Integumentary System (Med-Surg)

The nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. Which action would the nurse take in response to the client's comment?

Explain that the incision should not be immersed in water until it has healed. Rationale: Because of the risk for infection, the client should avoid tub baths, hot tubs, pools, and immersion in other bodies of water until after the wound has healed and these activities are approved by the primary health care provider. Immersion in water for a prolonged period interferes with wound healing, because water may macerate tissue. Having a friend along does not change the fact that immersion in water for a prolonged period will interfere with wound healing. The client needs to continue physical therapy after discharge whether or not the client goes swimming.

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

Keeping the client's skin directly off plastic surfaces Rationale: For the prevention of a pressure ulcer, the client's skin should be kept directly off plastic surfaces. While the client is positioned on his or her side, direct positioning on the trochanter should be avoided. The head of the bed should not be kept elevated above 30 degrees. This is to prevent shearing. A rubber ring or donut under the client's sacral area should be avoided.

The nurse is assisting a primary health care provider with insertion of a central venous access catheter. Which equipment will the nurse plan to have in the room to help prepare for the procedure? Select all that apply. One, some, or all responses may be correct.

Mask Gown Checklist Sterile Gloves Rationale: The primary health care provider who inserts the vascular access device wears sterile gloves, gown, and mask. Anyone in the room during the procedure must also wear a mask. Use a checklist during insertion to make sure everything is done correctly. Chlorhexidine is used for skin disinfection, because it has the best outcomes for preventing infection; povidone-iodine is not used.

The nurse instructs a client about safety measures and precautions when taking care of a pressure ulcer. During a follow-up visit, the nurse finds increased tissue necrosis with damaged capillary beds. Which actions by the client would the nurse expect are the reason for the client's condition? Select all that apply. One, some, or all responses may be correct.

Massaging the reddened skin areas Using donut-shaped pillows for pressure relief Rationale: The client with a pressure ulcer should gently pat the skin rather than massaging the reddened skin areas, which results in dryness. Using donut-shaped pillows may aggravate the client's condition. The other choices are correct actions by the patient. Placing pillows or foam wedges between two bony surfaces during positioning may provide comfort to the client. The client should avoid maintaining the head of the bed elevated above 30 degrees to prevent shearing. Keeping the client's heels off the bed surface using a bed pillow under the ankles ensures safety in the client.

Which mechanism of action for wet-to-damp saline-moistened gauze for wound debridement is correct?

Removing the necrotic tissue mechanically. Rationale: Wet-to-damp saline-moistened gauze mechanically removes the necrotic tissue. The dilution of viscous exudates is promoted through the continuous wet-gauze technique. Topical enzyme preparations cause a breakdown of the denatured protein of the eschar. Moisture-retentive dressings promote the spontaneous separation of necrotic tissue through autolysis.

Which surgery is used to treat excessive wrinkling or sagging of facial skin?

Rhytidectomy Rhytidectomy is the removal of excess skin and tissue from the face; this is the surgery used to treat wrinkling or sagging of facial skin. Rhinoplasty is the removal of excessive tissue or cartilage from the nose. Dermabrasion is the process of removing the facial epidermis or a portion of the dermis to treat acne scars. Blepharoplasty is the removal of bulging fat in the periorbital area; this is used to treat bags under the eyes.

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?

Skin Integrity Rationale: Necrotizing fasciitis destroys subcutaneous tissue and fascia and predisposes the client to infection and sepsis. Although fluid volume and physical mobility are important, they are not the primary concern at this time. Necrotizing fasciitis is a problem of the integumentary, not the urinary, system.

Arrange in order the steps involved in a biopsy procedure for the diagnosis of skin infections.

1. Establishing a sterile field and assembling all needed supplies and instruments 2. Wiping the skin of the client with alcohol 3. Providing local anesthesia using a small-gauge needle 4. Removing the tissue specimens and placing in 10% formalin for fixation 5. Placing the specimens for culture in sterile saline solution 6. Controlling bleeding of the skin by applying pressure 7. Covering the site with an adhesive bandage or a dry gauze dressing

An adult client sustains partial- and full-thickness burns of the left thigh and left arm. Using the Lund-Browder chart, the nurse calculates the percentage of total body surface area burned. Which percentage will the nurse record?

16.5% Rationale: According to the Lund-Browder chart the total body surface area is calculated: left thigh = 9.5% and left arm = 7%, which totals 16.5%. The responses 23.5%, 28.5%, and 30.5% are incorrect calculations.

If a person's clothes catch on fire, which action is the most important to perform after the flames are extinguished?

Assess the person's breathing. Rationale: Assessing the person's airway is the most important action to perform. A patent airway is most vital; if the person is not breathing, cardiopulmonary resuscitation (CPR) should be instituted. The other options are correct but not as important as airway. The person should be kept nothing by mouth because large burns decrease intestinal peristalsis and the person may vomit and aspirate. Covering the person with a light blanket or sheet is appropriate. Calculating the extent of the person's burns is not the priority; this assessment is done after transfer to a medical facility.

Which skin infection would cause facial paralysis?

Herpes zoster Rationale: Facial paralysis is the clinical sign of Bell palsy, a complication of the herpes zoster infection. This is seen when the trigeminal nerve is infected by the varicella-zoster virus. Candidiasis is a fungal infection not associated with Bell palsy. Herpes simplex is a viral infection and may not cause Bell palsy. Dermatophytosis is also a fungal infection not associated with Bell palsy.

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment Rationale: The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury?

Hyperkalemia and hyponatremia Rationale: Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.

Which characteristic does the nurse associate with a punch biopsy?

It is performed using a circular cutting instrument 2 to 6 mm in diameter. Rationale: Punch biopsy is a common technique that involves the use of a small circular cutting instrument with a diameter of 2 to 6 mm. Shave biopsies are usually recommended for superficial or raised lesions. Excisional biopsies are comparatively more uncomfortable than punch or shave biopsies. Shave biopsies remove the skin portion that rises above surrounding tissues.

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

Loratadine Rationale: Loratadine is a nonsedative medication used in treating sedation caused by antihistamine medications. Hydroxyzine and diphenhydramine are antihistamine medications used in the treatment of pruritus; sedation is a side effect of these medications. Triamcinolone acetonide is an intralesional corticosteroid used in the treatment of psoriasis.

The nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation?

Pain Rationale: Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. A neurological check is not necessary unless the client's neurological status has worsened since the stroke. Both skin and wound checks can be assessed once client comfort has been determined and handled.

A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information would the nurse include in the teaching plan?

"Clean the mouth with a soft toothbrush or a gentle spray." Rationale: Chemotherapy destroys the rapidly dividing cells of the oral mucosa; frequent gentle oral hygiene limits additional trauma. Although it is recommended to rinse the mouth every 2 hours, the client does not need to brush teeth and clean the mouth as often. Lemon juice is too caustic to the compromised mucosa. Flossing can disrupt and traumatize the gum surfaces; oral hygiene is needed more than once a day. Commercial mouthwashes contain alcohol, which is irritating to the mucosa.

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct.

Monitoring vital signs Cutting off the clothing Inserting a urinary catheter Removing the client's jewelry Establishing an intravenous line Rationale: According to the Rule of Nines, the client has full-thickness burns to 22.5% of the body (18% chest and 4.5% right arm). The nurse would monitor vital signs (including oxygen saturation), remove the client's clothing and jewelry, insert a urinary catheter to maintain intake and output, and insert an intravenous line to administer fluids.

Which medication can cause chemical burns?

Anthralin Rationale: Anthralin is a strong irritant that has an action similar to tar. Therefore this medication can cause chemical burns with topical use. Prednisone is a corticosteroid applied topically to treat psoriasis. Tazarotene and calcipotriene are teratogenic (cause birth defects).

Which skin color alteration may be observed in a client diagnosed with methemoglobinemia?

Blue Rationale: Blue discoloration of the skin may indicate an increase in deoxygenated blood, which is associated with methemoglobinemia. Red (erythema) may be associated with generalized inflammation. White (pallor) may indicate a decreased level of hemoglobin or it may signify a risk of anemia and shock. A yellow-orange skin discoloration may indicate jaundice and is associated with liver disorders.

In which area does the pictured skin condition frequently appear on a client's skin?

Buttocks Rationale: The client has a furuncle, which is a small, tender, erythematous nodule that becomes pus-filled and tender over time. This lesion occurs more often in areas of hair-bearing skin, especially buttocks, thighs, abdomen, and axillae. Type 1 herpes simplex may develop on the face. Cellulitis may commonly affect the lower legs. More often, candidiasis occurs in the perineal region.

Arrange the order of airway management in a client with burns.

1. Intubate the client within 1 to 2 hours after injury. 2. Place the client on ventilatory support. 3. Escharotomies of the chest wall, if necessary. 4. Extubation is indicated when edema resolves.

A client is admitted with cellulitis of the left leg and a temperature of 103°F (39.4°C). The primary health care provider prescribes intravenous (IV) antibiotics. Which action is the priority before administering the antibiotics?

Determine the client's allergies. Rationale: Allergies are important. Medication hypersensitivity and anaphylaxis are most common with antimicrobial agents. Applying a warm, moist dressing over the area is a dependent function; it is not crucial to starting antibiotic therapy. Measuring the amount of swelling in the client's leg is an important assessment, but it is not crucial to starting antibiotic therapy. Withholding treatment until culture results are available may extend the infection.

A client with epilepsy reports diffuse redness and large blisters on the buccal mucosa. Administration of which medication could be a possible reason for the client's condition?

Barbiturates Rationale: Barbiturates are used to treat epilepsy and are the most common causative agents of toxic epidermal necrolysis (TEN). Diffuse redness and large blisters on the buccal mucosa are the clinical signs of TEN. Though pyrazolones and sulfonamides also cause TEN, they are not used in treating epilepsy. Benzodiazepines are used in treating epilepsy but do not cause TEN.

Which gastrointestinal (GI) change may be found in the client with burn injuries?

Abdominal Distention Rationale: The client with burn injuries may have abdominal distention due to loss of peristalsis. Gastrointestinal motility may be inhibited with burn injuries. Blood flow may be reduced and mucosal damage might have occurred.

The nurse is caring for a client with a body surface burn injury of 55%. Which information will the nurse consider when planning care for this client?

Is prone to poor healing because of a hypermetabolic state Rationale: Burn injuries cause a hypermetabolic state. This results in lipid and protein catabolism, which in turn can inhibit wound healing. A hypermetabolic state increases the risk for slowed wound healing, increasing the chance for infection. Cooling the environment would cause an increase in caloric need as the body tries to warm to core temperature. Clients with burn injuries require increased calories and protein to promote wound healing. For an adult client, 20 calories/kg does not provide an adequate increase of calories or protein for the hypermetabolic state associated with burns.

Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply. One, some, or all responses may be correct.

Photoaging Wrinkling of the Skin Rationale: The skin damages that happen from chronic exposure to ultraviolet rays are photoaging and skin wrinkling. Dryness, vascular lesions, and benign neoplasm are changes related to aging.

Which intervention relieves integumentary itching, promoting comfort of the client exposed to poison ivy?

Wet compress Rationale: Wet compresses provide comfort and treatment of conditions such as poison ivy. Saline may be used to irrigate wounds. Cold and heat therapy are not specifically applied to integumentary sites affected by poison ivy.

An older adult has undergone chemotherapy. Which agent could be administered to decrease the risk of a potentially contagious common viral infection?

Zoster vaccine Rationale: Herpes zoster or shingles is the most common viral infection that is potentially contagious to anyone who has not had varicella or who is immunosuppressed, such as clients on chemotherapy. Incidence increases with age mainly for adults 50 years old or older. Administering the zoster vaccine helps in preventing the risk of shingles. Famciclovir is an antiviral medication that helps in reducing the symptoms of the infection. Gabapentin is prescribed to clients suffering from neuralgia caused by shingles. Vaccines for HSV-1 are not available.

A client who has been in a coma for 2 months is being maintained on bed rest. At which angle will the nurse place the head of the bed to prevent the effects of shearing force?

30 degrees Rationale: Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and cause this phenomenon. Angles of 45 degrees, 60 degrees, and 90 degrees raise the head of the bed too high, which contributes to the client sliding down in bed.

The nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority?

Extent of burn Rationale: During the emergent stage of a burn, the nurse first assesses the extent and then the cause of the burn, then where it occurred, and then determines first aid measures that were used. For immediate treatment of the burn, the nurse would be concerned with the body location and extent of the burn.

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

Medication eruption Rationale: Medication eruptions are characterized by bright-red erythematosus macules and papules on the skin, which occur because of an adverse reaction to a medication. Atopic dermatitis is characterized by scaling and excoriation, which occurs due to food allergies, chemicals, or stress. Contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens. Nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques.

Which risk would the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn?

The risk of septicemia and its potential complications from treatment Rationale: Skin is the first line of defense against infection. When much of it is destroyed, the client is vulnerable to infection. Complications, such as infection and contractures, still may occur during the acute phase and as the client is healing. Psychosocial adjustments, previous roles, and insufficient community resources are priorities in the rehabilitative phase. Risk of oral mucous membrane injury is in the emergent (resuscitation) stage. Emotional support is provided in all three phases.

Which action would the nurse take when caring for a client with burns who is being treated with collagenase and polysporin powder therapy?

Use the treatment on partial-thickness wounds with eschar. Rationale: Collagenase with polysporin powder should be used on partial-thickness wounds with eschar. It should be applied once a day. During the administration of mafenide acetate, arterial blood gas levels should be monitored. Collagenase with polysporin powder should be used with a barrier dressing such as occlusive petrolatum gauze.

A client sustained minor skin injuries after an accident. Which event occurs close to the time of injury?

Migration of leukocytes to the site of injury Rationale: Beginning at the time of injury and lasting 3 to 5 days is the inflammatory phase in which migration of leucocytes takes place. Scar tissue is formed in the maturation phase. Formation of granulation tissue and migration of fibroblasts occurs in the proliferative phase.

A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. Which percentage of total body surface area (TBSA) would the nurse calculate?

36 Rationale: Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% total for both arms) and 18% for the anterior trunk; thus the total body surface area burned is 36%. The choices 20%, 25%, and 30% are too low.

Which condition is an example of a bacterial infection?

Impetigo Rationale: Impetigo is the bacterial infection of skin caused by group A β-hemolytic streptococci or Staphylococcus aureus. Candidiasis is the fungal infection caused by Candida albicans. Plantar warts and verruca vulgaris are viral infections caused by the human papilloma virus.

Which integumentary changes can be anticipated in a client with a platelet count of 60,000/µL (60 × 109/L)? Select all that apply. One, some, or all responses may be correct.

Petechiae Ecchymosis Hematoma Rationale: Normal blood platelet counts range between 150,000 and 400,000/µL (150-400 × 109/L). A count of less than 100,000/µL (100 × 109/L) is referred to as thrombocytopenia, which results in prolonged bleeding time. Petechiae, ecchymosis, and the formation of hematoma are the results of bleeding disorders. Cyanosis is caused by cardiorespiratory problems, vasoconstriction, asphyxiation, and deoxygenated blood. Varicosity is caused by interruption of venous return commonly found on lower legs with aging.

While palpating the skin of a client, the nurse observes pitting edema on the dorsum of the foot. Which condition could be a possible cause of this?

Fluid and Electrolyte Imbalance Rationale: Fluid and electrolyte imbalance results in pitting edema of the skin. An endocrine imbalance may result in nonpitting edema. Excessive collagen production leads to increased skin thickness. Stimulation of the autonomic nervous system may result in an increase in skin moisture.

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

"I will advise the client to squeeze the pustules." Rationale: The client should not squeeze the pustule because it contains pus and squeezing may cause the spread of bacterial infections to unaffected areas. All the other options are appropriate statements. Taking daily baths with an antibacterial soap reduces and prevents the spread of infection. The crusts should be gently removed before applying topical medications so that medications can be easily absorbed. Applying warm compresses to areas of cellulitis increases comfort.

A client with vesiculopustular lesions with honey-colored crusts on the face visits a primary health care provider. Which bacterial condition is suspected?

Impetigo Rationale: Impetigo is associated with vesiculopustular lesions that have honey-colored crusts. Impetigo usually manifests on the face. Cellulitis is a bacterial infection in which hot, tender, erythematous, and edematous areas with diffuse borders are present. Carbuncle is a bacterial infection with many pustules in an erythematous area. Erysipelas is a bacterial infection characterized by a red, hot, sharply demarcated plaque that is indurated and painful.

The nurse is caring for a client with a closed soft tissue injury. How would the nurse describe this injury?

As a contusion Rationale: Closed wounds are contusions and hematomas because the skin is not broken. Abrasions, lacerations, and avulsions are considered open because there is a break in the skin integrity.

A severely burned client has been hospitalized for 3 days and is now in the acute phase. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. Which complication would the nurse conclude the client is most likely developing?

Cerebral hypoxia Rationale: Cerebral cells require high levels of oxygen. When the partial pressure of oxygen within the circulatory system falls, the client becomes restless, and cognitive functions become impaired. With kidney failure the client becomes progressively confused and lethargic because of the buildup of toxins in the body. Hypovolemic shock is more likely to occur in the emergent (resuscitation) phase. With metabolic acidosis the client is lethargic.

Which infection is caused due to fungus?

Dermatophytosis Rationale: Dermatophytosis is a fungal infection in which single or multiple patches appear on the skin. Furuncle is a bacterial infection in which small, tender, erythematous nodules filled with pus appear on the skin. Folliculitis is a bacterial infection in which erythematous pustules appear singly or in groups on the skin. Herpes zoster is a viral infection in which lesions are present on an erythematous base.

Which laboratory result would the nurse check to evaluate a client's fluid loss from extensive burns?

Hematocrit Rationale: An increased Hct level indicates hemoconcentration secondary to fluid loss. The BUN level may be used to indicate dehydration from burns, but interpretation can be complicated by other conditions accompanying burns that also cause an increase in the BUN. An increase in the sedimentation rate indicates the presence of an inflammatory process, not fluid loss. The pH level reflects acid-base balance.

Which topical medications are typically used to treat a client with acne vulgaris? Select all that apply. One, some, or all responses may be correct.

Clindamycin Erythromycin Rationale: Topical clindamycin and erythromycin are typically used to treat acne vulgaris. Mupirocin is used to treat impetigo. Metronidazole is used to treat rosacea and bacterial vaginosis. Gentamicin is used to treat gram-negative organisms.

The nurse identifies silvery scales on a client's elbows and knees. Which finding in the client's history will help the nurse identify the origin of this rash?

Stress in recent months Rationale: The client is exhibiting the clinical manifestations of psoriasis, which is characterized by white, scaly plaques on the scalp, knees, or elbows. The cause is unknown, but it is believed to be a multifaceted and related to stress and immune response. Harsh soaps may cause dry, itchy, cracked skin but not silvery scales. Tar-based soaps may be recommended. Psoriasis is not caused by excursions into uncultivated, weedy areas and the lesions are not necessarily associated with HIV.

The nurse is caring for two clients with a below-the-knee amputation. The first client was in a motor vehicle collision. The second client has a history of chronically decreased arterial perfusion. Which information would cause the nurse to conclude that the postoperative courses of these two clients may differ?

The second client's incision will take longer to heal. Rationale: Decreased arterial circulation in the second client will delay healing. The first client received an amputation without preoperative preparation for the loss of the limb and will most likely have greater difficulty adapting. Clients with chronic limb pain before surgery (e.g., the second client with chronically decreased arterial perfusion) are more likely to have phantom limb sensations. Both clients' responses may be influenced by their occupations, but there is no data to support this conclusion.