Advanced Med Surg Quiz 1

A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections? A. Chronic obstructive pulmonary disease B. Rheumatoid arthritis C. Gout D. Diabetes

ANS: D Rationale: Clients with diabetes are particularly susceptible to skin infections. COPD, RA, and Gout are less commonly associated with integumentary manifestations.

A nurse is caring for a client whose chemical injury has necessitated a skin graft to the client's left hand. Which statement is true regarding skin graft use? A. The use is not a type of reconstruction. B. Skin grafts form their own blood supply C. They are only transplanted from another donor. D. Skin is transferred from a distant site to the graft site

ANS: D Rationale: Skin grafting is a technique in which a section of skin is detached from its own blood supply and transferred as free tissue to a distant (recipient) site. Skin grafting can be used to repair almost any type of wound and is the most common form of reconstructive surgery.

A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation? A. telangiectasias B. ecchymoses C. purpura D. urticaria

Ans: B Rationale: Telangiectasias consists of red marks on the skin caused by stretching of superficial blood vessels. Ecchymoses are bruises, and purpura consists of pinpoint hemorrhages into the skin. Urticaria is wheals or hives.

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and left forearm. What extent of burns does the client most likely have, measured in percentage?

ANS: 18% Rationale: When estimating the percentage of body area or burn surface area that has been burned, the rules of 9 is used: the face is 9% and the forearm is 9%, for a total of 18% in this client.

While waiting to see the health care provider, a client shows the nurse skin areas that are flat, non-palpable, and have had a change of color. The nurse recognizes that the client is demonstrating: A. Macules B. Papules C. Vesicles D. Pustules

ANS: A Rationale: A macule is a flat, non-palpable skin color change, while a papule is an elevated, solid, palpable mass. A vesicle is a circumscribed, elevated, palpable mass containing serous fluid, while a pustule is a pus-filled vesicle.

A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion? A. Vesicle B. Macule C. nodule D. wheal

ANS: A Rationale: A vesicle is a primary skin lesion that is elevated and has fluid contained in the dermis. Examples of vesicles would be a blister of insect bite. Wheals, macules, and nodules are not characterized by elevation and the presence of serous fluid.

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A. The client is likely experiencing a delayed onset of respiratory complications. B. The client has likely developed a systemic infection C. The client's respiratory complications are likely related to psychosocial stress. D. The client is likely experiencing an anaphylactic reaction to a medication.

ANS: A Rationale: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. A systemic infection would be less likely to cause respiratory complications. This problem is more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but it is less likely than a response to the initial injury.

A nurse is caring for a client in the emergent/ resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A. Sodium deficit B. Decreased prothrombin time (PT) C. Potassium deficit D. Decreased hematocrit

ANS: A Rationale: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of a burn injury include sodium deficit, potassium excess, and elevated hematocrit. PT does not typically decrease.

A client is admitted to the burn unit after being transported a long distance. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A. Ischemia B. referred pain C. Cellulitis. D. Venous thromboembolism (VTE)

ANS: A Rationale: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur to the distal injury site.

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response? A. " That's something that you and your doctor will likely talk about after your scars mature." B. " That is something for you to talk to your doctor about because it's not a nursing responsibility." C. " I know this is really important to you, but you have to realize that no one can make you look like you used to." D. "Unfortunately, it's likely that these scars will look like this for the rest of your life."

ANS: A Rationale: BUrn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is nor a nursing responsibility, the nurse should still respond appropriately to the client's query. It is true that the client will not realistically look like he or she used to, but this does not instill hope.

A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the client is likely seeking treatment for which of the following? A. Wrinkles near the lips and eyes. B. Removal of acne scars C. Vascular lesions on the cheeks D. Real or perceived misshaping of the eyes

ANS: A Rationale: Chemical face peeling is especially useful for wrinkles at the upper and lower lop, forehead, and periorbital areas. Chemical face peeling does not remove acne scars, remove vascular lesions, or reshape the eyes.

A client has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the client about topical corticosteroid use on these lesions? A. Cataract development is possible. B. The ointment is likely to cause weeping. C. Corticosteroid use is contraindicated on these lesions. D. The client may develop glaucoma

ANS: A Rationale: Clients using topical corticosteroid preparations repeatedly on the face and around the eyes should be aware that cataract development is possible. Weeping and glaucoma are less likely. There is no consequent risk of glaucoma.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

ANS: A Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate? A. "Does anyone in your family have eczema or psoriasis?" B. "Have any of your family members been diagnosed with malignant melanoma?" C. "Do you have a family history of vitiligo or port-wine stains?" D. " Does any member of your family have a history of Keloid scarring?"

ANS: A Rationale: Eczema and psoriasis are known to have a genetic component. This is not true of any of the other listed integumentary disorders.

A client in the emergent/ resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings? A. Hyperkalemia, hyponatremia, elevated hematocrit B. Hypokalemia, hypernatremia, decreased hematocrit C. Hyperkalemia, hypernatremia, decreased hematocrit D. Hypokalemia, hyponatremia and increased hematocrit

ANS: A Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, and hemoconcentration that leads to an increased hematocrit.

A client's blistering disorder has resulted in the formation of multiple lesions in the client's mouth. What intervention should be included in the client's plan of care? A. Provide chlorhexidine solution for rinsing the client's mouth B. Avoid providing regular mouth care until the client's lesions heal C. Liaise with the primary provider to arrange parenteral nutrition D. Encourage the client to gargle with a hypertonic solution after each meal.

ANS: A Rationale: Frequent rinsing of the mouth with chlorhexidine solution is prescribed to rid the mouth of debris and to soothe ulcerated areas. A hypertonic solution would be likely to cause pain and further skin disruption. Meticulous mouth care should be provided and there is no reason to provide nutrition parenterally.

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan? A. Lifelong management is likely needed B. Avoid public places until symptoms subside. C. Wash skin frequently to prevent infection. D. Liberally apply corticosteroids as needed.

ANS: A Rationale: Psoriasis usually requires lifelong management. Psoriasis is not contagious. Many clients need reassurance that the condition is not infectious, not a reflection of poor personal hygiene, and not skin cancer. Excessive frequent washing of skin produces more soreness and scaling. Overuse of topical corticosteroids can result in skin atrophy, striae, and medication resistance.

A client presents at the free clinic with a black, wart-like lesion on his face, stating, "I've done some research, and I'm pretty sure I have malignant melanoma." Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis? A. The client requires no treatment unless he finds the lesion to be cosmetically unacceptable. B. The client's lesion will be closely observed for 6 months before a plan of treatment is chosen. C. The client has one of the few dermatologic malignancies that respond to chemotherapy. D. The client will likely require wide excision.

ANS: A Rationale: Seborrheic keratoses are benign, wart-like lesions of various sizes and colors ranging from light tan to black. There is no harm in allowing these growths to remain because there is no medical significance to their presence.

A client with vitamin D deficiency is receiving education from the nurse. What would be and appropriate recommendation by the nurse? A. Spend time outdoors at least twice per week. B. Increase intake of leafy green vegetables C. Promote intake of clear fluids D. Eat red meat at least once per week.

ANS: A Rationale: Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). It is estimated that most people need 5 to 30 minutes of sun exposure twice a week in order to this synthesis to occur. Increasing intake of water is not related to resolving vitamin D deficiency. Vitamin D is unrelated to meat and vegetable intake.

A nurse is preparing to assist a surgeon in a skin grafting procedure. What can a skin graft be used for ? A. Denuded skin after burns B. Slow healing wounds C. Uncomplicated wound closure D. Infected wounds

ANS: A Rationale: Skin grafts are commonly used to repair surgical defects such as those that result from excision of skin tumors, to cover areas denuded of skin (e.g. burns), and to cover wounds in which insufficient skin is available to permit wound closure. They are also used when primary closure of the wound increases the risk of complications or when primary wound closure would interfere with function. It is not used for uncomplicated wound closure. Skin grafts are not used for infected wounds.

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of the burn? A. The causative agent B. The client's pre-injury health status C. The client's prognosis for recovery D. The circumstances of the accident

ANS: A Rationale: The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The client's pre-injury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? A. A client-controlled analgesia (PCA) system B. Oral opioids supplemented by NSAIDs C. Distraction and relaxation techniques supplemented by NSAIDs D. A combination of benzodiazepines and topical anesthetics

ANS: A Rationale: The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the client. The use of client-controlled analgesia (PCA) gives control to the client and achieves this goal. Clients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required.

An 80-year-old client is brought to the clinic by one of the client's children. The client asks the nurse why the client has gotten so many "spots" on the skin. What would be an appropriate response by the nurse? A. "As people age, they normally develop uneven pigmentation in their skin." B. "These 'spots' are called 'liver spots' or 'age spots'." C. "Older skin is more apt to break down and tear causing sores." D. "These are usually the result of nutritional deficits earlier in life."

ANS: A Rationale: The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Stating the names of these spots and identifying older adults' vulnerability to skin damage do not answer the question. These lesions are not normally a result of nutritional imbalaces.

A nurse is providing self-care education to a client who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the client? A. "Wash your face with water and gentle soap each morning and evening." B. "Before bedtime, clean your face with rubbing alcohol on a cotton pad." C. "Gently burst new pimples before they form a visible head." D. "Set aside some time each day to squeeze blackheads and remove the plug."

ANS: A Rationale: The nurse should inform the client to wash the face and other affected areas with mild soap and water twice each day to remove surface oils and prevent obstruction of the oil glands. Cleansing with rubbing alcohol is not recommended and all forms of manipulation should be avoided.

A public health nurse is educating a group of administrators about decreasing hospitalizations for burns. Which population will the nurse note as the target population for burn injuries? A. Older adults B. Women more than men C. Adults 35-40 years of age D. School-aged teenagers

ANS: A Rationale: The population that is most at risk for hospitalization are older adults. Statistically men have a higher incidence of burns over women. Adults from 35-40 years of age are not shown to have a high prevalence. School-aged teenagers do not have a higher prevalence of burns with hospitalization than the aging population.

A nurse is caring for a client who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. The nurse knows that systematic treatment will most likely include which element? A. Corticosteroid therapy B. SKin biopsy C. Topical corticosteroids D. Penicillin therapy

ANS: A Rationale: Treatment for bullous pemphigoid includes system corticosteroid therapy. This would not include skin biopsy as this is for diagnostics. Topical corticosteroids don't treat systematically. The goal of therapy is to respond to inflammation, not to treat infection.

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which client is most likely to have a life-threatening complications? A. A 4-year-old victim burned over 24% of the body B. A 27-year-old male burned over 36% of his body in a car accident. C. A 39-year-old female client burned over 18% of her body D. A 60-year-old male burned over 16% of his body in a brush fire.

ANS: A Rationale: Young children and older adults continue to have an increased mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the client.

A client with human deficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse should interpret these lesions as most likely suggestive of what situation? A. A reduction in the client's CD4 count B. A reduction in the client's viral load C. An adverse effect of antiretroviral therapy D. Virus-induced changes in allergy status

ANS: A Rationale: Cutaneous signs may be the first manifestation of human deficiency virus (HIV), appearing in more than 90% of HIV-infected people as immune function deteriorates. These skin signs correlate with low CD4 counts and may become very atypical in immunocompromised people. Viral load increases, not decreases, as the disease progresses. Antiretrovirals are not noted to cause cutaneous changes, and viruses do not change an individual's allergy status.

A nurse in the emergency department (ED) is triaging a 5-year-old who has been brought to the ED by the parents for an outbreak of urticaria. What would be the most appropriate question to ask this client's parents? A. "Has your child eaten any new foods today?" B. " Has your child bathed in the past 24 hours?" C. "Did your child go to a friend's house today?" D. "Was your child digging in the dirt today?"

ANS: A Rationale: Foods can cause skin reactions, especially in children. In most cases, this is a more plausible cause of urticaria than bathing, contact with other children, or soil-borne pathogens.

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? A. Splinter hemorrhage B. Beau line C. Paronychia D. Clubbing

ANS: B Rationale: A beau line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A. Administer IV fluids B. Administer broad spectrum antibiotics C. Administer IV potassium chloride D. Administer packed red blood cells

ANS: A Rationale: Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally given. Potassium chloride would exacerbate the client's hyperkalemia.

A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what event? A. Hemodynamic stability B. Gastrointestinal hypermotility C. Respiratory arrest D. Hypokalemia

ANS: A Rationale: The initial systemic event after a major burn injury is hemodynamic instability, which results from a loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.

The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor? A. An insect bite B. Dehydration C. Sunburn D. Excessive perspiration

ANS: A Rationale: The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, suck as chemicals, microbes, insect bites, and other trauma. Dehydration, sunburn, and excessive perspiration are not examples of penetration of an environmental factor.

A nurse educator is teaching a group of nurses about Kaposi sarcoma. What would the educator identify as characteristics of endemic Kaposi sarcoma? SATA A. Affects people predominantly in the eastern half of Africa B. Affects men more than women C. Does not affect children D. Cannot infiltrate E. Can progress to lymphadenopathic forms

ANS: A,B, E Rationale: Endemic (African) Kaposi sarcoma affects people predominantly in the eastern half of Africa, near the equator. Men are affected more often than women, and children can be affected as well. The disease may resemble classic KS or it may infiltrate and progress to lymphadenopathic forms.

A client is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? SATA A. Promote truthful communication B. Avoid asking the client to make decisions C. Teach the client coping strategies D. Administer benzodiazepines are prescribed E. Provide positive reinforcement.

ANS: A,C,E Rationale: The nurse can assist the client to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the client practice appropriate strategies, and giving positive reinforcement when appropriate. The client may benefit from being able to make decisions regarding his or her care. Benzodiazepines may be needed for short-term management of anxiety, but they are not used to enhance coping.

The nurse in an ambulatory care center is admitting an older adult client who has bright red moles on the skin. What benign changes in the skin of an older adult appear as bright red moles? A. Cherry angiomas B. Solar lentigines C. Seborrheic keratoses D. Xanthelasmas

ANS:A Rationale: Cherry angiomas appear as bright red "moles", while solar lentigines are commonly called "liver spots". Seborrheic keratoses are described as crusty brown "stuck on" patches, while xanthelasmas appear as yellowish, waxy deposits on the upper eyelids.

A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client's subsequent care? A. Teaching the client to safely and effectively administering immunosuppressants B. Helping the client identify and avoid the offending agent C. Teaching the client how to maintain meticulous skin hygiene D. Helping the client perform wound care in the home environment

ANS: B Rationale: A focus of care for clients with irritant contact dermatitis is identifying and avoiding the offending agent. Immunosuppressants are not used to treat eczema and wound care is not normally required, except in cases of open lesions. Poor hygiene has no correlation with contact dermatitis.

Assessment of a client's leg reveals the presence of a 1.5-sm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document in the presence of what type of skin lesion? A. Keloid B. Ulcer C. Fissure D. Erosion

ANS: B Rationale: A pressure ulcer that is stage 2 or greater is on that extends past the epidermal layer and can develop necrotic tissue. Keloids lack necrosis and consist of scar tissue. A fissure is linear, and erosions do not extend to the dermis.

A client with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy? A. Tzanck smear B. Skin biopsy C. Patch testing D. Skin scrapings

ANS: B Rationale: A skin biopsy is done to rule out malignancies of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as Herpes Zoster. Patch testing is performed to identify substances to which the client has developed an allergy. Skin scrapings are done for suspected fungal infections.

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A. Perform mechanical debridement to remove the exudate and prevent further infection. B. Inform the primary care provider promptly because the graft may need to be removed C. Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D. Document this finding as an expected phase of graft healing.

ANS: B Rationale: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem, and the nurse would not independently perform debridement.

A nurse is caring for a client whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform? A. Teach the client about early signs of secondary blistering diseases. B. Teach the client about self-care after treatment. C. Assess the client's risk for recurrent malignancy. D. Assess the client for adverse effects of radiotherapy.

ANS: B Rationale: Because many skin cancers are removed by excision, clients are usually treated in outpatient surgical units. The role of the nurse is to teach the client about prevention of skin cancer and about self-care after treatment. Assessing the client's risk for recurrent malignancy is primarily the role of the health care provider. Blistering diseases do not result from cancer or subsequent excision is not accompanied by radiotherapy.

A nurse practitioner is seeing a 16-year-old client who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications? A. Acyclovir B. Benzoyl Peroxide and erythromycin C. Diphenhydramine D. Triamcinolone

ANS: B Rationale: Benzoyl peroxide and erythromycin gel is among the topical treatments available for acne. Acyclovir is used in the treatment of herpes zoster as an oral antiviral agent. Diphenhydramine is an oral antihistamine used in the treatment of pruritis. Intralesional injections of triamcinolone have been utilized in the treatment of psoriasis.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the client and family C. Treating infection D. Promoting thermoregulation

ANS: B Rationale: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.

A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A." The client is on a calorie-restricted diet in order to divert energy to wound healing." B. " The client's body has consumed fat deposits for fuel because calorie intake is lower than normal." C. " The client hasn't actually lost weight. Instead, there's been a change in the distribution of body fat." D. " The client lost many fluids while being treated in the emergency phase of burn care."

ANS: B Rationale: Clients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Clients are placed on a calorie restriction during recovery, and fluid losses would not account for weight loss after in the recovery period. Changes in the overall distribution of body fat do not occur.

A nurse practitioner working in a dermatology clinic finds an open lesion on a client who is being assessed. What should the nurse do next? A. Obtain a swab for culture B. Assess the characteristics of the lesion C. Obtain a swab for pH testing D. Apply a test dose of broad-spectrum topical antibiotic.

ANS: B Rationale: If acute open wounds or lesions are found on inspection of the skin, a comprehensive assessment should be made and documented. Testing for culture and pH are not necessarily required, and assessment should precede these actions. Antibiotics are not applied on an empirical basis.

A client comes to the dermatology clinic requesting the removal of epidermal nevi on the client's right cheek. The nurse knows that the procedure especially useful in treating such lesions is what? A. Skin graft B. Laser treatment C. Chemical face peeling D. Free flap

ANS: B Rationale: Lasers are useful in treating cutaneous vascular lesions such as epidermal nevi. Skin grafts, chemical face peels, and free flaps would not be used to remove this lesion.

The nurse is providing education to a client that is scheduled for a mechanical debridement of a wound. The nurse knows that mechanical debridement involves which element? A. A spontaneous separation of dead tissue from the viable tissue. B. Removal of eschar until the point of pain and bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed D. Early closure of the wound

ANS: B Rationale: Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accompanied through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Shaving the burned skin layers and early wound closure are examples of surgical debridement.

A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? A. Psychosis B. Post traumatic stress disorder C. Delirium D. Vascular dementia

ANS: B Rationale: PTSD is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not among the noted psychiatric and psychosocial complications of burns.

A nurse is explaining the importance of sunlight on the skin to a client with decreased mobility who rarely leaves the house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? A. E B. D C. A D. C

ANS: B Rationale: Skin exposure to ultraviolet light can convert substances necessary for synthesizing Vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of Vitamin D, calcium, and phosphorus.

A client is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the client develops fine blisters, papules and severe itching. The nurse knows that this is indicative of what strength reaction? A. Weak positive B. Moderately positive C. Strong positive D. Severely positive

ANS: B Rationale: The development of redness, fine elevations, or itching is considered a weak positive reaction, fine blisters, papules, and severe itching indicate a moderately positive reaction and blisters, pain, and ulceration indicates a strong positive reaction.

The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and health promotion. The nurse determines that the client has understood the teaching by observing the client: A. Perform range of motion exercises B. Avoid placing body weight on the healing site. C. Elevate body parts that are susceptible to edema D. Demonstrate the technique for massaging the wound site

ANS: B Rationale: The major goals of pressure injury treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, achievement of the goal of the client teaching.

A nurse is doing a shift assessment report on a group of clients after first taking report. An older client is having the second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the client's chest. The nurse should ask what priority question regarding the presence of a reddened rash? A. "Is the rash worse at a particular time or season?" B. "Are you allergic to any food or medications?" C. " Are you having any loss of sensation in that area?" D. " Is your rash painful?"

ANS: B Rationale: The nurse should suspect an allergic reaction to the antibiotic therapy. Allergies can be a significant threat to the client's immediate health, thus questions addressing this possibility would be prioritized over those addressing sensation. Asking about previous rashes is important, but this would likely be framed in the context of an allergy assessment.

A wound care nurse is reviewing skin anatomy with a group of medical nurses. Which area of the skin would the nurse identify as providing a cushion between the skin layers, muscles, and bones? A. Dermis B. Subcutaneous tissue C. Epidermis D. Stratum Corneum

ANS: B Rationale: The subcutaneous tissue, or hypodermis, is the innermost later of the skin that is responsible for providing a cushion between the skin layers, muscles, and bones. The dermis is the largest portion of the skin, providing strength and structure. The epidermis is the outermost layer of stratified epithelial cells and composed of keratinocytes. The stratum corneum is the outermost layer of the epidermis, which provides a barrier to prevent epidermal water loss.

A school nurse has sent home four kids who show evidence of pediculosis capitis. What is an important instruction of the nurse should include in the note being sent home to parents? A. The child's scalp should be monitored for 48-72 hours before starting treatment. B. Nits may have to be manually removed from the child's hair shafts. C. The disease is self-limiting and symptoms will abate within 1 week. D. Efforts should be made to improve the child's level of hygiene.

ANS: B Rationale: Treatment for head lice should begin promptly and may require manual removal of nits following medicating shampoo. Head lice are not related to a lack of hygiene. Treatment is necessary because the condition will not likely resolve spontaneously within 1 week.

A gerontologic nurse is teaching a group of nurses about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? A. By avoiding the use of moisturizing lotions on older adults' skin B. By protecting older adults against shearing injuries. C. By avoiding the use of ice packs to treat muscle pain. D. By protecting older adults against excessive sweat accumulation.

ANS: B Rationale: Cellular changes associated with aging include thinning at the junction of the dermis and epidermis, which creates a risk for shearing injuries. Moisturizing lotions can be safely used to address the increased dryness of older adults' skin. Ice packs can be used, provided skin is assessed regularly and the client possesses normal sensation. Older adults perspire much less than younger adults, thus sweat accumulation is rarely an issue.

When caring for a client with toxic epidermal necrolysis (TEN). the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what condition(s)? SATA A. Possible malignancy B. Epidermal necrosis C. Neurologic involvement D. Increased metabolic needs E. Possible gastrointestinal mucosal sloughing

ANS: B,D, E Rationale: Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential because these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and respiratory mucosal sloughing. These factors are less likely to suggest malignancy or neurologic involvement, as these are not common complications of TEN.

A nurse who provides care on a burn unit is preparing to apply a client's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A. Apply the new ointment without disturbing the existing layer of ointment. B. Apply the ointment using a sterile tongue depressor. C. Apply a layer of ointment approximately 1/16 inch thick. D. Gently irrigate the wound bed after applying the antibiotic ointment.

ANS: C Rationale: After removing the old ointment from the wound bed, the nurse should apply a layer of ointment 1/16-inch thick using clean gloves. The wound would not be irrigated after application of new ointment.

A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A. Obtain an order to reduce the rate of the client's Iv fluid infusion B. Report the client's early signs of acute kidney injury (AKI) C. Recognize that the client is experiencing an expected onset of diuresis. D. Administer sodium chloride as prescribed to compensate for this fluid loss.

ANS: C Rationale: As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A. Confusion B. High fever C. Decreased blood pressure D. Sudden agitation

ANS: C Rationale: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.

A nurse is providing care for a client who has psoriasis. Following the appearance of skin lesions, the nurse should prioritize what assessment? A. Assessment of the client's stool for evidence of intestinal sloughing B. Assessment of the client's apical heart rate for dysrhythmias C. Assessment of the client's joints for pain and decreased range of motion D. Assessment for cognitive changes resulting form neurologic lesions

ANS: C Rationale: Asymmetric rheumatoid factor-negative arthritis of multiple joints occurs in up to 42% of people with psoriasis, most typically after the skin lesions appear. The most typical joints affected include those in the hands of feet, although sometimes larger joints such as the elbow, knees, or hips may be affected. As such, the nurse should assess for this musculoskeletal complication. GI, cardiovascular, and neurologic function are not affected by psoriasis.

A client has experienced burns to the upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A. Instruct the client to keep the wound site in a dependent position. B. Administer PRN analgesia as prescribed C. Assess the client's peripheral pulses distal to the dressing D. Assess with passive ROM exercises to "set" the new dressing

ANS: C Rationale: Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be given prior to dressing change. ROM exercises do not normally follow a dressing change.

A nurse is teaching a client with a partial-thickness wound how to wear the elastic pressure garment. How often should the nurse instruct the client to wear this garment? A. 4-6 hours a day for 6 months B. During waking hours for 2-3 months after the injury C. Continuously D. At night while sleeping for a year after the injury

ANS: C Rationale: Elastic pressure garments are worn continuously (i.e., 24 hours a day).

A 35-year-old kidney transplant client comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposi sarcoma. The nurse caring for this client recognizes that this is what type of Kaposi sarcoma? A. Classic B. AIDS related C. Iatrogenic D. Endemic

ANS: C Rationale: Iatrogenic/ organ transplant-associated Kaposi sarcoma occurs in transplant recipients and people with AIDS. This form of KS is characterized by local skin lesions and disseminated visceral and mucocutaneous diseases. Classic Kaposi sarcoma occurs predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of age. Endemic KS affects people predominantly in the eastern half of Africa. AIDS- related KS is seen in people with AIDS.

An older adult resident of a long-term facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care? A. Avoid the application of skin emollients. B. Apply antibiotic ointment, as prescribed following baths. C. Avoid using hot water during the client's baths. D. Administer acetaminophen four times daily as prescribed.

ANS: C Rationale: If baths have been prescribed, the client is reminded to use tepid (not hot) water toi shake off the excess water and blot between intertriginous areas (body folds) with a towel. Skin emollients should be applied to reduce pruritus. Acetaminophen and antibiotics do not reduce pruritus.

The nurse is performing an initial assessment of a client who has raised, pruritic rash. The client denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this client at this time? A. "Is anyone in your family allergic to anything?" B. "How long have you had this abrasion?" C. "Do you take any over-the-counter (OTC) drugs or herbal preparations?" D. "What do you do for a living?"

ANS: C Rationale: If suspicious areas are noted, the client is questioned about nonprescription or herbal preparations that might be in use. Ascertaining a family history of allergies would not give helpful information at this time. The client's lesion is not described as an abrasion. The client's occupation may or may not be relevant; it is more important to assess for herb or drug reactions.

A client is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the client, the nurse would be alert to what precipitating factor? A. Recent heavy ultraviolet exposure B. Substandard hygienic conditions C. Recent administration of new medications D. Recent varicella infection

ANS: C Rationale: In adults, TEN is usually triggered by a reaction to medications. Antibiotics, anticonvulsant agents, butazones, and sulfonamides are the most frequent medications implicated. TEN is unrelated to UV exposure, hygiene, or varicella infection.

The nurse is performing a comprehensive assessment of a client's skin surfaces and intends to assess moisture, temperature, and texture. The nurse should perform the component of assessment in what way? A. By examining the client under a wood light B. By inspecting the client's skin in direct sunlight. C. By palpating the client's skin D. By performing percussion of major skin surfaces

ANS: C Rationale: Inspection and palpation are techniques commonly used in examining the skin. A client would only be examined under a wood light if there were indications it could be diagnostic. The client is examined in a well lit room, not in direct sunlight. Percussion is not a technique used in assessing the skin.

A nurse is reviewing gerontologic considerations relating to the care of clients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue? A. Decreased resistance to ultraviolet radiation B. Increased vulnerability to infection C. Diminished protection of tissues and organs D. Increased risk of skin malignancies

ANS: C Rationale: Loss of the subcutaneous tissue substances of elastin, collagen, and fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. This age-related change does not correlate to an increased vulnerability to sun damage, infection, or cancer.

A new client has come to the dermatology clinic to be assessed for a reddened rash on the abdomen. For what diagnostic test should the nurse prepare the client to identify the causative agent? A. Skin scrapings B. Skin biopsy C. Patch testing D. Tzanck smear

ANS: C Rationale: Patch testing is performed to identify substances to which the client has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignance and to establish an exact diagnosis of skin lesions. A tzanck smear is used to examine cells from blistering skin conditions, such as Herpes Zoster.

A new client presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the client's fingernail surfaces are pitted. The nurse should suspect the presence of what health problem? A. Eczema B. Systematic lupus erythematosus (SLE) C. Psoriasis D. Chronic obstructive pulmonary disease (COPD)

ANS: C Rationale: Pitted surface of the nail is a definite indication of psoriasis. Pitting of the nails does not indicate eczema, SLE, or COPD

A client has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning the client's care, The nurse should include what nursing diagnosis? A. Risk for deficient fluid volume related to excess sebum synthesis. B, Ineffective thermoregulation related to occlusion of sebaceous glands. C. Disturbed body image related to excess sebum production D. Ineffective tissue perfusion related to occlusion of sebaceous glands

ANS: C Rationale: Seborrhea causes highly visible manifestations that are likely to have a negative effect on the client's body image. Seborrhea does not normally affect fluid balance, thermoregulation, or tissue perfusion.

While assessing a 25-year-old female, the nurse notes that the client has hair on her lower abdomen. Earlier in the health interview, the client stated that her menses are irregular. The nurse should suspect what type of health problem? A. A metabolic disorder B. A malignancy C. A hormone imbalance D. An infectious process

ANS: C Rationale: Some women with higher levels of testosterone have hair in the areas generally thought of as masculine, such as the face, chest, and lower abdomen. This is often a normal genetic variation, but if it appears along with irregular menses and weight changes, it may indicate a hormonal imbalance. This combination of irregular menses and hair distribution is inconsistent with metabolic disorders, malignancy, or infection.

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of pasal cell carcinoma (BCC)? A. Teaching participants to improve their overall health through nutrition B. Encouraging participants to identify their family history of cancer C. Teaching participants to limit their sun exposure D. Teaching participants to control exposure to environmental and occupational radiation

ANS: C Rationale: Sun exposure is the best known and most common cause of BCC. BCC is not commonly linked to general health debilitation, family history, or radiation exposure.

A client presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition? A. Skin biopsy B. Patch test C. Tzanck smear D. Examination with a Wood light

ANS: C Rationale: The Tzanck smear is a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus. The secretions from a suspected lesion are applied to a glass slide, stained, and examined. This is not accomplished by biopsy, patch test, or Wood light.

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? A. Emergent B. Immediate resuscitative C. Acute D. Rehabilitation

ANS: C Rationale: The acute or intermediate phase of burn care follows the emergent/ resuscitative phase and begins 48-72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal? A. Educating participants about the relationship between general health and the risk of cancer B. Educating participants about treatment options for skin cancer. C. Educating participants about the early signs and symptoms of skin cancer. D. Educating participants about the health risks associated with smoking and assisting with smoking cessation.

ANS: C Rationale: The best hope of decreasing the incidence of skin cancer lies in educating clients about the early signs. There is a relationship between general health and skin cancer, but teaching individuals to identify the early signs and symptoms and is more likely to benefit overall outcomes related to skin cancer. Teaching about treatment options is not likely to have major effect on outcomes of the disease. Smoking is not among the major risks of skin cancer.

When planning the skin care of a client with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest? A. The scalp B. The elbows C. The palms of the hands D. The knees

ANS: C Rationale: The epidermis is the thickest over the palms of the hands and the soles of the feet.

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care? A. Assess the drainage in the dressing B. Slowly remove the soiled dressing C. Perform hand hygiene D. Don nonlatex gloves

ANS: C Rationale: The nurse and health care provider must adhere to standard precautions and wear gloves when inspecting the skin or changing a dressing. Use of standard precautions and proper disposal of any contaminated dressing is carried out according to Occupational Safety and Health Administration (OSHA) regulations. Hand hygiene must precede other aspects of wound care.

A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention? A. Chemotherapy B. Radiation therapy C. Surgical excision D. Biopsy of sample tissue

ANS: C Rationale: The primary goal of surgical management of squamous cell carcinoma is to remove the tumor entirely. Radiation therapy is reserved for older clients, because x-ray changes may be seen after 5-10 years, and malignant changes in scars may be induced by irradiation 15-30 years later. Obtaining a biopsy would not be a goal of treatment; it may be an assessment. Chemotherapy and radiation therapy are generally reserved for clients who are not surgical candidates.

A client requires a full-thickness graft to cover a chronic wound. How is the donor site selected? A. The largest area of the body without hair is selected. B. Any area that is not normally visible can be used C. An area matching the color and texture of the skin at the surgical site is selected D. An area matching the sensory capability of the skin at the surgical site is selected.

ANS: C Rationale: The site where the intact skin is harvested is called the donor site. Selection of the donor site is made to match the color and texture of the skin at the surgical site and to leave as little scarring as possible.

A nurse is developing a care plan for a client with a partial thickness burn and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A. To prevent neuropathies B. To prevent wound breakdown C. To prevent contractures D. To prevent heterotopic ossification

ANS: C Rationale: To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in the alignment. Gentle range of motion exercises and a consult to a PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

A client has just been told that he has deep malignant melanoma. The nurse caring for this client should anticipate that the client will undergo what treatment? A. Chemotherapy B. Immunotherapy C. Wide excision D. Radiation therapy

ANS: C Rationale: Wide excision is the primary treatment for malignant melanoma, which removes the entire lesion and determines the level and staging. Chemotherapy may be used after the melanoma is excised. Immunotherapy is experimental and radiation therapy is palliative.

A client with a partial-thickness burn injury had a xenograft applied 2 weeks ago. The nurse notices that the xenograft is separating from the burn wound. What is the nurse's most appropriate intervention? A. Reinforce the xenograft dressing with another piece of Biobrane. B. Remove the xenograft dressing and apply a new dressing. C. Trim away the separated xenograft. D. Notify the health care provider for further emergency-related orders.

ANS: C Rationale: Xenografts adhere to granulation tissue. As the tissue heals the xenograft will become removed from the scar tissue. Applying more of the xenograft will not continue to heal the wound (as it is already healed). It is not an emergency and reinforcement is not necessary.

A nurse in a dermatology clinic is reading the electronic health record of a new client. The nurse notes that the client has a history of a primary skin lesion. What skin lesion may this client have? A. Crust B. Keloid C. Pustule D. Ulcer

ANS: C Rationale: A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin. Crusts, Keloids, and ulcers are secondary lesions.

A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care? A. Ensuring that the family knows that impetigo is not contagious. B. Teaching about the safe and effective use of topical corticosteroids. C. Teaching about the importance of maintaining high standards of hygiene. D. Ensuring that the family knows how to safely burst the child's vesicles.

ANS: C Rationale: Impetigo is associated with unhygienic conditions; educational interventions to address this are appropriate. The disease is contagious, thus vesicles should not be burst manually. Because of the bacterial etiology corticosteroids are ineffective.

A nurse is preparing to perform the physical assessment of a newly admitted client. During which of the following components of the assessment should the nurse wear gloves? SATA A. Palpation of the nail beds B. Palpation of the client's upper extremities C. Palpation of a rash on the client's trunk D. Palpation of a lesion on the client's upper back E. Palpation of the client's finger joints

ANS: C,D Rationale: Gloves are worn during skin examination if a rash or lesions are to be palpated. It is not normally necessary to wear gloves to palpate a client's extremities or fingers unless contact with body fluids is reasonably foreseeable.

A client is brought to the emergency department from the site of a chemical fire, where the client suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? A. Superficial partial thickness B. Deep partial thickness C. Full partial thickness D. Full thickness

ANS: D Rationale: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the client will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis and portion of the deeper dermis; the client will report pain and sensitivity to cold air. Full partial-thickness is not a depth of burn.

While performing an initial assessment of a client admitted with appendicitis, the nurse observes an elevated blue-black lesion on the client's ear. The nurse knows that this lesion is consistent with what type of skin cancer? A. Basal cell carcinoma B. Squamous cell carcinoma C. Dermatofibroma D. Malignant melanoma

ANS: D Rationale: A malignant melanoma presents itself as a superficial spreading melanoma which may appear in a combination of colors, with hues of tan, brown, and black mixed with gray, black-blue or white. The lesion tends to be circular, with irregular, outer portions. BCC usually begins as a small, waxy nodule with rolled translucent, pearly borders; telangiectatic vessels may be present. SCC appears as a tough, thickened, scaly tumor that may be asymptomatic or it may involve bleeding. A dermatofibroma presents as a firm, dome-shaped papule or nodule that may be skin colored or pinkish brown.

A nurse is planning the care of a client with herpes zoster. What medication, if given withing the first 24 hours of the initial eruption, can arrest herpes zoster? A. Prednisone B. Azathioprine C. triamcinolone D. Acyclovir

ANS: D Rationale: Acyclovir, if started early, is effective in significantly reducing the pain and halting the progression of the disease. There is evidence that infection is arrested if oral antiviral agents are given within the first 24 hours. Prednisone is an anti-inflammatory agent used in a variety of skin disorders, but not in the treatment of herpes. Azathioprine is an immunosuppressive agent used in the treatment of pemphigus. Triamcinolone is utilized in the treatment of psoriasis.

A client's health assessment has resulted in a diagnosis of alopecia areata. What nursing diagnosis should the nurse most likely associate with this health problem? A. Chronic pain B. Impaired skin integrity C. Impaired tissue integrity D. Disturbed body Image

ANS: D Rationale: Alopecia areata causes hair loss in smaller defined areas. As such, it is common for the client to experience a disturbed body image. Hair loss does not cause pain and does not affect skin or tissue integrity.

A 65-year-old man presents at the clinic reporting nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect? A. Stasis ulcers B. Bullous pemphigoid C. Psoriasis D. Classic Kaposi sarcoma

ANS: D Rationale: Classic Kaposi sarcoma occurs predominantly in men of mediterranean or Jewish ancestry between 40 and 70 years of age. Most clients have nodules or plaques on the lower extremities that rarely metastasize beyond this area. Classic KS is chronic, relatively benign, and rarely fatal. Stasis ulcers do not create nodules. Bullous pemphigoid is characterized by blistering. Psoriasis characteristically presents with silvery plaques.

A nurse is working with a client who has a diagnosis of Cushing syndrome. When completing a physical assessment, the nurse should specifically observe for what integumentary manifestation? A. Alopecia B. Yellowish skin tone C. Patchy Bronze pigmentation D. Hirsutism

ANS: D Rationale: Cushing syndrome causes excessive hair growth, especially in women. Alopecia is hair loss from the scalp and other parts of the body. Jaundice causes a yellow discoloration in light-skinned clients, but this does not accompany Cushing syndrome. Clients that have Addison disease exhibit a bronze discoloration to their skin due to increased melanin production.

A nurse is assessing a teenage client with acne vulgaris. The client's mother states, "I keep telling him that this is what happens when you eat as many french fries as he does," What aspect of the pathophysiology of acne should the inform the nurse's response? A. A sudden change in the client's diet may exacerbate, rather than alleviate, the client's symptoms. B. French fries are one of the foods that are known to directly cause acne. C. Elimination of fried foods from the client's diet will likely lead to resolution within several months. D. Diet is thought to play a minimal role in the development of acne.

ANS: D Rationale: Diet is not believed to play a major role in acne therapy. A change in diet is not known to exacerbate symptoms. However, there does appear to be a correlation between foods high in refined sugars and acne; therefore, these foods should be avoided.

The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? A. Apply skin emollients as prescribed after granulation has occurred. B. Keep injured areas immobilized whenever possible to promote healing. C. Administer oral or IV corticosteroids as prescribed. D. Encourage physical activity and range of motion exercises.

ANS: D Rationale: Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process.

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing IV access, the nurse should anticipate the administration of what fluid? A. 0.45% NaCl with 20 mEq/L KCL B. 0.45% NaCl with 40 mEq/L KCL C. normal saline D. Lactated ringer

ANS: D Rationale: Fluid resuscitation with lactated ringer (LR) should be initiated using the American Burn Association's (ABA) fluid resuscitation formulas. LR is the crystalloid of choice because its composition and osmolality most closely resemble plasma and because use of normal saline is associated with hyperchloremic acidosis. Potassium chloride solutions would exacerbate the hyperkalemia that occurs following burn injuries.

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis? A. Grouped vesicles occurring on the lips and oral mucous membranes B. Grouped vesicles occurring on the genitalia C. Rough, fresh, or gray skin protrusions D. Grouped vesicles in linear patches along a dermatome

ANS: D Rationale: Herpes zoster, or shingles, is an acute inflammation of the dorsal root ganglia, causing localization, vesicle skin lesions following a dermatome. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes, usually producing cold sores or fever blisters. Herpes simplex 2 primarily affects the genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray protrusions.

A dark-skinned client is admitted to the medical unit with liver disease. To correctly assess this client for jaundice, on what body area should the nurse look for yellow discoloration? A. elbows B. lips C. Nail beds D. Sclerae

ANS: D Rationale: Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes.

A client has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized? A. Maintain the client on bed rest for the first 24 hours postoperative B. Apply distraction techniques to relieve pain C. Provide soft or liquid diet that is high in protein to assist with healing. D. Anticipate the need for, and administer, appropriate analgesic medication.

ANS: D Rationale: Nursing interventions after surgery for a malignant melanoma center on promoting comfort, because wide excision surgery may be necessary. Anticipating the need for an administering appropriate analgesic medications are important. Distraction techniques may be appropriate for some clients, but these are not a substitute for analgesia. Bed rest and a modified diet are not necessary.

An occupational health nurse is called to the floor of a factory where a worker sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A. Apply ice to the site of the burn for 5-10 minutes B. Wrap the client's affected extremity in ice until help arrives C. Apply an oil-based substance to the burned area until help arrives. D. Wrap cool towels around the affected extremity intermittently

ANS: D Rationale: Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Oils are contraindicated.

A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A. Activity intolerance B. Anxiety C. Ineffective coping D. Acute pain

ANS: D Rationale: Pain is inevitable during recovery from any burn injury. Pain in the burn client has been described as one of the most severe types of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the client's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses.

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A. Maintenance of bed rest to aid healing B. Choosing appropriate splints and functional devices C. Administration of beta adrenergic blockers D. Prevention of venous thromboembolism

ANS: D Rationale: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A. Assess the client for signs of electrolyte imbalances. B. Administer fluids as prescribed C. Assess the risk for injury recurrence D. Assess the client's psychosocial state

ANS: D Rationale: Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury? A. I B. II C. III D. IV

ANS: D Rationale: Stage III and IV pressure injuries are characterized by extensive tissue damage. In addition to the interventions listed for stage !, these advanced draining, necrotic pressure injuries must be cleaned (debrided) to created an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? A. The length of time since the burn B. The location of burned surface area C. The source of the burn D. The total body surface area (TBSA) affected by the burn

ANS: D Rationale: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence of absence of systemic effects.

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Pain B. Fluid balance C. Anxiety and fear D. Airway management

ANS: D Rationale: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the nurse's technique. How should the nurse best interpret this client's behavior? A. The client may be experiencing an adverse drug reaction that is affecting cognition and behavior. B. The client may be experiencing neurologic or psychiatric complications of the client's injuries. C. The client may be experiencing inconsistencies in the care being provided. D. The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.

ANS: D Rationale: The client may experience feelings of anger. The anger may be directed outward toward those who escaped unharmed or toward those who are now providing care. While drug reactions, complications, and frustrating inconsistencies in care cannot be automatically ruled out, it is not uncommon for anger to be directed at caregivers.

A 30-year-old client has just returned from the operating room after having a "flap" done following a motorcycle accident. The client's spouse asks about the major complications following this type of surgery. What is the nurse's best response? A. "The major complication is when the client develops chronic pain." B. " The major complication is when the client loses sensation in the flap." C. " The major complication is when the pedicle tears loose and the flat dies." D. " The major complication is when the Blood supply fails and the tissue in the flap dies."

ANS: D Rationale: The major complication of a flap is necrosis of the pedicle or base as a result of failure of the blood supply. This is more likely than tearing of the pedicle and chronic pain is more serious than loss of sensation.

A client who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Low Self Esteem related to use of facial prosthetic secondary to reconstructive surgery. Which nursing intervention would be appropriate for this diagnosis? A. Referring the client to a speech therapist B. Gradually adding soft foods to diet C. Administering analgesics as prescribed D. Teaching the client how to use and care for the prosthesis

ANS: D Rationale: The process of facial reconstruction is slow and tedious. Because a person's facial appearance affects self-esteem so greatly, this type of reconstruction is often a very emotional experience for the client. Reinforcement of the client's successful coping strategies improves self-esteem. If prosthetic devices are used, the client is taught how to use and care for them to gain a sense of greater independence. This is an intervention that relates to Disturbed Body Image in these clients. None of the other listed interventions relate directly to the diagnosis of Disturbed Body Image.

A client with an exceptionally low body mass index has been admitted to the emergency department with signs and symptoms of hypothermia. The nurse should know that this client's susceptibility to heat loss is related to atrophy of what skin component? A. Epidermis B. Merkel cells C. Dermis D. Subcutaneous tissue

ANS: D Rationale: The subcutaneous tissues and the amount of fat deposits are important factors in body temperature regulation. The epidermis is an outermost layer of stratified epithelial cells. Merkel cells are receptors that transmit stimuli to the axon through a chemical synapse. The dermis makes up the largest portion of the skin, providing strength and structure. It is composed of two layers: papillary and reticular.

While assessing a dark-skinned client at the clinic, the nurse notes the presence of patchy, milky-white spots. The nurse knows that this finding is characteristic of what diagnosis? A. Cyanosis B. Addison disease C. Polycythemia D. Vitiligo

ANS: D Rationale: With cyanosis, nail beds are dusky. With Polycythemia, the nurse notes a ruddy blue face, oral mucosa, and conjunctiva. A bronzed appearance, or "external tan", is associated with Addison disease. Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark skin as patchy, milky-white spots, often symmetric bilaterally.

An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment? A. Increased thickness of the subcutaneous skin layer B. Increased vascular supply to superficial skin layers C. Changes in the character and quantity of bacterial flora D. Increased time required for wound healing

ANS: D Rationale: Wound healing becomes slower with age, requiring more time for older adults to recover from surgical and traumatic wounds. There are no changes in skin flora with increased age. Vascular supply and skin thickness both decrease with age.

A nurse is providing care for a client who has developed Kaposi sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body? A. Connective tissue cells in diffuse locations B. Smooth muscle cells of the gastrointestinal and respiratory tract C. Neural tissue of the brain and spinal cord D. Endothelial cells lining small blood vessels

ANS: D Rationale: Kaposi sarcoma (KS) is a malignancy of endothelial cells that line the small blood vessels. It does not originate in connective tissue, smooth muscle cells of the GI and respiratory tract, or in neural tissue.

The nurse is providing an educational presentation addressing the topic of "Protecting Your Skin". When discussing the anatomy of the skin, the nurse should state that what cells are responsible for producing the pigmentation of the skin? A. Islets of Langerhans B. Squamous cells C. T-cells D. Melanocytes

ANS: D Rationale: Melanocytes are the special cells of the epidermis that are primarily responsible for producing the pigment melanin. Islets of Langerhans are clusters of cells in the pancreas. Squamous cells are flat, scaly, epithelial cells. T-Cells function in the immune response.

A nurse is aware that the outer layer of the skin consists of dead cells that contain large amounts of keratin. The physiological functions of keratin include which of the following? SATA A. Producing antibodies B. Absorbing electrolytes C. Maintaining acid-base balance D. Physically repelling pathogens E. Preventing fluid loss

ANS: D, E Rationale: The dead cells of the epidermis contain large amounts of Keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Keratin has the capacity to repel pathogens and prevent excessive fluid loss from the body. It does not contribute directly to antibody production, acid-base balance, or electrolyte levels.

An unresponsive client with light complexion has been brought to the emergency room by EMS. While assessing this client, the nurse notes that the client's face is the cherry-red color. What should the nurse suspect? A. Carbon monoxide poisoning B. Anemia C. Jaundice D. Uremia

ANS:A Rationale: Carbon monoxide poisoning causes a bright red cherry color in the face and upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry red color to nail beds, lips, and oral mucosa. When anemia occurs in light-skinned persons, the skin has generalized pallor. Anemia in dark-skinned persons manifests as a yellow-brown coloration. Jaundice appears as a yellow coloration of the sclerae. Uremia gives a yellow-orange tinge to the skin.

A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider to order for the wound? A. Silver sulfadiazine 1% (Silvadene) water-soluble cream B. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C. Silver nitrate 0.5% aqueous solution D. Acticoat

ANS:B Rationale: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing.

A triage nurse in the emergency department (ED) receives a phone call from a frantic parent who saw their 4-year-old child tip a pot of boiling water onto themselves. The parent has called an ambulance. What should the nurse in the ED receiving the call instruct the parent to do? A. Cover the burn with ice and secure a towel B. Apply butter to the area that is burned C. Immerse the child in a cool bath D. Avoid touching the burned area under any circumstances.

ANS:C Rationale: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first aid measure. Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn.