Integumentary & Burns NCLEX
An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage? 1. 22.5% 2. 31.5% 3. 36% 4. 40.5%
1. 22.5%
Which client are at risk for developing skin breakdown? SELECT ALL THAT APPLY 1. a client who is underweight 2. a client diagnosed with sinusitis 3. a client diagnosed with heart failure 4. a client diagnosed with spinal cord injury 5. a client diagnosed with benign prostatic hypertrophy
1. a client who is underweight 3. a client diagnosed with heart failure 4. a client diagnosed with spinal cord injury
The nurse prepares to assist in instructing a client about lyme disease. Which should the nurse include in the instructions? 1. it is caused by a tick carried by a deer 2. it is caused by contamination from cat feces 3. it is contagious by skin contact with an infected individual 4. it is caused by the inhalation of spores from bird droppings
1. it is caused by a tick carried by a deer
A client is receiving a full thickness graft to a burn on the hand. The nurse understands that a full thickness graft is being applied instead of a split-thickness graft because of which reason? 1. it provides better cosmetic results 2. it allows the extremity to be mobilized sooner 3. it allows the graft to be stretched to cover more area 4. it allows for wound exudate to be absorbed by the cover dressing
1. it provides better cosmetic results
The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristic of this type of lesion to be documented in the client's record? SELECT ALL THAT APPLY 1. lesion has waxy border 2. an irregularly shaped lesion 3. papule, with res, central crater 4. a small papule with a dry, rough scale 5. a firm nodular lesion topped with a crust
1. lesion has waxy border 2. an irregularly shaped lesion
An African American client has been admitted for a skin rash on his lower back. Which techniques should the nurse best rely on when assessing the skin rash? SELECT ALL THAT APPLY 1. palpation 2. induration 3. percussion 4. auscultation 5. visualization
1. palpation 2. induration
The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis , which should the nurse expect to note during data collection? 1. red, shiny skin around the nail bed 2. white, taut skin in the popliteal area 3. white ,silvery patches on the elbows 4. swelling of the skin near the parotid glad
1. red, shiny skin around the nail bed
Which should be the anticipated therapeutic outcome of a escharotomy procedure performed for a circumferential arm burn? 1. the return of distal pulses 2. decreasing edema formation 3. brisk bleeding from the injury site 4. the formation of granulation tissue
1. the return of distal pulses
A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet expecting which to be prescribed? SELECT ALL THAT APPLY 1. wound culture 2. antibiotic therapy 3. cold compresses 4. warm compresses 5. intermittent heat lamp treatments 6. alternating hot and cold compresses
1. wound culture 2. antibiotic therapy 4. warm compresses
The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection?SELECT ALL THAT APPLY 1. wound from repair of a perforated appendix 2. surgical wound after an open cholecystectomy 3. gunshot wound that punctured the small intestine 4. sterile wound resulting from a total radical mastectomy 5. traumatic wound to the abdomen and intentionally left open for several days 6. wound related to debridement of a chronic pressure injury resulting in a cavity like defect
1. wound from repair of a perforated appendix 3. gunshot wound that punctured the small intestine 5. traumatic wound to the abdomen and intentionally left open for several days 6. wound related to debridement of a chronic pressure injury resulting in a cavity like defec
The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for FURTHER teaching? 1. " i need to wear sunscreen when participating in outdoor activities" 2. " i need to avoid sun exposure before 10 a.m and after 4 p.m" 3." i need to wear a hat, opaque clothing, and sunglasses when in the sun" 4. " i need to examine my body monthly for any lesions that may be suspicious"
2. " i need to avoid sun exposure before 10 a.m and after 4 p.m"
The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for FURTHER teaching about the measures that will prevent the spread of infection? 1." i need to take the full course of the antibiotics" 2. " my clothes can be laundered with other household members" 3. " i must wash my hands thoroughly and frequently throughout the day" 4. " i need to wash my dishes and eating utensils separate from other household members"
2. " my clothes can be laundered with other household members"
The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury should be which percentage? 1. 31.5 % 2. 36% 3. 42% 4. 45%
2. 36%
The nurse inspects the skin of a client who is suspected of having psoriasis. Which findings should the nurse note if this disorder is present? 1. oily skin 2. silvery-white scaly lesions 3. patchy hair loss and round, red macules with scales 4. the presence of wheal patches scattered about the trunk
2. silvery-white scaly lesions
The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take action next in the care of this client? 1.get out a robe and slippers for the client 2. administer an opioid analgestic last taken 6 hours ago 3. immediately place the client on nothing by mouth 4. gather dressing supplies to send with the client to hydrotherapy
2. administer an opioid analgestic last taken 6 hours ago
The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which interventions in the plan of care to the client? SELECT ALL THAT APPLY 1. administering prescribed acyclovir 2. applying prescribed topical antibiotic 3. administering prescribed corticosteroid 4. administering prescribed oral amphotericin B 5. applying Domeboro solution to the affected skin
2. applying prescribed topical antibiotic 3. administering prescribed corticosteroid 5. applying Domeboro solution to the affected skin
The client recovering from a third-degree burn asks the nurse about grafts. The nurse explains to the client that the best type of graft is which? 1, allograft 2. autograft 3. xenograft 4. biosynthetic
2. autograft
The nurse is reinforcing instructions to a client on how to care for a punch biopsy site after the procedure is done. Which should the nurse include in the instructions? SELECT ALL THAT APPLY 1. leave the area open to air 2. change the bandage daily until site is healed 3. apply topical antibiotic ointment as prescribed 4. return to the office in 7 days for suture removal 5. take prescribed oxycodone as prescribed for pain
2. change the bandage daily until site is healed 3. apply topical antibiotic ointment as prescribed
The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure injury in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure injury? SELECT ALL THAT APPLY 1. utilize a rubber ring 2. clean with mild soap and water 3. encourage adequate nutritional intake 4. massage the area around the affected area 5. apply a dressing that allows oxygen to pass through
2. clean with mild soap and water 3. encourage adequate nutritional intake 5. apply a dressing that allows oxygen to pass through
The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client? 1. placing the affected leg flat 2. elevating and immobilizing the affected leg 3. immobilizing the client in a dependent position 4. placing the affected leg in a dependent position
2. elevating and immobilizing the affected leg
The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? SELECT ALL THAT APPLY 1. simple or (dermal) phase 2. inflammatory or (lag) phase 3.superficial or (intact skin) phase 4. rehabilitative ( recovery) phase 5. maturation or (remodeling) phase 6. proliferative or (connective tissue repair) phase
2. inflammatory or (lag) phase 5. maturation or (remodeling) phase 6. proliferative or (connective tissue repair) phase
The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas?SELECT ALL THAT APPLY 1. face 2. knees 3. elbows 4. abdomen 5. base of the spine
2. knees 3. elbows 5. base of the spine
The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, tjr client's vital signs include an oral temperature of 102.8 F, pulse of 98 beats per minute, respiration's of 24 breaths per minute, and blood pressure of 105/64.Parental nutrition is infusing at 82mL/hr. Based on these data, the nurse plans to initially perform which action? 1. recheck the vital signs in 1 hour 2. monitor the client for signs of infection 3. change the parenteral nutrition solution and IV tubing 4. determine when the client was last medicated for pain
2. monitor the client for signs of infection
The nurse is reviewing a focused assessment done on a client's integumentary system. Which physical examination assessments are related to inspection? SELECT ALL THAT APPLY 1. biopsy results 2. nails for shape, contour, color, thickness and cleanliness 3. skin for color, integrity, scars, lesions, and signs of breakdown 4. facial and body hair for distribution, color, quantity and hygiene 5. skin temperature , texture, moisture, thickness, turgor, and mobility
2. nails for shape, contour, color, thickness and cleanliness 3. skin for color, integrity, scars, lesions, and signs of breakdown 4. facial and body hair for distribution, color, quantity and hygiene 5. skin temperature , texture, moisture, thickness, turgor, and mobility
The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. positive patch test 2. positive culture results 3. abnormal biopsy results 4. wood's light examination indicative of infection
2. positive culture results
The nurse inspects a pressure injury on a client's sacrum and notes that the site has a partial thickness skin loss and the formation of a blister. The nurse should document the pressure injury as which category? 1. stage 1 2. stage 2 3. stage 3 4. stage 4
2. stage 2
A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client? 1. there is no pain associated with this procedure 2. the local anesthetic may cause a burning or stinging sensation 3. a preoperative medication will be given so you will be sleeping and will not feel any pain 4. there is some pain , but the health care provider will prescribe an analgesic following the procedure
2. the local anesthetic may cause a burning or stinging sensation
The nurse is reinforcing instructions to a client diagnosed with eczema about measures that decrease itching and moisturize the skin. Which should the nurse include in the instructions? SELECT ALL THAT APPLY 1. keep humidity at 10%to 12% 2. use moisturizers and sunscreen 3. wash new clothing before it is worn 4. use mild detergent and rinse cloths twice 5. maintain room temperature at 68 F to 75 F 6. wear open weave fabrics and loose clothing
2. use moisturizers and sunscreen 3. wash new clothing before it is worn 4. use mild detergent and rinse cloths twice 5. maintain room temperature at 68 F to 75 F 6. wear open weave fabrics and loose clothing
The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client? 1. cold compresses to the affected area 2. warm compresses to the affected area 3. alternating hot and cold compresses continuously 4. intermittent heat lamp treatments four times per day
2. warm compresses to the affected area
The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide? SELECT ALL THAT APPLY 1. sunscreen should be applied every 8 hours 2.use sunscreen when participating in outdoor activities 3. wear a hat, opaque clothing, and sunglasses when in the sun 4. avoid sun exposure in the late afternoon and early evening 5. examine your body monthly for any lesions that may be suspicious
2.use sunscreen when participating in outdoor activities 3. wear a hat, opaque clothing, and sunglasses when in the sun 5. examine your body monthly for any lesions that may be suspicious
The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for FURTHER teaching? 1. " i need to bathe using a mild soap and to rinse thoroughly" 2. " i need to avoid direct sunlight on the newly healed skin area" 3. " i should never wear clothing over the newly healed skin area" 4. " i need to avoid the use of lanolin products to the newly healed skin area"
3. " i should never wear clothing over the newly healed skin area"
The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruitus. Which client statement indicates the need for FURTHER teaching? 1. " i need to avoid using astringents on my skin" 2. " I should drink 8 to 10 glasses of water a day" 3. " i should use a dehumidifier, especially during the winter months" 4. " i should limit myself to one shower per day and apply an emollient to my skin after the shower"
3. " i should use a dehumidifier, especially during the winter months"
Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? 1. " i will apply the ointment once a day and leave it open to the air" 2. " i will apply the ointment twice a day and leave it open to the air" 3. " i will apply the ointment once a day and cover it with a sterile dressing" 4. " i will apply the ointment at bedtime and in the morning and cover it with a sterile dressing"
3. " i will apply the ointment once a day and cover it with a sterile dressing"
The nurse is reinforcing discharge instructions to a client who has a skin buopsy. Which statement by the client indicated the need for FURTHER teaching? 1. " i will use antibiotic ointment as prescribed" 2. i will return in 7 days to have sutures removed" 3. " i will remove the dressing when i get home and wash the site with tap water" 4. " i will call the health care provider if I see any drainage from the wound"
3. " i will remove the dressing when i get home and wash the site with tap water"
A client with a burn injury is scheduled for an autograft. The nurse planning care for the client immediately after the graft procedure. Which should the nurse include in the plan of care? SELECT ALL THAT APPLY 1. leaving the donor site open to air 2. immobilizing the graft area for 24 hours 3. administering pain medication prescribed 4. applying a pressure dressing on the grafted site 5. monitoring the donor site and the graft site for signs of infection
3. administering pain medication prescribed 5. monitoring the donor site and the graft site for signs of infection
A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporated which aspect of this medication? 1. can cause systemic effects 2. has a very agreeable odor 3. can stain the skin and hair 4. carries no risk of phototoxicity
3. can stain the skin and hair
The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome? 1. common 2. suggestive of anemia 3. characteristic of a thrush infection 4. indicative of a need to improve oral hygiene
3. characteristic of a thrush infection
The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equiptment? 1. patch test 2. skin biopsy 3. culture of the lesion 4. wood's light examination
3. culture of the lesion
A client is undergoing radiation therapy to treat lung cancer. Whch instructions should the nurse reinforce to the client with the regard to skin care? SELECT ALL THAT APPLY 1. place a thin film of lotion over the area daily 2. use a cold pack on the area if feeling discomfort 3. do not remove any of the markings for radiation treatment 4. use the hand to wash the affected area rather than a washcloth 5. shower or wash the area once a day using warm water and mild soap
3. do not remove any of the markings for radiation treatment 4. use the hand to wash the affected area rather than a washcloth 5. shower or wash the area once a day using warm water and mild soap
The client returns to the clinic for follow-up treatment after a skin biopsy is a suspicious lesion that was performed 1 week ago. The biopsy report indicated that the lesion is a melanoma. The nurse understands that which characteristic describes this type of lesion? SELECT ALL THAT APPLY 1. metastasis is rare 2. it is encapusulated 3. it is highly metastatic 4. it is characterized by local invasion 5. lesion is a nevus that has changed in color
3. it is highly metastatic 5. lesion is a nevus that has changed in color
The nurse is caring for a client on transmission based precautions who has herpes zoster, or shingles. Which are some of the MOST important skin issues associated with this condition?SELECT ALL THAT APPLY 1. there is no pattern or segmental assignment of the lesions 2. skin eruptions occur before any discomfort or pain appears 3. lesions are very contagious when they are fluid filled blisters 4. eruptions can last several weeks , and the severe pain (postherpetic neuralgia) often persist after the lesions have resolved 5. to reduce the risk of transmitting the virus to others. clients with lesions are separated from other clients until lesions have crusted
3. lesions are very contagious when they are fluid filled blisters 4. eruptions can last several weeks , and the severe pain (postherpetic neuralgia) often persist after the lesions have resolved 5. to reduce the risk of transmitting the virus to others. clients with lesions are separated from other clients until lesions have crusted
A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client? 1. "come to the emergency department" 2. " apply calamine lotion immediately to the exposed skin areas" 3. take a shower immediately , and lather and rinse several times" 4. " it is not necessary to do anything if you cannot see anything on your skin"
3. take a shower immediately , and lather and rinse several times"
The nurse documents that the client has a stage 2 pressure injury on the decubitius area. Which describes a stage 2 pressure ulecer? 1. the area has a deep crater like appearance 2. there is tissue necrosis with damage to the muscle 3. the ulcer is superficial and characterizes an abrasion 4. the area is red and does not blanch with external pressure
3. the ulcer is superficial and characterizes an abrasion
A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure , the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion? 1.this is a normal expectation 2. heat should be applied to the area 3. venous circulation is being impaired 4. the client is exhibiting generalized hypoxia
3. venous circulation is being impaired
A client , admitted to the emergency department , is suspected of having frostbite of the hands.Which finding should the nurse note in this condition? 1. a pink edematous hand 2. red skin with edema in the nail beds 3. white skin that is insensitive to touch 4. black fingertips surrounded by an erythematous rash
3. white skin that is insensitive to touch
A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure? 1. " i need to have clear fluids only on the morning of the test" 2. " i need to take my predinisone on the morning of the test" 3. " i need to shower on the morning of the test using povidoneiodine 4. " i need to stop taking my antihistamine 2 days before i come to the clinic for the test."
4. " i need to stop taking my antihistamine 2 days before i come to the clinic for the test."
A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response should the nurse give to the client's question? 1. " it's just a superficial infection" 2. " it is an inflammation of the lymphatic system" 3. " it is due to an infection caused by staphylocococcus" 4. " it is a skin infection that involves the deeper skin layers and subcutaneous fat"
4. " it is a skin infection that involves the deeper skin layers and subcutaneous fat"
After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "Feeling better overall." Which nursing intervention most likely contributed to the client's feelings? 1. pain management program 2. frequent comfort measures 3. dressing change twice daily 4. ambulation three times daily
4. ambulation three times daily
Which individual is least likely to be at risk for the development of Kaposi's sarcoma? 1. a renal transplant client 2. a male with a history of same- sex partners 3. a client receiving antineoplastic medications 4. an individual working in an environment in which exposure to asbestos is possible
4. an individual working in an environment in which exposure to asbestos is possible
A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with the early stage of cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should expect which assessment finding? 1. swelling in the genital area 2. swelling in the lower extremities 3. large open plaques in the facial area 4. appearance of reddish-blue lesions on the lower extremities
4. appearance of reddish-blue lesions on the lower extremities
The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription? 1. obtain blood cultures 2. administer antibiotics 3. administer acetaminophen for fever 4. apply cold compresses to the affected area
4. apply cold compresses to the affected area
A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy ? 1. rubbing the application into the skin 2. placing the area under a heat lamp for 20 min 3. applying a dry sterile dressing over the affected area 4. covering the application with warm , moist dressing and a occlusive outer wrap
4. covering the application with warm , moist dressing and a occlusive outer wrap
A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury? 1.decreased heart rate 2. increased urinary output 3. decreased blood pressure 4. elevated hematocrit levels
4. elevated hematocrit levels
The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? 1. a dependent position 2. elevation of the knees 3. flat, without elevation 4. elevation above the level of the heart
4. elevation above the level of the heart
A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for lyme disease. Which nursing action is appropriate? 1. tell the client that a blood test is needed immediately 2. inform the client that there is no test available for lyme disease 3. tell the client that testing in not necessary unless arthalgia develops 4. inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable
4. inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable
The client, diagnosed with Lyme disease stage 2 , ask the nurse " what is indicative of stage 2?" The nurse explains to the client that which sign or symptom is assessed in stage 2? 1. arthralgias 2. join enlargement 3. erythematous rash 4. neurological deficits
4. neurological deficits
The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nures expect to find when checking the client' sacral area? 1. intact skin 2. the presence of tunneling 3. a deep, crater-like appearance 4. partial-thickness skin loss of the epidermis
4. partial-thickness skin loss of the epidermis
The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition? 1. rapid and continual rewarming of the toes when flushing occurs 2. rapid and continual rewarming of the toes on cold water for 45 minutes 3. rapid and continual rewarming of the toes in hot water for 15 to 20 minutes 4. rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs
4. rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs
The nurse in a health care provider's office has scheduled a client with a possible allergen causing dermatitis to be seen in a 1 week for a patch test. The nurse explains the procedure for the patch test and includes which in the explanation? SELECT ALL THAT APPLY 1. an intradermal injection of allergens will be done 2. the results most likely will be evaluated in the office the next day 3. the skin will be scratched and the allergen dropped onto the area 4. the allergen will be placed on the skin and covered with an airtight dressing 5. a negative reaction occurs when there is no erythema, swelling or complaint of itching
4. the allergen will be placed on the skin and covered with an airtight dressing 5. a negative reaction occurs when there is no erythema, swelling or complaint of itching
The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse underdtands that moist desquamation is best described as which? 1. a rash 2. dermatitis 3. reddened skin 4. weeping of the skin
4. weeping of the skin
An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client;s clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn? WHAT %?
75%