Disruptions of the integument-Med Surg

Initial fluid shift occurs in the first __ hr and continues for ___ to ___ hrs

12, 24, 36

Fluid remobilization starts at 24 hour, diuretic stage begins at ____ to ____ hr after injury

48 to 72

The client can require ___ % to ____ % increased calorie intake, which may be more than _______ calories/day.

50, 150, 5000

The burn patient has developed an increasing dread of painful dressing changes. What would be the most appropriate treatment to ask the health care provider to prescribe? A. Midazolam to be used with morphine before dressing changes B. Morphine in a dosage range so that more may be given before dressing changes C. Buphrenorphine (Buprenex) to be administered with morphine before dressing changes D. Patient-controlled analgesia so that the patient may have control of analgesic administration

A

What skin condition has hyperkeratotic scaly lesions, is a precursor of squamous cell carcinoma, and may be treated with topical fluorouracil (5-FU)? A. Actinic keratosis B. Basal cell carcinoma C. Malignant melanoma D. Squamous cell carcinoma

A

The patient has diabetes mellitus and chronic obstructive pulmonary disease that has been treated with high dose corticosteroids for the past several years. Which dermatologic manifestations could be related to these systemic problems (select all that apply)? A. Acne B. Increased sweating C. Dry, coarse, brittle hair D. Impaired wound healing E. Erythematous plaques of the shins F. Decreased subcutaneous fat over extremities

A, D, E, F

A woman calls the health clinic and describes a rash that she has over the abdomen and chest. She tells the nurse it has raised, fluid-filled, small blisters that are distinct. A. Identify the type of primary skin lesion described by this patient B. What is the distribution terminology for these lesions? C. What additional information does the nurse have to document the critical components of these lesions?

A-Vesicles B-Discrete, localized to the chest and abdomen C-Color, size, height, shape, configuration, and odor

Beings 36-48 hr after injury when the fluid shift resolves Ends with closure of the wound Priorities include data collection and maintenance of the cardiovascular, respiratory, and gastrointestinal systems, (including nutrition); wound care; pain control, and psychosocial interventions

Acute

A female patient with chronic skin lesions of the face and arms tells the nurse that she cannot stand to look at herself in the mirror anymore because of her appearance. Based on this information, the nurse identifies which nursing diagnosis? A. Anxiety related to personal appearance B. Disturbed body image related to perception of unsightly lesions C. Social isolation related to decreased activities as a result of poor self image D. Ineffective health management related to lack of knowledge of cover up techniques

B

A home health nurse is visiting an older obese woman who has recently had hip surgery. She tells the patient's caregiver that the patient has intertrigo. When the caregiver asks what that is, the nurse should tell the caregiver that it is A. Thickening of the skin B. Dermatitis in the folds of her skin C. Loss of color in diffuse areas of her skin D. A firm plaque caused by fluid in the dermis

B

Which statements characterize malignant melanomas (select all that apply)? A. Related to chemical exposure B. Neoplastic growth of melanocytes C. Skin cancer with highest mortality rate D. Irregular color and asymmetric shape E. Frequently occurs on previously damaged skin

B, C, D

Identify the factors that increase nutritional needs of the patient during the emergent and acute phases of burn injury(select all that apply). A. Electrolyte imbalance B. Core temperature elevation C. Calories and protein used for tissue repair D. Hypometabolic state secondary to decreased gastrointestinal function E. Massive catabolism characterized by protein breakdown and increased gluconeogenesis

B, C, E

in areas where the skin is thinner, there is more damage to underlying tissue (any part of the face, hand, perineum, feet)

Body location of the burn

When assessing an African American patient, the nurse notes ashen color of the nail beds. What should the nurse do *next*? A. Palpate for rashes on the legs B. Assess for jaundice in the sclera of the eye C. Assess the mucous membranes for cyanosis D. Assess for pallor of the skin on buttocks

C

from burns in an enclosed area, findings include headache weakness, dizziness, confusion, erythema (pink or cherry red skin) and upper airway edema, followed by sloughing of the respiratory tract mucosa

Carbon monoxide inhalation

result from open flames and explosions

Dry heat injuries

Diagnostic studies can include ____ scans, computed tomography, ________________, _____________, and MRI to determine extent of burn injury

kidney, ultrasonography, bronchoscopy

Total protein and albumin ___ due to fluid loss

low

The nurse *initially* suspects the possibility of sepsis in the burn patient based on which change? A. Vital signs B. Urinary output C. Gastrointestinal Function D. Burn wound appearance

A

Which type of burn injury would cause myoglobinuria, long bone fractures, and cardiac dysrhythmias and/or cardiac arrest? A. Thermal B. Electrical C. Chemical D. Smoke and inhalation

B

The nurse plans care for a patient with a newly diagnosed malignant melanoma based on the knowledge that initial treatment may involve (select all that apply) A. Shave biopsy B. Mohs surgery C. surgical excision D. Localized radiation E. Fluorouracil (5-FU) F. Topical nitrogen mustard

B & C

What characteristic is commonly seen with dysplastic nevus syndrome? A. Associated with sun exposure B. Precursor of squamous cell carcinoma C. Slow-growing tumor with rare metastasis D. Lesion has irregular color and asymmetric shape

D

A nurse caring for a disheveled patient with poor hygiene observes that the patient has small red lesions flush with the skin on the head and body. The patient complains of severe itching at the sites. For what should the nurse further assess the patient? A. Nits on the shafts of his head hair B. The presence of ticks attached to the scalp C. A history of sexually transmitted infections D. The presence of burrows in the interdigital webs

A

A patient with deep partial-thickness burns over 45% of his trunk and legs is going for debridement in the cart shower 48 hours post-burn. What is the drug of choice to control the patient's pain during this activity? A. IV morphine B. Midazolam C. IM meperidine (Demerol) D. Long-acting oral morphine

A

During the rehabilitation phase of burn injury, what can control the contour of the scarring? A. Pressure garments B. Avoidance of sunlight C. Splinting joints in extension D. Application of emollient lotions

A

The patient is visiting the free clinic to refill her medications. During the generalized assessment the nurse documents alopecia; an increased heart rate; warm, moist, flushed skin, and thin nails. The patient also states she is anxious and has lost weight lately. Which systemic problem will the nurse *most* likely suspect and relate to the health care provider? A. Hyperthyroidism B. Systemic lupus erythematosus C. Vitamin B1 (Thiamine) deficiency D. Human immunodeficiency virus (HIV) infection

A

To prevent lichenification related to chronic skin problems, what does the nurse encourage the patient to do? a. Use measures to control itching. A. use measures to control itching b. Wear sterile gloves when touching the lesions. c. Use careful handwashing and safe disposal of soiled dressings. d. Use topical antibiotics with wet-to-dry dressings over the lesions.

A

What are the *most* appropriate compresses to use to promote comfort for a patient with an inflamed, pruritic dermatitis? A. Cool tap water compresses B. Cool acetic acid compresses C. Warm sterile saline compresses D. Warm potassium permanganate compresses

A

What is a skin graft that is used to transfer skin and subcutaneous tissue to large areas of deep tissue destruction called? A. Skin flap B. Free graft C. Soft tissue extension D. Free graft with vascular anastomoses

A

What is the *initial* cause of hypovolemia during the emergent phase of burn injury? A. Increased capillary permeability B. Loss of sodium to the interstitium C. Decreased vascular oncotic pressure D. Fluid loss from denuded skin surfaces

A

When monitoring urinary system during burns what do you make sure you have accurate readings of?

I & O

What is the *most* common diagnostic test used to determine a causative agent of skin infections? A. Culture B. Tzanck test C. Immunofluorescent studies D. Potassium hydroxide (KOH) slides

A

What is the *most* common reason elective cosmetic surgery is requested by patients? A.Improve self-image B. Remove deep acne scars C. Lighten the skin in pigmentation problems D. Prevent skin changes associated with aging

A

When assessing a patient's full-thickness burn injury during the emergent phase, what would the nurse expect to find? A. Leathery, dry, hard skin B. Red, fluid-filled vesicles C. Massive edema at the injury site D. Serous exudate on a shiny, dark brown wound

A

Which skin condition occurs as an allergic reaction to mite eggs? A. Scabies B. Impetigo C. Folliculitis D. Pediculosis

A

Damage to the entire epidermis and dermis Can extend into the subcutaneous tissue Nerve damage Red, Black, Brown, Yellow, or White No blisters Severe edema Eschar hard and inelastic Sensation minimal or absent Heals within weeks to months Scarring Grafting

Full Thickness

A patient has a plaque lesion on the dorsal forearm. Which type of biopsy is *most* likely to be used for diagnosis of the lesion? A. Punch biopsy B. Shave biopsy C. Incisional biopsy D. Excisional biopsy

B

A patient is receiving chemotherapy. She calls the health care provider's office and says she is experiencing itching in her groin and under her breasts. What is the *first* nursing assessment that would be done before the nurse makes an appointment for the patient with the health care provider to determine the treatment? A. Her height and weight B. What the areas look like C. If chemotherapy was completed D. Culture and sensitivity of the areas

B

A patient's deep partial-thickness facial burns are treated with the open method. What should the nurse do when caring for the patient? A. Ensure that sterile water is used in the debridement tank B. Wear a cap, mask, gown, and gloves during patient contact C. Use sterile gloves to remove the dressings and wash the wounds D. Apply topical antimicrobial ointment with clean gloves to prevent wound trauma

B

An active athletic person calls the clinic and describes her feet as having linear breaks through the skin . What is the *best* documentation of this problem? A. Scales B. Fissure C. Pustule D. Comedo

B

Burn patient has a nursing diagnosis of impaired physical mobility related to a limited range of motion (ROM) resulting from pain. What is the best nursing intervention for this patient? A. Have the patient perform ROM exercises when pain is not present B. Provide analgesic medications before physical activity and exercise C. Teach the patient the importance of exercise to prevent contractures D. Arrange for the physical therapist to encourage exercise during hydrotherapy

B

The nurse assesses that bowel sounds are absent and abdominal distention is present in a patient 12 hours post-burn. The nurse notifies the health care provider and anticipates doing what action *next*? A. Withhold all oral intake except water B. Insert a nasogastric tube for decompression C. Administer a H2-Histamine blocker such as ranitidine (Zantac) D. Administer nutritional supplements through a feeding tube placed in the duodenum

B

The nurse observes that redness remains after palpation of a discolored lesion the patient's leg. This finding is a characteristic of A. Varicosities B. Intradermal Bleeding C. Dilated blood vessels D. Erythematous lesions

B

The patient asks the nurse what telangiectasia looks like. Which is the *best* description for the nurse to give the patient? A. A circumcscribed, flat discoloration B. Small, superficial, dilated blood vessels C. Benign tumor of blood or lymph vessels D. Tiny purple spots resulting from tiny hemorrhages

B

The patient was admitted tot he burn center with a full-thickness burn 42 hours after the thermal burn occurred. The nurse will apply actions related to which phase of burn management for this patient's care? A. Acute B. Emergent C. Postacute D. Rehabilitative

B

What is an appropriate intervention to promote debridement and removal of scales and crusts of skin lesions? A. Warm oatmeal baths B. Warm saline compresses C. Cool sodium bicarbonate baths D. Cool magnesium sulfate compresses

B

What is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body? A. Fever B. Shivering C. Severe Pain D. Unconsciousness

B

What is the most common skin cancer and has pearly borders? A. Actinic keratosis B. Basal cell carcinoma C. Malignant melanoma D. Squamous cell carcinoma

B

What should the nurse include in the instructions for a patient with urticaria? A. Apply topical benzene hexachloride B. Avoid contact with the causative agent C. Gradually expose the area to increasing amounts of sunlight D. Use over the counter antihistamines routinely to prevent the condition

B

Which description characterizes seborrheic keratosis? A. White, patchy yeast infection B. Warty, irregular papules or plaques C. Excessive turnover of epithelial cells D. Deep inflammation of subcutaneous tissue

B

A 24-year old female patient does not want the wound cleansing and dressing change to take place. She asks, "What difference will it make anyway?" What will the nurse encourage the patient to do? A. Have the wound cleaned and the dressing changed B. Have a snack before having the treatments completed C. Talk about what is troubling her with the nurse and/or her family D. Call the chaplain to come and talk to her and convince her to have the care

C

A patient with a contact dermatitis is treated with calamine lotion. What is the rationale for using this base for a topical preparation? A. A suspension of oil and water to lubricate and prevent drying B. An emulsion of oil and water used for lubrication and protection C. Insoluble powders suspended in water that leave a residual powder on the skin D. A mixture of a powder and ointment that causes drying when moisture is absorbed

C

At the end of the emergent phase and initial acute phase of burn injury, a patient has a serum sodium level of 152 mEq/L (152 mmol/L) and a serum potassium level of 2.8 mEq/L (2.8 mmol/L). What could have caused these imbalances? A. Free oral water intake B. Prolonged hydrotherapy C. Mobilization of fluid and electrolytes in the acute phase D. Excessive fluid replacement with dextrose in water without potassium supplementation

C

How is the immune system altered in a burn injury? A. Bone marrow stimulation B. Increase in immunoglobulin levels C. Impaired function of white blood cells (WBCs) D. Overwhelmed by microorganisms entering denuded tissue

C

How should the nurse position the patient with ear, face, and neck burns? A. Prone B. On the side C. Without pillows D. With extra padding around the head

C

When the nurse is assessing the skin of an older adult, which factor is likely to contribute to dry skin? A. Increased bruising B. Excess Perspiration C. Decreased Extracellular Fluid D. Chronic ultraviolet light exposure

C

Which burn patient should have orotracheal and endotracheal intubation? A. Carbon monoxide poisoning B. Electrical burns causing cardiac dysrhythmias C. Thermal burn injuries to the face, neck, or airway D. Respiratory distress from eschar formation around the chest

C

The nurse has received the change of shift report on his group of patients. Indicate the priority order in which the nurse should see these patients: A. A 40 year old female who is returning from the postanesthesia care unit (PACU) following surgical debridement of her back and legs B. A 76 year old male with partial thickness burns of his arms and abdomen who is complaining of severe pain C. A 62 year old female who was just admitted following partial-thickness burns to her anterior chest, face, and neck D. An 18 year old male with full thickness burns of his lower extremities who is refusing to go for his scheduled dressing change

C, B, A, D

Which skin conditions are more common in immunosuppressed patients (select all that apply)? A. Acne B. Lentigo C. Candidiasis D. Herpes Zoster E. Herpes Simplex 1 F. Kaposi sarcoma

C, E, F

What is the *primary* difference between an excoriation and an ulcer? A. Ulcers do not penetrate below the epidermal junction B. Excoriations involve only thinning of the epidermis and dermis C. Excoriations will form crusts, or scabs, whereas ulcers remain open D. An Excoriation heals without scarring because the dermis is not involved

D

What is the name for papillomavirus infection seen on the skin? A. Furuncle B. Carbuncle C. Erysipelas D. Plantar wart

D

When obtaining important health information from a patient during assessment of the skin it is *most* important for the nurse to ask about A. A history of freckles as a child B. Patterns of weight gain and loss C. Communicable childhood illnesses D. Skin problems related to the use of medications

D

When performing a physical assessment of the skin, what should the nurse do first? A. Palpate the temperature of the skin with the fingertips B. Assess the degree of turgor by pinching the skin on the forearm C. Inspect specific lesions before performing a general examination of the skin D. Ask the patient to undress completely so that all areas of the skin can be inspected

D

Which skin condition would be treated with laser surgery? A. Preauricular lesion B. Redundant soft tissue conditions C. Obesity with subcutaneous fat accumulation D. Fine wrinkles reduction or facial lesion removal

D

Resusciation phase: _____________ more than 10% strongly indicates smoke inhalation

Carboxyhemoglobin

result from exposure to a caustic agent. Cleaning agents in the home (drain cleaner, oven cleaner, bleach) and agents in the industrial setting (caustic soda, sulfuric acid) can cause chemical burns

Chemical burns

results when a person touches electrical wiring or equipment

Conductive electrical injury

occur when hot metal, tar, or grease contacts the skin

Contact burns

A 66 year old African American patient is scheduled to have a basal cell carcinoma on is cheek excised in his HCP's office. What discharge teaching is *most* important for the nurse to include for this patient? A. You will probably need radiation as well after the excisions B. It is good you are having it removed to avoid massive tissue destruction C. It is too bad you can't have this done by laser because it leaves less scarring

D

A patient has a 20% TBSA deep partial-thickness and full-thickness burn to the right anterior chest and entire right arm? What is *most* important for a nurse to assess in this patient? A. Presence of pain B. Swelling of the arm C. Formation of eschar D. Presence of pulses in the arms

D

A patient with psoriasis is being treated with psoralen plus UVA light (PUVA) phototherapy. During the course of therapy, for what duration should the nurse teach the patient to wear protective eyewear that blocks all UV rays? A. Continuously for 6 hours after taking the medication B. Until the pupils are able to constrict on exposure to light C. For 12 hours following treatment to prevent retinal damage D. For 24 hours following treatment when outdoors or when indoors near a bright window

D

Which characteristics accurately describe chemical burns (select all that apply)? A. Metabolic asphyxiation may occur B. Metabolic acidosis occurs immediately following the burn C. The visible skin injury often does not represent the full extent of tissue damage D. Lavaging with large amounts of water is important to stop the burning process with these injuries. E. Alkaline substances that cause these burns continue to cause tissue damage even after being neutralized

D, E

result from contact with electrical current that travels through the air from one conductor to another

Flash (arc) burns

Damage to all layers of skin Extends to muscle, tendons, and bones Black No blisters No edema Eschar hard and inelastic Heals within weeks to months Scarring Grafting

Deep full thickness

Damage to entire epidermis and deep into the dermis Red to white No blisters Moderate edema Eschar soft and dry Painful and sensitive to touch Heals in 2 to 6 weeks Scarring likely Possible grafting

Deep partial thickness

classify burns according to the layers of skin and tissue involved: superficial, partial, full, and deep full thickness

Depth of burn

result when an electrical current passes through the body and can cause severe damage, including loss of organ function, tissue destruction with subsequent need for amputation of a limb, and cardiac or respiratory arrest

Electrical burns

Resusciation phase: Glucose will be ___________ due to stress

Elevated

Begins with the injury and continues for 24-48 hours Priorities include securing the airway, supporting circulation and organ perfusion by fluid replacement, managing pain, preventing infection through wound care, maintaining body temperature, and providing emotional support

Emergent (resuscitative phase)

Can result from fluid shifts from the intercellular and intravascular space to the interstitial space. Additional findings include hypotension, tachycardia, and decreased cardiac output

Hypovolemia and shock

findings include singed nasal hair, eyebrows, and eyelashes, sooty sputum; hoarseness, wheezing; edema of the nasal septum; and smoke smelling breath. Indications of the impending loss of the airway include hoarseness, brassy cough, drooling or difficulty swallowing, and audible wheezing, crowing, and stridor

Inhalation damage

a more exact method estimating the extent of burn by the percentage of surface area of specific anatomic parts, particularly the head and legs

Lund and Browder Method

result from contact with hot liquid or steam. Scald injuries are more common in older adults and younger children

Moist heat injuries

most often results from therapeutic treatment for cancer or from sunburn

Radiation burns

Begins when most of the burn area has healed Ends when the client acheives the highest level of functioning possible Priorities include psychosocial support; prevention of scars and contractures; and resumption of activities,, including work, family, and social roles This phase can last for years

Rehabilitative

quick method to approximate the extent of burns by dividing the body into multiples of nine. The sum equals the TBSA.

Rule of nines

Damage to the entire epidermis and some parts of the dermis Pink to red Blisters Mild to moderate edema No eschar Painful Heals within 3 weeks No scarring, but minor pigment changes

Superficial partial thickness

Damage to epidermis Pink to red, no blisters, mild edema, no eschar Painful/tender Sensitive to heat Heals within 3 to 6 days No scarring

Superficial thickness

Minor burns provide______________, cleanse with mild soap and ___________ water (avoid excess friction), use antimicrobial ointment Apply a dressing (nonadherent, hydrocolloid) if clothing is irritating the burn Instruct the family to avoid using __________ lotions or ______ on the burn Determine the need for a ________ immunization

analgesics, tepid, greasy, butter, tetanus

Fluid remobilization: Hgb and Hct will be ___________ (hemodilution) due to the fluid shift from the interstitial space back into vascular fluid

decreased

Potassium _______ due to kidney loss and movement back into cells (hypokalemia)

decreased

Resusciation phase: Sodium will be ____________ due to third spacing (hyponatremia)

decreased

Sodium remains ______________ due to kidney and wound loss

decreased

Fluid remobilization: Blood glucose will be ______ due to the stress response

elevated

Resusciation phase: BUN levels will be __________ due to fluid loss

elevated

Resusciation phase: CBC Differential Hct and Hgb will be ___________ (hemoconcentration) due to the loss of fluid volume and the fluid shift into the intersitial space (third spacing)

elevated

Resusciation phase: Potassium will be _____________ due to cell destruction

elevated

Fluid remobilization: ABGs--slight ________ and metabolic ____________

hypoxemia, acidosis

Fluid remobilization: WBC count- will have an initial ______ then _______ with left shift

increase, decrease

Moderate and Major burns Sympathetic nervous system manifestations such as __________, ________ respiratory rate, _________ gastrointestinal motility, and ________blood glucose are expected findings Monitor ____________ rate and __________ Upper airway edema becomes pronounced ___ to ____ hr after the beginning of fluid resuscitation. Crowing, ___________, or dyspnea requires nasal or oral intubation

tachycardia, increased, decreased, increased, rate, depth, 8, 12, stridor

result when clothes ignite from heat or flames that electrical sparks produce

theraml burns