Med-Surg: Dermatological

A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages?

II Rationale: With a stage II pressure ulcer, there is a partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage.

A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a potential malignancy of a mole?

Ulceration Rationale: Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.

A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which of the following nutrients promotes wound healing?

Vitamin C Rationale: A diet high in protein and vitamin C is recommended because these nutrients promote wound healing.

A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated and solid, with very distinct borders. The nurse should document the findings as which of the following skin lesions?

Papules Rationale: A papule is a small, solid elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles.

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings?

Leukopenia Rationale: Transient leukopenia is an adverse effect of silver sulfadiazine.

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following?

Third-degree frostbite Rationale: When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood filled and the skin does not blanch.

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications?

Acyclovir Rationale: The nurse should anticipate a prescription for acyclovir, an antiviral medication, because it inhibits replication of the virus that causes herpes zoster.

A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement?

Immobilize the limb at the level of the heart. Rationale: The emergency management of a client who has a snakebite focuses on limiting the spread of venom. any constrictive clothing or jewelry should be removed before the swelling worsens, and the affected limb should be immobilized at the level of the heart.

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources?

Pig skin Rationale: Heterografts are obtained from an animal, usually a pig.

A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention?

Surgical incision Rationale: With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention.

A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which of the following traits places a client at risk for developing malignant melanoma?

Light skin Rationale: Light skin and less pigmentation place a client at risk for developing malignant melanoma.

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider?

Temperature of 39.1 C (102.4 F) Rationale: An elevated temperature is an indication of infection and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominately gram-positive opportunistic organisms.

A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include?

Avoid exposure to the midday sun. Rationale: The nurse should instruct the clients to avoid skin exposures to the sun, especially during the midday hours of 1000 to 1600 because sun rays are the strongest at that time.

A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicated an understanding of the teaching?

I will be on a special shower table. Rationale: The special shower table facilitates examination and debridement of the wound during hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature and there is a lower risk of wound infection.

A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestations of a malignant melanoma?

Irregularly shaped lesion with blue tones Rationale: Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client's upper back and lower legs.

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image?

May I go with my family to the visitor's lounge? Rationale: This statement demonstrates a positive self-image. The client is asking to visit with her family in a public setting.

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate?

Melanomas Rationale: Melanomas are malignant neoplasms with atypical melanocytes in both the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causes metastases in the bone, liver, lungs, spleen, the CNS, and lymph nodes.

A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include?

Shift your weight in the wheelchair every 15 minutes. Rationale: This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure.

A nurse is evaluation the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?

Sodium 132 mEq/L Rationale: This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.

A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures?

Surgical excision Rationale: The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting.