Saunders Integumentary Study Guide

Which clients are at risk for developing skin breakdown? Select all that apply. A. A client who is underweight B. A client diagnosed with sinusitis C. A client diagnosed with heart failure D. A client diagnosed with spinal cord injury E. A client diagnosed with benign prostatic hypertrophy

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

An African American client has been admitted for a skin rash on his lower back. Which techniques would the nurse best rely on when assessing the skin rash? Select all that apply. A. Palpation B. Induration C. Percussion D. Auscultation E. Visualization

A. Palpation B. Induration

The nurse receives several clients from an apartment fire in the emergency department. Which clients) will the nurse prioritize as needing to be transferred to another facility with a burn unit once stabilized? Select all that apply. A. a client with second-degree burns on the torso comprising 12% of total body surface area B. a client with third-degree burns on the face and hands comprising 5% of total body surface area C. a client with second-degree burns on the back and buttocks comprising 7% of total body surface area D. a client with first- and second-degree burns on the posterior scalp comprising 2% of total body surface area E. a client with first- and second-degree burns to the perineum and thighs comprising 15% of total body surface area

A. a client with second-degree burns on the torso comprising 12% of total body surface area B. a client with third-degree burns on the face and hands comprising 5% of total body surface area E. a client with first- and second-degree burns to the perineum and thighs comprising 15% of total body surface area

A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which would the nurse include in the plan of care? Select all that apply. A. Leaving the donor site open to air B. Immobilizing the graft area for 24 hours C. Administering pain medications as prescribed D. Applying a pressure dressing on the grafted site E. Monitoring the donor site and the graft site for signs of infection

C. Administering pain medications as prescribed E. Monitoring the donor site and the graft site for signs of infection

The nurse is reinforcing sun exposure precautions to a group of older clients. Which would the nurse include in the instructions? Select all that apply. A. Sunscreen is not needed on cloudy days. B. Wear loosely woven clothing for protection. C. Apply sunscreen liberally 15 to 30 minutes before sun exposure. D. Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. E. It is best to avoid exposure to the sun during the day between 10:00 a.m. and 4:00 p.m.

C. Apply sunscreen liberally 15 to 30 minutes before sun exposure. D. Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. E. It is best to avoid exposure to the sun during the day between 10:00 a.m. and 4:00 p.m.

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply. A. Assess the stoma and skin. B. Remove the used pouch and barrier. C. Perform hand hygiene and don gloves. D. Lightly scrub the stoma with soap and water. E. Press the adhesive backing of the pouch against the skin. F. Cut the opening on the appliance ½ inch larger than stoma.

D. Lightly scrub the stoma with soap and water. F. Cut the opening on the appliance ½ inch larger than stoma.

A nurse observes that an IV vesicant drug has extravasated. What is the nurse's appropriate action? Select all that apply. A. Place a warm compress on the area. B. Chill the area with an ice pack. C. Raise the client's arm above the level of the heart. D. Stop the infusion. E. Notify the charge nurse.

D. Stop the infusion. E. Notify the charge nurse.

The nurse in a primary health care provider's office has scheduled a client with a possible allergen-causing dermatitis to be seen in 1 week for a patch test. The nurse explains the procedure for the patch test and includes which in the explanation? Select all that apply. A. An intradermal injection of allergens will be done. B. The results most likely will be evaluated in the office the next day. C. The skin will be scratched and the allergen dropped onto the area. D. The allergen will be placed on the skin and covered with an airtight dressing. E. A negative reaction occurs when there is no erythema, swelling, or complaint of itching.

D. The allergen will be placed on the skin and covered with an airtight dressing. E. A negative reaction occurs when there is no erythema, swelling, or complaint of itching.

The nurse in the emergency department is caring for a client who sustained a large laceration to the lips and cheek from a dog bite. Which actions would the nurse take? Select all that apply. A. Administer analgesics as prescribed B. Anticipate a plastic surgery consultation C. Report the dog bite to the police department D. Administer prophylactic antibiotics as prescribed E. Determine when the client last had a hepatitis B vaccination

A. Administer analgesics as prescribed B. Anticipate a plastic surgery consultation C. Report the dog bite to the police department D. Administer prophylactic antibiotics as prescribed

A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions would the nurse take before transferring the client to the burn center? Select all that apply. A. Apply cool water to the area. B. Place ice packs over the area. C. Apply an absorbent material to the area. D. Wrap burned fingers separately to prevent sticking together. E. Cover the burns with a clean dry cloth as directed by a burn center.

A. Apply cool water to the area. D. Wrap burned fingers separately to prevent sticking together. E. Cover the burns with a clean dry cloth as directed by a burn center.

Which nursing intervention(s) are effective in preventing pressure injuries? Select all that apply. A. Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. B. When turning the client, slide and avoid lifting them. C. Avoid raising the head of the bed more than 90 degrees. D. Turn and reposition the client every 1 to 2 hours unless contradicted E. If the client uses a wheelchair, seat them on a rubber or plastic doughnut. F. Use pillows to position the client and increase comfort.

A. Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. D. Turn and reposition the client every 1 to 2 hours unless contradicted. F. Use pillows to position the client and increase comfort.

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse would expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. A. Lesion has a waxy border B. An irregularly shaped lesion C. Papule, with a red, central crater D. A small papule with a dry, rough scale E. A firm nodular lesion topped with a crust

A. Lesion has a waxy border B. An irregular shaped lesion

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions) can help prevent pressure injury formation in this client? Select all that apply. A. Reposition the client every 2 hours. B. Perform range-of-motion exercises. C. Use commercial soaps to keep the skin dry. D. Tuck bed covers tightly in the foot of the bed. E. Encourage the client to eat a well-balanced diet.

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

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the primary health care provider's prescription sheet expecting which to be prescribed? Select all that apply. A. Wound culture B. Antibiotic therapy C. Cold compresses D. Warm compresses E. Intermittent heat lamp treatments F. Alternating hot and cold compresses

A. Wound culture B. Antibiotic therapy D. Warm compresses

The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply. A. Wound from repair of a perforated appendix B. Surgical wound after an open cholecystectomy C. Gunshot wound that punctured the small intestine D. Sterile wound resulting from a total radical mastectomy E. Traumatic wound to the abdomen and intentionally left open for several days F. Wound related to debridement of a chronic pressure injury resulting in a cavity-like defect

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

The nurse is caring for a client with a diagnosis of pemphigus. The nurse would include which interventions in the plan of care for the client? Select all that apply. A. Administering prescribed acyclovir B. Applying prescribed topical antibiotic C. Administering prescribed corticosteroid D. Administering prescribed oral amphotericin B E. Applying Domeboro solution to the affected skin

B. Applying prescribed topical antibiotic C. Administering prescribed corticosteroid E. Applying Domeboro solution to the affected skin

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure injury in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure injury? Select all that apply. A. Leave the area open to air. B. Change the bandage daily until site is healed. C. Apply topical antibiotic ointment as prescribed. D. Return to the office in 7 days for suture removal. E. Take prescribed oxycodone as prescribed for pain.

B. Change the bandage daily until site is healed. C. Apply topical antibiotic ointment as prescribed.

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure injury in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure injury? Select all that apply. A. Utilize a rubber ring B. Clean with mild soap and water C. Encourage adequate nutritional intake D. Massage the area around the affected area E. Apply a dressing that allows oxygen to pass through

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

A nurse is performing a dressing change for a client with a complex wound. The nurse notes increased exudate and maceration present and believes the current dressing is inappropriate. Despite reviewing the dressing options, the nurse is unsure of which dressing to apply. Which action(s) should the nurse take? Select all that apply. A. Reapply the type of dressing that was removed. B. Consult a nurse experienced with wound care best practice. C. Reapply the type of dressing that was removed. D. Follow up by exploring wound care education opportunities. E. Replace the dressing with one that is more absorbent.

B. Consult a nurse experienced with wound care best practice. D. Follow up by exploring wound care education opportunities.

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. A. Simple or (dermal) phase B. Inflammatory or (lag) phase C. Superficial or (intact skin) phase D. Rehabilitative (recovery) phase E. Maturation or (remodeling) phase F. Proliferative or (connective tissue repair) phase

B. Inflammatory or (lag) phase E. Maturation or (remodeling) phase F. Proliferative or (connective tissue repair) phase

The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas? Select all that apply. A. Face B. Knees C. Elbows D. Abdomen E. Base of the spine

B. Knees C. Elbows E. Base of the spine

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. A. Apply a pleasantly scented dusting powder to the axillae and groin, beneath the breasts, and between the toes. B. Monitor the skin for breakdown daily during client's bath. C. Apply deodorant or antiperspirant immediately after shaving under the arms. D. Keep skin clean and dry to prevent breakdown. E. Always use alcohol for back rubs. F. Turn and reposition the client every two hours.

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

The nurse is reviewing a focused assessment done on a client's integumentary system. Which physical examination assessments are related to inspection? Select all that apply. A. Biopsy results B. Nails for shape, contour, color, thickness and cleanliness C. Skin for color, integrity, scars, lesions, and signs of breakdown D. Facial and body hair for distribution, color, quantity and hygiene E. Skin temperature, texture, moisture, thickness, turgor, and mobility

B. Nails for shape, contour, color, thickness and cleanliness C. Skin for color, integrity, scars, lesions, and signs of breakdown D. Facial and body hair for distribution, color, quantity and hygiene E. Skin temperature, texture, moisture, thickness, turgor, and mobility

The nurse obtains data from a client on bed rest reporting an itchy rash with an erythematous, slightly edematous areas on the back, posterior lower legs, and posterior elbows. What education should be reinforced regarding contact dermatitis? A. The disorder is contagious. B. This is an allergic reaction. C. Based on the location, it is likely that detergents in the bed linens caused the rash. D. The skin is infected wherever the rasn has developed. E. Oatmeal baths are a good treatment for a rash of this type because of the large area involved. F. Washing with antibacterial soap will help the rash.

B. This is an allergic reaction. C. Based on the location, it is likely that detergents in the bed linens caused the rash. E. Oatmeal baths are a good treatment for a rash of this type because of the large area involved.

The nurse is reinforcing instructions to a client diagnosed with eczema about measures that decrease itching and moisturize the skin. Which would the nurse include in the instructions? Select all that apply. A. Keep humidity at 10% to 12%. B. Use moisturizers and sunscreens. C. Wash new clothing before it is worn. D. Use mild detergent and rinse clothes twice. E. Maintain room temperature at 68°F to 75°F. F. Wear open-weave fabrics and loose clothing.

B. Use moisturizers and sunscreens. C. Wash new clothing before it is worn. D. Use mild detergent and rinse clothes twice. E. Maintain room temperature at 68°F to 75°F. F. Wear open-weave fabrics and loose clothing.

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions would the nurse provide? Select all that apply. A. Sunscreen should be applied every 8 hours. B. Use sunscreen when participating in outdoor activities. C. Wear a hat, opaque clothing, and sunglasses when in the sun. D. Avoid sun exposure in the late afternoon and early evening hours. E. Examine your body monthly for any lesions that may be suspicious.

B. Use sunscreen when participating in outdoor activities C. Wear a hat, opaque clothing, and sunglasses when in the sun E. Examine your body monthly for any lesions that may be suspicious

A client is undergoing radiation therapy to treat lung cancer. Which instructions would the nurse reinforce to the client with regard to skin care? Select all that apply. A. Place a thin film of lotion over the area daily. B. Use a cold pack on the area if feeling discomfort. C. Do not remove any of the markings for radiation treatment. D. Use the hand to wash the affected area rather than a washcloth. E. Shower or wash the area once a day using warm water and mild soap.

C. Do not remove any of the markings for radiation treatment. D. Use the hand to wash the affected area rather than a washcloth. E. Shower or wash the area once a day using warm water and mild soap.

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 characteristics describe this type of a lesion? Select all that apply. A. Metastasis is rare. B. It is encapsulated. C. It is highly metastatic. D. It is characterized by local invasion. E. Lesion is a nevus that has changed in color.

C. It is highly metastatic. E. Lesion is a nevus that has changed in color.

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. A. Request a prescription for an antibiotic prior to going. B. Use an antibiotic ointment prophylactically on skin. C. Keep cuts and scrapes clean and covered. D. Wash hands with soap and water regularly. E. Avoid sharing towels and razors with others.

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

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. A. There is no pattern or segmental assignment of lesions. B. Skin eruptions occur before any discomfort or pain appears C. Lesions are very contagious when they are fluid-filled blisters. D. Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. E. To reduce the risk of transmitting the virus to others, clients with lesions are separated from other clients until lesions have crusted.

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