizing lotion over the pressure areas (x) Keeping the skin clean and dry without using harsh soaps Rotating the client from side to side Gently massaging the skin around the pressure areas

LvL 6 to 7

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? (x) chicken and orange slices cheeseburger and french fries cheese omelet and bacon gelatin salad and tea During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? (x) serum creatinine level of 2.5 mg/dL (221 µmol/L) little fluctuation in daily weight hourly urine output of 60 mL serum albumin level of 3.8 g/dL (38 g/L) A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate? Apply sunscreen only after going into the water. Avoid peak exposure hours from 0900 to 1300. Wear loosely woven clothing for added ventilation. (x) Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure. A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan? Wear only synthetic fabrics. (x) Use a topical skin moisturizer daily. Bathe only three times per week. Keep the thermostat above 75° F (23.9° C ). A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity? (x) Turn him regularly. Perform passive range-of-motion (ROM) exercises. Encourage fluid intake. Message bony prominences. When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst Moderate to severe pain Urine output of 70 ml the first hour (x) Hoarseness of the voice While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: squamous cell carcinoma. actinic keratoses. (x) melanoma. basal cell carcinoma. After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at the greatest risk for skin breakdown? Inability to express need for repositioning (x) Incontinence and right-sided hemiparesis Demonstration of neglect of left side of body Unwillingness to ask for assistance A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which of the following statements by the nurse are correct about this type of burn? Select all that apply. Pain medication has been administered orally and was effective. (x) This is a severe burn and nerve endings have been destroyed. This is a superficial burn, so no pain is present. (x) The child must be monitored for signs of fluid shift. (x) Rehabilitation and skin grafting will be necessary. The nurse is caring for an immune compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems? (x) Avoid sharing combs and brushes. Wash hair with a dandruff-preventing shampoo. Wear a tight cap when going outside. Allow hair to air dry after shampooing.

LvL 2 to 3

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? Ulcer Scar Crust (x) Scale The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: correct water and electrolyte imbalances. \ allow the gastrointestinal tract to rest. provide supplemental vitamins and minerals. (x) ensure adequate caloric and protein intake. A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number. Ans: 36 A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding? "Increase in redness of the ulcer means better blood flow." "I will limit my intake of red meat to once a week." "I'll make sure that I keep the site covered at all times." (x) "I'll eat plenty of fruits and vegetables." A client who is bound to a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid dressings every 3 to 5 days. During the past few weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair, he uses a cushion. During his appointment the nurse notes that he is not using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about his treatment regimen? Explain pressure ulcer development in terms that the client understands. (x) Ask the client to explain his treatment regimen. Provide a brief anatomy and physiology lesson on how pressure ulcers develop. Call the family contact to ask about how the treatments have been done. A nurse is performing a skin assessment on a younger adult. Which of the following skin changes should the nurse observe in this client? Angiomas, bruits, caput medusae, and discoloration (x) Asymmetry, border irregularity, color variation, and diameter Alopecia, blanching, circumference, and dryness Avascularity, blanching, cyanosis, and discomfort A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? Albumin Dextrose 5% in water (D5W) (x) Lactated Ringer's solution Normal saline solution with 20 mEq of potassium per 1,000 ml Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? absence of infection in the wounds adequate vascularization in the grafted area immobilization of the area being grafted (x) use of analgesics as necessary for pain relief Which measure would be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery? Blow the nose gently. (x) Apply ice compresses. Apply warm, moist compresses. Lie in a prone position. Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? Acute pain related to vertigo Risk for injury related to vertigo Imbalanced nutrition: Less than body requirements related to nausea and vomiting Risk for deficient fluid volume related to vomiting

LvL 3 to 4

When bandaging the burned client's hand, the nurse should make certain that: the hand and fingers are not elevated above heart level. the bandage is free of elastic. (x) the hand and finger surfaces do not touch. the bandage material is moistened w/ sterile NS solution. Which disciplines should be consulted when caring for a client with a stage III heel ulcer? (x) Nutrition support and orthotics Physical therapy and respiratory therapy Occupational therapy and infectious disease Plastic surgery and cardiology An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: (x) promote the growth of epithelial tissue. provide for permanent wound closure. encourage formation of tough skin. facilitate development of subcutaneous tissue. A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg (x) Urine output of 20 ml/hour White pulmonary secretions Rectal temperature of 100.6° F (38° C) A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. (x) Reposition the client every 2 hours. (x) Perform range-of-motion exercises. Use commercial soaps to keep the skin dry. Tuck bed covers tightly into the foot of the bed. (x) Encourage the client to eat a well-balanced diet. During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? serum albumin level of 3.8 g/dL (38 g/L) little fluctuation in daily weight hourly urine output of 60 mL (x) serum creatinine level of 2.5 mg/dL (221 µmol/L) [ elevated] w/ < IV vol, the kidneys can't achieve adequate perfusion. Absence of baseline normal levels of perfusion cause a fluid shift which results in the elevated crit. normal range: 0.6 to 1.0. it can differ in men and women. During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate? body weight urine specific gravity urine output body temperature The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care? (x) Place the client on a pressure redistribution bed. Place a foam pad on the existing mattress. Turn the client every 2 to 4 hours. Administer pain medications as ordered. A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned: ans: 45%

LvL 4 to 5

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved him. He tells the nurse, "The nursing assistant on the last shift was rough. I asked her to look at my backside, but she told me she was too busy." What should the nurse do first? Contact the shift supervisor. Prepare a disciplinary warning for the nursing assistant. (x) Document her findings. Prepare an incident report. A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Massage lotion over bony prominences when turning. Turn and reposition the client every 4 hours. (x) Develop a written, individual turning schedule. Use two people when sliding the client up in bed. While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is: (x) "All family members need to be treated." "After you're treated, family members won't be at risk for contracting scabies." "If someone develops symptoms, tell him to see a physician right away." "Just be careful not to share linens and towels with family members." A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which of the following statements by the nurse are correct about this type of burn? Select all that apply. Pain medication has been administered orally and was effective. This is a superficial burn, so no pain is present. (x) Rehabilitation and skin grafting will be necessary. (x) This is a severe burn and nerve endings have been destroyed. (x) The child must be monitored for signs of fluid shift. The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do first? Ask the client's daughter to purchase a foam mattress. Instruct the home health aide to reposition the client every 2 hours while the client is awake. Make a home visit to verify the changes in the ulcer. (x) Contact the health care practitioner (HCP) to request a hydrocolloid dressing.

LvL 5 to 6

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? - Stage 2 When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? Impaired skin integrity related to disease process (x) Ineffective airway clearance related to edema of the respiratory passages Risk for infection related to breaks in the skin Impaired physical mobility related to the disease process Which disciplines should be consulted when caring for a client with a stage III heel ulcer? (x) Nutrition support and orthotics Physical therapy and respiratory therapy Occupational therapy and infectious disease Plastic surgery and cardiology The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot. The client originally scraped the foot on a rock while walking barefoot outside; the scrape became infected and eventually required hospitalization for wound care and several days of IV antibiotics. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse? "I will eat lots of fruit and vegetables and take vitamin C to help this heal." "I will be sure to wear shoes to protect my feet when I go out to get the mail." "I will manage my pain by putting this foot up on a pillow when it hurts." (x) "I will take the antibiotics until the redness goes away and my foot feels better." The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do first? Instruct the home health aide to reposition the client every 2 hours while the client is awake. Ask the client's daughter to purchase a foam mattress. (x) Contact the health care practitioner (HCP) to request a hydrocolloid dressing. Make a home visit to verify the changes in the ulcer.

Lvl 1 to 2