Care of the patient with an Integumentary Disorder

The nurse is interviewing an older adult. Which statement is cause for the greatest concern?

"This black mole on my neck is itching."

The nurse notes that the patient has clubbing of the fingertips. Based on this finding, which question would the nurse ask?

Have you been diagnosed with a respiratory disorder?

. The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?

Severity of the symptoms.

What should the nurse examine in assessing a patient for tinea corporis?

Abdomen

A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction would be most helpful in managing the pruritus?

Use cool, wet dressings and baths to promote vasoconstriction.

The most deadly skin cancer is

melanoma

Which patient instruction should the nurse include in the teaching plan relative to the management of systemic lupus erythematosus?

Maintain a balance between rest and activity

What should the nurse do when administering a therapeutic bath to a patient who has severe pruritis?

Use Barrow's solution to help promote healing .

What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for her acne?

Use dependable birth control to avoid pregnancy.

A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What should the nurse do when administering this drug?

Use gloves.

To assess the temperature and texture of the patient's skin, which technique would the nurse use?

Use the palms of the hands to compare opposite body areas.

The home health aide phones the nurse and says, "I helped the patient bathe. I wore gloves during the bath, but then afterwards he said that he was just diagnosed with herpes zoster." Which question should the nurse ask first?

"Have you received two doses of varicella vaccine?

Which patient statement indicates that more teaching is needed regarding antibiotic therapy for the treatment of cellulitis?

"My skin is cleared up. I don't think I need the medication anymore."

The nurse making the initial assessment of a burned patient in the emergency room observes that the entire right arm (anterior and posterior), right anterior leg, chest, and abdomen are covered with reddened skin and blisters. Using the Rule of Nines, the nurse estimates the percentage of burn to be

36%.

A frail, older adult home heath patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

Access frequently for herpes zoster.

Drug therapy for the patient experiencing an outbreak of herpes simplex could include?

Acyclovir

The nurse knows that the health care provider frequently prescribes isotretinoin (Accutane) for patients with acne. Which question is the most important to routinely ask?

Are you pregnant or contemplating a pregnancy in the near future?

The school nurse is assessing a 15-year old girl and notices multiple linear superficial cuts over the girl's anterior forearms. What should the nurse do first?

Ask the girl directly what happened to her arms.

Based on the patient's low hemoglobin and hematocrit, the nurse would assess for pallor. The patient is a very dark-skinned individual. How would the nurse assess this patient for pallor?

Assess for pallor by looking at the mucous membranes, lips, nail beds, and conjuctivae of the lower eye lids

The nurse is caring for a 26-year-old male patient who was burned 72 hours ago. He has partial-thickness burns to 24% of his body surface area. He begins to excrete large amounts of urine. What should the nurse do?

Assess for signs of fluid overload

A patient with severe eczema is starting a coal tar derivative treatment. What should the nurse include in the teaching plan for the patient relative to this treatment?

Avoid exposure to sunlight for 72 hours after use

What is the best instruction by the nurse regarding reducing the risk factors for melanoma?

Avoid exposure to the sun and use protective measures when exposure occurs.

A patient diagnosed with tinea pedis is prescribed Burow's solution soaks. The patient asks how this medication will work. What should be included in the teaching plan?

Burow's solution has astringent characteristics

What is a common diagnostic criterion for identifying systemic lupus erythematosus (SLE)?

Butterfly rash on face, sensitivity to sunlight, polyarthralgias, and polyarthritis.

Which of the following are nursing interventions and patient teaching for the treatment of head lice and scabies?

Clothing, linens, and bath articles thoroughly cleaned in hot water Stress nature and transmission of the disease

Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?

Curling Ulcer.

A patient reports hair loss (hypotrichosis). Which assessment is the nurse most likely to conduct to assist the health care provider in determining the etiology of hypotrichosis?

Dietary assessment

Education for the patient who has been prescribed Benandryl should include which instructions?

Do not operate heavy machinery while taking the medication.

A patient is admitted for pain and tenderness in his lower right leg. The nurse's assessment reveals the extremity is warm, swollen, and has a slightly pitted appearance. Which measure would the nurse use to relieve the discomfort?

Elevate the leg with pillows to reduce edema.

Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where can the melanocytes be found?

Epidermis

Prioritize the interventions for a hospitalized severely burned victim during the emergent phase.

Establish airway Initiate fluid therapy Insert Foley catheter Insert nasogastric tube Administer analgesics Tetanus prophylaxis

Which of the following are major functions of the skin?

Excretion of wastes Protection Temperature regulation Prevention of dehydration Vitamin D synthesis

The nurse would be prepared to administer epinephrine as needed to which patient?

Has raised red wheals and hives and an expiratory wheeze.

The nurse hears during the shift report that the patient was admitted for penicillin-induced dermatitis medicamentosa. Which question is the most important to ask?

Has the patient had any respiratory distress?

The health care provider has diagnosed a patient with paronychia. Which assessment is the nurse most likely to perform before administering the ordered therapy?

History of allergies to antibiotics

What should a patient be assessed for upon the diagnosis of genital herpes?

Human immunodeficiency virus (HIV).

. What would the nurse dressing a necrotic pressure ulcer with a minimal exudate most likely use?

Hydrocolloid dressing

A child has been sent to the school nurse with pruritis and honey-colored crusts on the lower lip and chin. The nurse believes these lesions are most likely:

Impetigo

Which may indicate a malignant melanoma in a nevus on a patient's arm?

Irregular border of the mole

When providing the open method of treatment for a patient who is 52 years old with burns to the lower extremities, what would a nurse include in the nursing plan?

Keep the room temperature at 85° F (29.4° C) to prevent chilling

A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?

Keloid

The nurse is assessing a patient who was recently transferred from home to a skilled nursing facility. The nurse sees a pressure ulcer with full-thickness tissue loss, which is covered by a thick, black layer of eschar. What should the nurse do first?

Leave eschar intact; collaborate with RN to develop care plan.

After suffering from a condition in which chronic pruritis and scratching occured, which might be an anticipated finding?

Lichenfication.

A patient presents to the ambulatory care center with complaints of an "itchy rash". When preparing to examine the rash, the nurse should use which type of lighting?

Natural lighting

The nurse is assessing the skin of several patients. What are the physiologic factors that influence skin color?

Oxygenation, pulmonary function, cardiac function, blood count and temperature.

The darker-skinned patient reports an itching sensation, but the nurse cannot detect a rash with visual inspection. What technique can the nurse use?

Palpation of warmth and induration.

A patient has been admitted to the hospital with burns to the upper chest. The nurse notes singed nasal hairs. The nurse needs to assess this patient frequently for which condition?

Respiratory complications

The nurse has staged a pressure ulcer that has a shallow crater with a dry pink wound bed as a:

Stage II

Prioritize the intervention of the first responder to the victim during the emergent phase of burn management.

Stop, drop, and roll. Provide an open airway. Control any bleeding. Remove all nonadherent clothing and jewelry. Cover victim with clean cloth or sheet. Transport victim to hospital.

The nurse hears in report that a young female patient is very upset because of alopecia; she cannot focus on the overall cancer treatment plan. In addition to therapeutic communication which nursing intervention could the nurse use?

Teach the patient about the use of scarves or wigs.

A nurse arrives at an accident scene where the victim has just received an electrical burn. What is the nurse's primary concern?

The likelihood of cardiac arrest.

A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complaints of pain and pruritus. Why would the nurse use a Woods lamp?

To cause fluorescence of the infected hairs.

What is the initial intervention for relief of the pruritus of dermatitis venenata (poison oak)?

Wash area with copious amounts of water

A patient, age 46, reports to his physician's office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, "It itches like crazy." Which type of lesion would the nurse include in her documentation?

Wheals

A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?

Within 12 hours after burn trauma

A patient of African-American ancestry having brown skin tones is hospitalized. The health care provider makes a diagnosis of anemia. What skin tones can be found during assessment to support this diagnosis?

Yellow toned.

The nurse takes into consideration that carbon monoxide intoxication secondary to smoke inhalation is often fatal because carbon monoxide:

binds with hemoglobin in place of oxygen.

During the data collection interview, the patient states she has noticed a grouping of red and swollen areas with yellowed centers on her back. She reports that they are painful. Based on your knowledge you anticipate a diagnosis of :

carbuncles

During primary survey assessment of a burn patient, the nurse checks for which of the following as early signs of carbon monoxide poisoning?

headache, nausea, vomiting, and unsteady gait.

Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from:

hypovolemic shock and renal failure.

A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is:

infection.

A nurse can assess cyanosis in a dark-skinned patient by noting the color of the:

lips and mucous membranes.

When assisting a mother to plan meals for a child recently diagnosed with eczema, the nurse should advise her that common allergies for a patient with this diagnosis may include:

orange juice, wheat and eggs

The nurse debriding a burn wound explains that the purpose of debridement is to:

prevent infection and promote healing.

Upon removal of the thick crust associated with impetigo contagiosa, the skin will appear:

red and smooth

The primary mode of transmission for herpes simplex is:

skin-to-skin contact

After experiencing concerns with a growth on her neck, a patient seeks care. During the assessment, you document the growth as a firm, nodular lesion with a crusted top. Based on your knowledge you anticipate a diagnosis of ?

squamous cell carcinoma.

The three major glands of the skin are

sudoriferous (sweat), ceruminous, and sebaceous (oil).

The school nurse recognizes the signs of scabies when a child presents with:

wavy threadlike lines on the body and pruritus.