Passpoint - Integumentary Disorders

While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

"All family members will need to be treated."

A client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."

A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction would best prevent skin damage?

"Apply sunscreen even on overcast days."

A client understands what resources are available to help him perform wound care at home when he states the following:

"Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need."

A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client?

"Cover the area when in direct sunlight."

A nurse is caring for a client with thrush. Which instructions would be anticipated for treatment of this disorder?

"Give the solution immediately after feedings."

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.

Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet. Reposition the client every 2 hours.

A client has a foot ulcer that hasn't shown signs of improvement over the last several months. What medical condition is most likely causing the wound healing delay?

Peripheral vascular disease

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

A child's parents ask for advice on the use of an insect repellent that contains DEET. Which statement would the nurse incorporate in the response?

"Spray the child's clothing instead of the skin."

A nurse reinforces the homecare instructions for a client diagnosed with basal cell epithelioma. Which statement by the client indicates an understanding of the instructions?

"The best time of the day to work outside is before 10 a.m. and after 2 p.m."

Which statement would the nurse include when reinforcing education for a parent about salmon patches (stork bites)?

"They're benign and usually fade in adult life."

The nurse is caring for a 15-year-old who has suffered third degree burns to 30% total burn surface area (TBSA). The health care provider has order morphine 0.5 mg by mouth every 3 to 4 hours as needed for pain. The elixir comes in 2mg/1 ml. How many milliliters would the nurse give? Record your answer using two decimal places.

0.25

A client arrives to the clinic with reports of a rash. The nurse observes the client and documents the lesion as a papule. What is the best way for the nurse to document this finding?

0.5-cm elevated area

A 2-year-old child has been diagnosed with cellulitis. The health care provider has order the client to get ceftriaxone 50 mg IM. The pharmacy sends 100 mg/2 mL. The nurse will administer the medication in the vastus lateralis. How many milliliters should be administered? Record your answer using a whole number.

1

An infant with hives is prescribed diphenhydramine 5 mg/kg over 24 hours in divided doses every 6 hours. The child weighs 8 kg. How many milligrams should be given with each dose? Record you answer using a whole number.

10

A 22 lb (10 kg) child is diagnosed with Kawasaki disease and started on gamma globulin therapy. The health care provider orders an IV infusion of gamma globulin, 2 g/kg, to run over 12 hours. How many grams should the nurse give the client? Record your answer using a whole number.

20

The nurse is collecting data from several clients at the clinic. Which client does the nurse determine is most likely receive the Zostavex vaccine for the prevention of shingles?

62-year-old client that had a mild case of shingles 4 years previously

In the client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

An elderly client who lives at home with her daughter is admitted with unexplained bruises on her arms and legs. Which action should the nurse take first?

Assess the client thoroughly and complete the health history.

While assessing a client, a nurse notes a stage I pressure ulcer on the client's left hip. How should the nurse report this finding?

Document the size, extent, and location of the wound in the client's medical record.

The nurse wants to help a client maintain healthy skin. Which nursing intervention will help achieve this goal?

Keeping the client well-hydrated

Which of the following nutritional deficiencies may delay wound healing?

Lack of vitamin C

The nurse is reinforcing education about treatment options for the parent of a child with lice. Which adverse effect would the nurse teach regarding lindane shampoo?

Lindane is associated with seizures.

The nurse is reinforcing instructions for a client regarding hypersensitivity after administering a skin test. Which instruction is most important for the nurse to reinforce when discussing the skin test?

Have the sites read on the correct date.

When assessing a client with partial thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

The nurse is caring for a 4-year-old with a full-thickness burn. Before sending the child to hydrotherapy for a scheduled wound debridement, which nursing action is a priority?

Implement pain control measures.

Which action should a nurse take first when admitting a client with herpes zoster infection?

Institute isolation precautions according to facility policy.

A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client?

Wound care nurse

The nurse is caring for a postoperative client and finds that the dressing has not been changed from the previous shift. Which action can the nurse take to ensure the client receives necessary dressing changes?

Write the order in the client's care plan.

A postoperative client has just been admitted to a unit from the postanesthesia care unit (PACU). When should the nurse change the dressing for the first time?

after the surgeon changes the first dressing and provides the written orders

A child has a red rash in a cicular shape on the legs. The lesions are not connected. Which classification is the most appropriate for this rash?

annular

A client has been admitted with burns on both legs. Which nursing intervention is most important to help prevent contractures?

applying knee splints

The nurse is gathering data from a child suspected of being a victim of abuse. What observation by the nurse would lead to this suspicion?

contusions of the back and buttocks

The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis?

dry, cracked lips, strawberry tongue swollen lymph nodes in the neck swollen red feet and hands

When collecting data on a child with cellulitis, which symptoms would the nurse expect to find?

fever, edema, tenderness, and warmth at the site

A child fell at camp and sustained a bruise to the thigh. Which description would accurately describe the bruise after 1 week?

greenish yellow

While caring for a 2-day-old neonate, a nurse notices the left side of the neonate reddens for 2 to 3 minutes. What does this finding suggest?

harlequin color change

Which finding should the nurse anticipate when evaluating the skin of an older adult client?

inelastic skin turgor

A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize?

lean meats and low-fat milk

When assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is:

maintaining the client's fluid, electrolyte, and acid-base balance.

The nurse is gathering data from a child that has a rash on the face, trunk, and extremities, but not on the palms of the hand. Which disorder should the nurse suspect this child may have?

measles

The nurse is caring for a child who has experienced vomiting and diarrhea for 2 days. Which finding would alert the nurse that the child is experiencing severe dehydration?

mottling and tenting of the skin

The nurse is admitting a client who states, "I was bit by a brown recluse spider." Which observations made by the nurse would indicate the client's report is accurate?

painful rash around a necrotic lesion

The nurse is gathering data from a child with papules on the face. Which finding should the nurse document that correlates with papules?

palpable elevated masses

A 1-year-old child is brought by a parent to the clinic with a rash on the abdomen and is diagnosed with scabies. What first line medication for the treatment of scabies does the nurse anticipate reinforcing education about?

permethrin cream 5%

A client is examined and found to have pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. How should the nurse document the findings?

petechiae

A child has a healed wound from a traumatic injury. A keloid has formed over the wound. Which finding best supports the wound description? Select all that apply.

pink, thickened and smooth rubbery in nature

The nurse is completing a sterile dressing change. Which action is identified as a break in sterile procedure?

placing the sterile field between the nurse and the wound

The nurse is obtaining data from a child who is suspected of having a scabies infestation. What finding by the nurse would correlate with this diagnosis?

pruritic papules, pustules, and linear burrows of the finger and toe webs

Following a full-thickness (third-degree) burn of his left arm, a client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:

range of motion.

The nurse is reading the progress notes for a client who has a pressure ulcer. Based on the nurse's note in the chart shown, what stage pressure ulcer does this client have?

stage II

The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect?

Ring or donut

A client is diagnosed with a fungal infection of the scalp. The nurse knows the client understands the treatment plan when which statement is made? Select all that apply.

"I should throw away my combs and hats." "I will need to take all of my medication even if the rash gets better."

A nurse is reinforcing education for a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates that education has been effective?

"I'll eat plenty of fruits and vegetables."

The nurse is assisting with the education of a community group about the prevention of melanoma. What statement indicates that reinforcement of education is required?

"Melanoma usually has defined borders."

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

Compromised skin graft

Laboratory test results confirm that a client's wound is infected with methicillin-resistant staphylococcus aureus. Which type of isolation precautions should the nurse institute for this client?

Contact

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?

Contact isolation

A client with a sacral pressure ulcer is limited to 2 hours of sitting in a chair twice per day. She is scheduled for physical therapy three times per day and dressing changes twice per day. How can a nurse best coordinate this client's care?

Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session.

The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

Which action by the nurse displays client advocacy during a skin assessment?

Ensuring client privacy by pulling the curtain closed

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Mafenide acetate

The nurse observes several areas of ecchymosis on a client's arms and is informed by the client that she is being abused by her partner. What's the most appropriate nursing intervention?

Make sure the client has a safe place to go if needed.

When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include? Select all that apply.

Monitor the skin for breakdown daily during client's bath. Keep skin clean and dry to prevent breakdown. Turn and reposition the client every two hours.

When reinforcing education for the parents of a child with Kawasaki disease, which information should the nurse be sure to include?

Prolonged fever, with peeling of the fingers and toes, are the initial symptoms.

A nurse is instructing a client with pressure ulcers about the importance of increasing his protein intake. Why should the nurse encourage protein intake by this client?

Protein is essential for tissue repair.

Which of the following would the nurse expect of an elderly client's skin?

Slowed healing

Which instructions should be included in the teaching plan of a client with acne vulgaris who has been prescribed tretinoin, benzoyl peroxide, and tetracycline? Select all that apply.

Take tetracycline on an empty stomach. Maintain the prescribed treatment because it is more likely to improve acne than a strict diet and scrubbing with soap and water.

The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce?

Take the drug 1 hour before or 2 hours after meals with large amounts of water.

The nurse observes an older client's skin turgor and finds inelasticity present. What is the nurse's most accurate interpretation of this finding?

The skin is considered to be a normal part of the aging process.

A parent brought a child into the clinic stating the child has head lice and was sent home from school. Which instructions would the nurse reinforce for the parents about the treatment of head lice?

The treatment should be repeated in 7 to 12 days.

A client with acne vulgaris is seeking treatment. The nurse will reinforce education on nightly apply of which medication?

Tretinoin

A nurse is caring for a client with a pressure ulcer. Which nursing interventions are appropriate for this client? Select all that apply

Turn and reposition the client at least every 2 hours. Post a turning schedule at the client's bedside and adapt position changes to the client's situation.

Which task can a licensed practical nurse (LPN) safely delegate to a nursing assistant?

Turning a client every 2 hours

A child is brought to the health care provider's office for multiple scratches and bites from a kitten and is being evaluated for cat-scratch disease. While collecting data, which symptom would the nurse expect to find with cat-scratch disease?

adenitis

The nurse is gathering data from several children in the clinic with reports of diarrhea. Which child would be at greatest risk for giardiasis?

child that attends group day care

A child is brought to the health care provider's office for treatment of a rash. Many petechiae are seen over the entire body. The nurse would suspect which condition?

bleeding disorder

A family that recently went camping brings their child to the clinic with a report of a rash after a tick bite. Which finding should the nurse expect to see in a child with Lyme disease?

bright rash with red outer border circling the bite site

A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:

cancer of the cervix.

A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition?

carbon monoxide poisoning

A client with herpes zoster is prescribed acyclovir, 200 mg by mouth every 4 hours while awake. The nurse should inform the client that this drug may cause:

diarrhea.

The nurse is caring for a client at risk for skin impairment. Which intervention is best to decrease this client's risk?

using a specialty mattress

The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing?

wash hands thoroughly

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should:

wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.

When teaching a client with intertrigo about prescribed skin care measures, the nurse should include which important instruction to prevent Candida albicans overgrowth?

"Never apply cornstarch to the affected areas."

A licensed practical nurse is assisting a triage nurse in the emergency department admit a 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?

36

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what percentage of the total body surface area has been burned?

36%

The nurse is working in a pediatric emergency department. Which client would the nurse see first?

5-year-old client with orbital cellulitis

A nurse is assisting with the development of a care plan for a client with impaired wound healing. Which client would be a risk factor for this diagnosis? Select all that apply.

75-year-old client with poorly controlled diabetes 60-year-old client with impaired mobility secondary to a CVA

A client has been admitted with scabies. Which graphic depicts this skin disorder?

:P

The nurse is reinforcing education about the treatment for paronychia. What would the nurse be sure to review with the parents?

Give warm soaks.

Which intervention has the highest priority when providing skin care to a bedridden client?

Keeping the skin clean and dry without using harsh soaps

The nurse is caring for a female client who is planning to start isotretinoin in 3 months. What should the nurse be sure to include in the instructions for the administration of this medication?

Now is the time to begin contraceptive precautions.

The nurse is gathering data from an older adult client at a long-term care facility and observes longitudinal nail ridges. What is the priority action by the nurse?

Observe the oral mucosa.

A client admitted with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take?

Obtain oxygen saturation using pulse oximetry.

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should monitor the client for which adverse reaction to this drug?

Ototoxicity

The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?

Overall risk of developing pressure ulcers

To treat a client with acne vulgaris, the physician is most likely to prescribe which topical agent for nightly application?

Tretinoin (retinoic acid)

The nurse is collecting data on a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 1 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?

Vesicles

A client is admitted to the emergency department with a deep, partial-thickness burn on the arm after a fire in the workplace. Which signs and symptoms should the nurse expect to see?

necrotic tissue through most of the dermis

A child has a desquamative rash of the hands and feet. Which additional finding should the nurse expect to observe with this rash?

peeling skin

The nurse is caring for a client in a dermatology clinic diagnosed with atopic dermatitis. The client states that they will be moving to a third world country for missionary work and will have to take vaccines. Which health care provider prescription should the nurse question?

prescription to administer the smallpox vaccine

A client comes to the clinic with itching, dark red lesions on the hands, wrist, and waistline that are bleeding. The nurse instructs the client to try pressing on the itchy lesions. What is the rationale for this intervention?

pressing the skin stimulates nerve endings

The nurse observes a ring-shaped rash that has a red raised border and a clearer center on the upper arm. The client asks the nurse what kind of rash it is. What is the best response by the nurse?

tinea corporis

Discharge instructions for a child with atopic dermatitis include keeping the fingernails cut short. Which rationale should the nurse give for this intervention?

to reduce breaks in skin from scratching that may lead to secondary bacterial infections

The nurse is caring for a client with skin grafts covering third-degree burns on the arms and legs. During dressing changes, the nurse should be sure to:

wrap elastic bandages distally to proximally on dependent areas.

The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is most important for the nurse to tell the client?

Avoid exposure to sun.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line

A nurse is instructing a group of nursing assistants about client care. The nurse tells them to turn clients how often to prevent skin breakdown?

Every 2 hours

Topical treatment with 2.5% hydrocortisone is prescribed for a 6-month-old infant with eczema. The nurse advises the parent to use the cream for no more than 1 week based on which rationale?

Excessive use can have adverse effects, such as skin atrophy and fragility.

The licensed practical nurse is collecting a wound culture from a client's gaping surgical incision. Which would the nurse consider to ensure proper culture collection?

Gently roll a sterile swab from the center of the wound outward to collect drainage.

The nurse is reinforcing education for a female adolescent client prescribed Isotretinoin for the treatment of severe acne. What information should the nurse include when reinforcing prevention of complications related to the medication?

It is required that two separate types of birth control be used 1 month before, during, and 1 month after taking the drug.

The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply.

Keep cuts and scrapes clean and covered. Wash hands with soap and water regularly. Avoid sharing towels and razors with others.

A parent brings a child to the health care provider's office because the child reports pain, redness, and tenderness of the left index finger. The child is diagnosed with paronychia. Which organism is the most likely cause of this superficial abscess of the cuticle?

Staphylococcus species

After sustaining a stroke, a client is transferred to the rehabilitation unit. A medical-surgical nurse reviews the client's residual neurological deficits with a rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

Urinary incontinence and right-sided hemiparesis

A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may:

dislodge the autografts

The nurse is caring for a preschool-age child who sustained burns in a house fire. The child is prescribed morphine every 4 hours for pain. Which parameter is most important when monitoring a child who's receiving morphine?

respirations

The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the:

risk manager.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse calculates that he has sustained burns to which percentage of his body?

27%

The physician prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?

"Doing so prevents evaporation of water from the hydrated epidermis."

The nurse is reinforcing education for an adolescent that is concerned about acne on the face. Which statement made by the teen indicates a need for further reinforcement of education?

"My breakouts are caused by eating fatty foods."

A nurse is caring for a 12-year-old child with a diagnosis of eczema. Which nursing interventions are appropriate for a child with eczema?

Administer tepid baths, and use moisturizers immediately after the bath.

A college student living in the dormitory comes to the school health clinic stating, "I think I have ringworm on the bottom of my foot." What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply.

Be sure to wear shower shoes when using a public shower. Change socks at least once a day. Keep skin clean and dry

The nurse is reinforcing education to parents of an infant about burn prevention. Which instructions should be reinforced regarding burns from tap water?

Before putting the infant in the tub, test the water with a hand.

A child has been brought to the ED with a bite to the arm from a dog. What action by the nurse will assist in the prevention of infection?

Clean and irrigate the wounds.

A nurse is explaining treatment to the parents of a child with hypertrophic scarring. Which method would be the best for controlling this condition?

compression garments

A nurse is working with a kidney transplant client with herpes zoster. Which precautions should the nurse anticipate for this client? Select all that apply.

gown gloves mask

A client is diagnosed with genital herpes simplex. Concerned about spread of the virus to others, the nurse questions the client about recent sexual activity. What is the average incubation period for localized genital herpes simplex infection?

3 to 7 days

The nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp

Behind the ears