Chapter 15 - Integumentary Problems

3

When you are evaluating a client who has been taking prednisone (Deltasone) 30 mg daily to treat contact dermatitis, which finding is most important to report to the HCP? 1. glucose 136 2. client stated "I am eating all the time" 3. client reports epigastric pain 4. BP 148/84

1

Which assessment finding calls for the most immediate further assessment or intervention? 1. bluish color around lips and earlobes 2. yellow color of skin and sclera 3. b/l erythema of the face and neck 4. dark brown spotting on the chest and back

3

You are caring or a client who has just had squamous cell carcinoma removed from the face. Which activity can you delegate to an experienced LPN? 1. teaching the client about risk factors for squamous cell carcinoma 2. showing the client how to care for the surgical site 3. monitoring the surgical site for swelling, bleeding, or pain 4. discussing the reasons for avoiding aspirin use for a week after surgery

4

You are employed as the charge nurse in a LTAC that employs RNs, LPNs, and UAPs. When you are planning care for a resident with a stage III sacral pressure ulcer, which nursing intervention is best to delegate to an LPN? 1. choosing the type of dressing to be used on ulcer 2. using Norton scale to assess for pressure ulcer risk factors 3. assisting the client in changing position at frequent intervals 4. cleaning and changing the dressing on the ulcer every morning

4

You are performing a skin assessment on a 70 yo new resident in the LTAC. Which finding is of most concern? 1. numerous striae noted across abdomen and buttocks 2. all the toenails are thick and yellow 3. silver scaling present on elbows and knees 4. an irregular border is seen on a black mole on the scalp

1

A 22 yo woman who has been taking isotretinoin (Claravis) to treat severe cystic acne makes all these statements while being seen for a follow-up exam. Which statement is of most concern? 1. my husband and I are thinking of starting a family soon 2. I don't think there has been much improvement in my skin 3. sometimes I get nauseated after taking my med 4. I have been having problems driving when it gets dark

4

A client admitted to the ED reports itching of the trunk and groin. You note multiple reddened wheals on the chest, back, and groin. Which question is most appropriate to ask next? 1. do you have a family hx of eczema? 2. have you been using sunscreen regularly? 3. how do you usually manage stress? 4. are you taking any new medications?

3

A client is scheduled for patch testing to determine allergies to several substances. Which action associated with this test should you delegate to a medical assistant working in the allergy clinic? 1. explain the purpose of testing to the client 2. examine the patch area for evidence of a rxn 3. schedule a follow-up appointment for the client in 2 days 4. monitor the client for anaphylaxis to testing

2

A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is admitted to the ED. Which ordered intervention will you implement first? 1. infuse LR at 250 mL/hr 2. rinse the back and legs with 4 L of sterile NS 3. obtain blood for a CBC and electrolyte levels 4. document the % of total BSA burned

3

As a home health nurse, you are caring for a 72 yo client who has a nursing dx of Impaired Skin Integrity r/t poor nutrition, bladder incontinence, and immobility. Which nursing actions should you delegate to the UAP? 1. telling the client and family to apply the skin barrier cream in a smooth, even layer 2. completing a diet assessment and suggesting changes in diet to improve the client's attention 3. reminding the family to help the client to the commode every 2 hours during the day 4. evaluating the client for improvement in documented areas of skin breakdown or damage

2

As charge nurse, you are providing orientation for a newly-hired RN. Which action by the new RN requires the most immediate action? 1. obtaining an anaerobic culture specimen from a superficial burn wound 2. giving doxycycline (Vibramycin) with a glass of milk to a client with cellulitis 3. discussing the use of herpes zoster vaccine with a 25 yo client 4. teaching a newly admitted burn client about the use of pressure garments

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You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished. 1. apply silver sulfadiazine (Silvadene) ointment 2. obtain specimens for aerobic and anaerobic wound cultures 3. administer morphine 10 mg IV 4. debride the wound of eschar using gauze sponges 5. cover the wound with a sterile gauze dressing

1

You are preparing to discharge four clients from the hospital and are planning their discharge teaching. Which client will it be most important to instruct about the need to use sunscreen? 1. 32 yo with a UTI who is being discharged with a prescription for tetracycline (Sumycin) 2. fair-skinned 55 yo who has just had neck surgery and who plans to walk in the yard for 15 minutes twice daily 3. dark-skinned 62 yo who has had keloid injected with hydrocortisone (Solu-cortef) 4. 78 yo with a red, pruritic rash caused by an allergic reaction to PCN (Bicillin)

1

You are the charge nurse in an LTC facility. An 80 yo client has candidiasis in the skinfolds of the abdomen and groin. Which intervention is best to delegate to an LPN? 1. applying nystatin (Mycostatin) powder to the area three times daily 2. cleaning the skinfolds every 8 hours with mild soap and drying thoroughly 3. evaluating the need for further antifungal treatment at least weekly 4. assessing for ongoing risk factors for skin breakdown and infx

3

You are the charge nurse on a medical-surgical unit and are working with a newly-graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? 1. 34 yo who was just admitted to the unit for periorbital cellulitis 2. 40 yo who needs discharge instructions after having skin grafts to the thigh 3. 67 yo who requires a dressing change after hydrotherapy for a pressure ulcer 4. 78 yo who needs teaching before a punch biopsy of a facial lesion

3

You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? 1. 23 yo who has just been admitted with burns over 30% of the body after a warehouse fire 2. 36 yo who requires discharge teaching about nutrition and wound care after having skin grafts 3. 45 yo with infected partial thickness back and chest burns who has a dressing change schedueld 4. 57 yo with full-thickness burns on both arms who needs assistance in positioning hand splints

2

You have just received a change of shift report for the burn unit. Which client should you assess first? 1. client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. client who has just arrived from the ED with facial burns sustained in house fire 3. client who has just transferred from the PACU after having skin grafts applied to the anterior chest 4. client admitted 3 wks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

3

You have just received the change-of-shift report in the burn unit. which client requires the most immediate assessment or intervention? 1. 22 yo admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left 2. 34 yo who returned from skin-graft surgery 3 hours ago and is reporting levl 8 pain 3. 45 yo with partial-thickness leg burns who has a temp of 102.6 F (39.2 C) and a BP of 98/46 4. 57 yo who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L

4

You take the health hx of a 60 yr old client who has been admitted to the same-day surgery unit for elective facial dermabrasion. Which information is most important to convey to the plastic surgeon? 1. client does not routinely use sunscreen 2. client has family hx of melanoma 3. client has not eaten anything for 8 hours 4. client takes 325 mg of aspirin daily