HESI Prep: Integumentary System

A client is admitted for malignant melanoma that was discovered during a routine eye examination. Which treatment would the nurse expect to be scheduled for the client?

Enucleation - Malignant melanoma of the eye is an intraocular tumor that metastasizes rapidly; therefore enucleation (removal of the eye) is the treatment of choice. Radiation may be used. Cryosurgery, chemotherapy, and antibiotics are not routinely used as treatments.

Which benign tumor forms on the surface of the client's epithelium?

Papilloma - A papilloma is a benign tumor that forms on the surface of the epithelium. A fibroma forms on the fibrous tissue. An adenoma forms on the glandular epithelium. A chondroma forms on the cartilage.

The nurse is caring for a client with burns receiving opioid analgesics and who is sedated. Which medications would the nurse anticipate to be prescribed to overcome this side effect of the opioid analgesics? Select all that apply. One, some, or all responses may be correct.

Pregabalin + Gabapentin - Pregabalin and gabapentin are adjuvant analgesics used to overcome the side effects caused by opioid analgesics. Morphine is an opioid analgesic used in the treatment of pain that can cause sedation. Lorazepam and midazolam are anxiolytic agents used to inhibit anxiety.

While assessing the skin of a client, the nurse notices that the skin does not return to the normal position immediately after a gentle pinch. Which conditions would be a cause of this? Select all that apply. One, some, or all responses may be correct.

aging, cachexia + dehydration - Tenting is an integumentary condition that refers to the failure of skin to return immediately to normal position after gentle pinching (skin turgor). Causes for tenting include aging, dehydration, or a severe malnutrition referred to as cachexia. Liver failure and sun exposure have no role in tenting. Liver failure can lead to jaundice or telangiectasia. Sun exposure can lead to skin cancer.

Which laboratory result would the nurse check to evaluate a client's fluid loss from extensive burns?

Hematocrit (Hct) - An increased Hct level indicates hemoconcentration secondary to fluid loss. The BUN level may be used to indicate dehydration from burns, but interpretation can be complicated by other conditions accompanying burns that also cause an increase in the BUN. An increase in the sedimentation rate indicates the presence of an inflammatory process, not fluid loss. The pH level reflects acid-base balance.

A client sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention but the client refuses. The nurse would instruct the client to go see a primary health care provider if which change occurs?

Urinary output decreases - Decreasing urinary output indicates hypovolemia that results from a fluid shift from the vascular space to the burned area. Blisters, edema and redness, and white patches are expected with deep partial-thickness burns.

In which area does the carcinoma in this image most commonly occur?

Site where moles are evident - The image signifies melanoma. These pigmented cancers may arise in melanin-producing epidermal cells. Melanoma most commonly occurs at the place where moles or birthmarks are evident. Basal cell carcinomas include a pearly papule with a central crater that mostly occurs in the sun-exposed areas. Squamous cell carcinomas may be found at the sites of such chronic irritation as scars, irradiated skin, burns, and leg ulcers. Actinic keratosis may develop on the back of the hands.

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct.

Wearing a medical alert bracelet, Initiating bleeding precautions, Refraining from estrogen therapy, Obtaining routine prothrombin times, Notifying providers of anticoagulation - A client taking anticoagulants would be instructed to wear a medical alert bracelet and take bleeding precautions, such as shaving with an electric razor. A client taking anticoagulants should be advised to refrain from estrogen therapy because this can lead to clot formation. All clients on anticoagulation therapy need to have routine prothrombin time testing and need to inform all health care providers of their anticoagulant use.

The nurse is teaching first aid to a group of community members. A participant asks which first aid should be administered, after calling 911, to a person who suffers extensive burns. Which response by the nurse is appropriate?

"Cover the burned areas with a bed sheet because this provides protection." - The appropriate response is to cover the newly burned skin areas with a clean, dry bed sheet while awaiting emergency assistance and after calling 911. This will provide protection by limiting contamination by microorganisms and preventing exposure to air, which increases pain. Ice can cause additional tissue damage. Cream is difficult to remove and may result in additional damage. Doing nothing does not meet the individual's immediate needs.

Based on the condition of the client in this image, which instruction would the nurse give the client? (photo shows hand with pigmentation spots)

"Keep track of any pigmented lesions." - The image signifies the presence of liver spots that occur due to changes in pigmentation. It is the hyperplasia of melanocytes, especially in sun-exposed areas. The nurse would teach the client to keep a record of pigmented lesions. Skin taping is avoided in case of skin transparency and fragility. Sun exposure should be avoided from 10:00 AM to 4:00 PM due to the high intensity of sunlight during these hours. Calcium supplements along with vitamin D decrease the risk of osteomalacia.

Which instruction would the nurse give to a client with reduced sensory perception?

"Use a bath thermometer." - A change in sensory perception may occur because of a physical change in the dermis. The client must be taught to use a bath thermometer to prevent scalds. Applying moisturizers is taught in case of decreased dermal blood flow to prevent dryness. The nurse advises the client to dress warmly in cold weather if the client is at increased risk for hypothermia. The client is advised to avoid frequent bathing if there is increased susceptibility to dry skin.

A client is recovering from full-thickness burns, and the nurse provides counseling on how to best meet nutritional needs. Which client food selections indicate to the nurse that the client understands the teaching?

Cheeseburger and a milkshake - Of the selections offered, a cheeseburger and a milkshake have the highest calories and protein, which are needed for the increased basal metabolic rate associated with burns and for tissue repair. Although orange juice provides vitamin C, beef barley soup does not provide adequate protein or calories. A bacon and tomato sandwich and tea do not provide an adequate amount of calories and protein; nor do a chicken salad sandwich and a soft drink.

Arrange the order of pathophysiology involved with the development of pressure ulcers on the sacrum, hips, and ankles of a client with quadriplegia.

local tissue compression → restriction of blood flow → reduced tissue perfusion → local cell death → development of pressure ulcer - Quadriplegic clients are immobile or wheelchair bound and incapable of changing position without assistance; therefore they have more chances of developing pressure ulcers. Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and oxygenation and, eventually, leading to cell death and the development of pressure ulcers.

Arrange the steps of applying negative pressure wound therapy in order of implementation.

1) Clean the wound. 2) Cut the foam dressing to the dimensions of the wound. 3) Apply a large occlusive dressing. 4) Make a small hole in the occlusive dressing over the foam dressing near the tubing attachment. 5) Connect the tubing to a pump. - While using negative pressure wound therapy for wound healing, the first step is to clean the wound. The second step is to cut the foam dressing to the dimensions of the wound. Third, a large occlusive dressing is applied. The fourth step is to make a small hole in the occlusive dressing over the foam dressing near the tubing attachment. Finally, the tubing is connected to a pump.

Which changes with a client's hair would be responsible developing white hair at the age of 23?

Decreased melanocytes - White hair appears in a client when a decrease in melanin and melanocytes occurs. Dry, coarse hair occurs when there is a decrease in oils. Thinning and loss of hair are due to decreased hair density. Facial hirsutism is due to decreased levels of estrogens.

The nurse is caring for a client who had a colostomy 36 hours ago. Which nursing intervention is the priority?

Observing for drainage and the condition of the abdominal stoma - Because of the recent trauma of surgery, hemorrhage and infection at the operative site can occur, so the priority nursing interventions are observing for surgical site drainage and monitoring the abdominal stoma condition. The client will have nothing by mouth until peristalsis returns, so there may not be any oral intake and this is not the priority intervention. Although emphasizing diet regulation to form stool and teaching incision care and colostomy irrigation could be performed at this time, observing for bleeding and infection has a higher priority during the first 48 hours after surgery.

Five days after a client has abdominal surgery the nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports that the client is experiencing wound dehiscence?

Serosanguineous drainage (blood + serum) - Serosanguineous drainage from the wound or on the dressing forewarns about separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Bowel sounds have no relationship to wound status; bowel sounds are expected around the third or fourth postoperative day as intestinal peristalsis returns. Loosening of sutures may occur after the initial wound edema subsides but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.

The nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate?

Slowing of a previously rapid pulse - The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. Decreasing CVP readings indicate hypovolemia. Urinary output of 15 to 20 mL/h indicates inadequate kidney perfusion; if fluid replacement is adequate, the urinary output should be more than 30 mL/h. A hematocrit level increasing from 50% to 55% indicates hypovolemia and increased hemoconcentration.

When reestablishing a Jackson-Pratt drain after emptying its contents, the nurse squeezes the collection container and recaps the drain. Which rationale for this action is accurate?

To restore suction - Closed suction drains such as Hemovac and Jackson-Pratt produce suction by means of compression and reexpansion of the system. A T-tube drains bile. Compression does not prevent infection. A Penrose drain works by gravity.

The nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which clinical findings to this disease would the nurse expect the client to exhibit? Select all that apply. One, some, or all responses may be correct.

butterfly facial rash + inflammation of the joints - The connective tissue degeneration of SLE leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the cheek region. Polyarthritis occurs in most clients, with joint changes similar to those seen in rheumatoid arthritis. Firm skin fixed to tissue occurs in scleroderma; in an advanced stage the client has the appearance of a living mummy. Muscle mass degeneration occurs in muscular dystrophy; it is characterized by muscle wasting and weakness. Inflammation of small arteries occurs in polyarteritis nodosa, a collagen disease affecting the arteries and nervous system.

Which skin growth would require health care provider follow-up to evaluate for possible skin cancer? Select all that apply. One, some, or all responses may be correct.

mole that is 12 mm wide - Melanomas are detected using the "ABCDE" method: asymmetry, border irregularity, color, diameter, and evolving. A mole that is 12 mm wide would need further assessment by the health care provider. Moles greater than 6 mm in diameter can indicate a melanoma. Moles that are solid black, have equal borders, are symmetrical, and have not changed would not be suspicious for melanoma and can be monitored.