Integumentary disorder practice questions memory

Which method of assessing burn size applies only to adults?

- Rule of nines

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?

-ambulation three times daily

a patient complains that he has basal cell carcinoma and is going to die, The nurse knows that:

-basal carcinoma is rarely terminal

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which of the following?

-punch biopsy of the cutaneous lesion

A nurse is assigned to assist in caring for a client with frostbite of the toes. Which of the following would the nurse anticipate to be prescribed for this condition?

-rapid and continual warming of the toes in a warm water bath until flushing of the skin occurs.

A nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during data collection?

-red shiny skin around the nail bed

During the inspection of a client's skin, the nurse notes redness and an abrasion type wound on the sacrum area. The nurse determines that this finding is indicative of a:

-stage 2 pressure ulcer

A nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse categorizes the ulcer as:

-stage II

The physician has scheduled a debridement for a patient who has partial-thickness burns on his chest and the right upper right leg. Which nursing intervention is most important?

-administer an opioid analgesic intravenously before debridement

The most common symptoms of scabies is

-nocturnal pruritus

which of the following assessments should the nurse report to the physician immediately for an adult patient with partial thickness burns over 25% of his body?

-hourly urinary output of 10 to 15 mL

Using the rule of nines, calculate the burn percentage for the client. Refer to the figure; the burned area is the darkly shaded area ( anterior side of the body including the genitalia)

-19%

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?

take a shower immediately and lather and rinse several times

The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which of the following should the nurse anticipate as being prescribed for the client?

- 100% oxygen via a tight fitting non-breather face mask

A nurse is caring for a client with circumferential burns of both legs. Which of the following leg positions is appropriate for this type of a burn?

- Elevation above the level of the heart

A nurse reinforces instructions to a client diagnosed with impetigo. Which statement by the client indicates a need for further instructions?

- I can my laundry with other household members' items

A nurse reinforces instruction to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by the client indicates further instruction?

- I need to avoid sun exposure BEFORE 10 am and after 4 pm

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 provides instructions to the client regarding preparation of the test. Which statement by the client indicates an understanding regarding the preparation for this procedure?

- 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. The nurse bases the response on the understanding that the characteristics of cellulitis include

- a skin infection into the deep dermis and subcutaneous fat.

A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. The nurse interprets this data as:

- a superficial injury to tissue from the radiation

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face ( the anterior half of the face) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent m=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 injury?

-36

A 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 would be which of the following?

-36%

An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client's upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, what would be the percent of the burn injury? Refer to the figure.

31.5%

A client sustains a burn injury to the entire right and left arms, right leg, and anterior thorax. According to the rule of nines, the nurse would determine that this injury constitutes which of the following body percentages?

54%

Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

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?

Covering the application with a warm, moist dressing and an occlusive outer wrap

A 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 instructions?

I should never wear warm clothing over the newly healed skin area

A nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which of the following client statements indicates the need for further instructions?

I should use a dehumidifier, especially during the winter months."

A patient has an inhalation burn injury. Which of the following is a medical emergency?

-Respiratory stridor

Which of the following would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

- the return of distal pulses

Which of the following individuals would be at the greatest risk for development of an integumentary disorder?

- an outdoor worker

A client has sustained full-thickness circumferential burns of the trunk. Which of the following should be the priority concern of the nurse?

- client's ability to adequately ventilate

A nurse reinforces instructions to a client who is to return to the health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?

- discontinue the prescribed antihistamine 2 days before the test.

A nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further instruction?

- if the patch come off I need to reapply it.

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?

- inform the client he will need to return in 4-6 weeks to be tested, because testing at this time is not reliable

A nurse prepares to assist in instructing a client about prevention of Lyme disease. Which of the following would the nurse include in the instructions?

- it is cause by tick carried by a deer

A client return to the clinic for a follow up treatment after biopsy of a suspicious lesion that was performed 1 week ago, The biopsy reports indicate that the lesion is a melanoma. The nurse understands that which of the following describes a characteristics of this type of a lesion?

- it is highly metastatic

A nurse inspect eh skin of the client who is suspected of having scabies. Which of the following findings would the nurse note if this disorders was present?

- multiple straight or wavy threadlike lines beneath the skin

The nurse reviews home care instructions with a client diagnosed with impetigo. Which statement indicates that the client does not understand the measures that will prevent the spread of infection?

- my clothes can be laundered with other household members' clothes

An evening nurse reviews the nursing documentation in the clients chart and notes that the day day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which of the following would the nurse expect to note when checking the client's sacral area?

- partial thickness skin loss of the epidermis

A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what "heterograft" means. The appropriate response to the client is:

- skin from another species

A nurse notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area of a client on bedrest. The nurse documents these findings as a:

- stage II pressure ulcer

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should the nurse's first action be?

- use the edge of a sterile surgical tool to scrape out the stinger

A nurse is told that an assigned client is suspected of having scabies. Which of the following precaution will the nurse institute during the care of the client?

- wear a gown and gloves

A client sustains a burn injury to the anterior right and left legs and perineal area. According to the rule of nines, the nurse would determine that this injury constitutes which of the following body percentages?

-19%

A nurse who is employed in a long term care facility is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

-An experienced nursing assistant who has never had chicken pox

An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. On data collection of the client, which of the following would indicate that the client sustained a respiratory injury as a result of the burn?

-use of accessory muscles for breathing

A nurse is caring for a client with a skin infection who is receiving amoxicillin (Amoxil) 500 mg every 8 hours. Which of the following indicates to the nurse that the client is experiencing a frequent side effect related to the medication?

-vaginal drainage

A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse notes that the flap has a slightly blue hue. The nurse concludes:

-venous circulation impaires

A nurse has reinforced discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further instruction?

I will remove the dressing when I get home and wash the site with tap water

The patient tells the nurse she has not gone out of the house for weeks because she could not cover her lesions on her face with makeup. the most appropriate nursing diagnosis would be

-disturbed body image, related to change in personal appearance

A nurse is assisting in caring for a client with a severe burn who has just received an autograft to the knee area of the right leg. The nurse plans to keep the right leg positioned in which manner?

-elevated and immobilized

A nurse is caring for a client after an autograft and grafting of a burn wound on the right knee. Which of the following would the nurse anticipate being prescribed for the client?

-elevating and immobilizing the affected leg

A client asks the nurse about the causes of acne. The nurse most appropriately responds by telling the client

-the exact cause of acne is unknown

It is important to teach the patient the warning signs of skin cancer. Which is the warning sign of skin cancer?

-Border irregularity

A client with a major burn is admitted to the emergency department. The nurse anticipates that which of the following medication routes will be prescribed for analgesics for this client?

-Intravenous

The nurse just finished as assessment for a patient with SLE. Which clinical manifestation would the nurse expect to find?

-Oral ulcers and erythematous rash over the nose

The nurse is assessing her clients for skin breakdown. Which of the following clients would have the lowest priority for concern in the development of skin breakdown?

-a client with a lowered mental awareness status

A patient is admitted with herpes zoster. The nurse should plan to administer which medication on a frequent basis?

-acyclovir (Zovirax)

A nurse is caring for a client with a diagnosis of pemphigus vulgaris. The nurse understands that a characteristic of this condition is

-blistering skin

An electric burn must be assessed for

-cardiac irregularities

A nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which first?

-peripheral pulses

A nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day post-injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially:

-monitor the client for signs of infection

Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which of the following is most indicative of this stage?

-neurological deficits

A client has a non-infected pressure ulcer on the left heel. The nurse should use which of the following sterile solutions to cleanse the wound as part of a dressing change procedure?

-normal saline

A nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should immediately:

-notified the registered nurse

A nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area would provide the best information?

-palm of the hands

A client with jaundice is complaining of pruritus. Which of the following strategies should the nurse institute to help control the problem and prevent injury?

-pat the skin, dry after bathing

The patient has a rash on her back that began about 10 days ago with a raised, scaly border and a pink center. Now she has a similar eruptions on both sides of her back, From these signs, the nurse would determine the rash to be:

-pityriasis rosea

The physicians instruct a mother to tale her child out in the sun for approx an hour or until the skin turned re (not sunburned). This is a common medical treatment for

-pityriasis rosea

The most important nursing intervention for the patient with a skin disorder is:

-prevention of secondary infections

It is most important to assess adolescent with acne for :

-low self esteem

the physician ha ordered griseofulvin for tinea capitis. the mother asks the nurse why an oral medication is used rather than a cream. The best reply is that:

-topical cream DO NOT reach the root of the hair to kill the fungus

A nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse determines that this occurrence:

-is a characteristics of a thrush

A client arrives at the emergency department and has experienced frostbite to the right hand. Which of the following would the nurse note when performing data collection regarding the client's hand?

- a white color of the skin, which is insensitive to touch

A nurse is reviewing the health care record of a client with a lesion that has been diagnosed as a malignant melanoma. The nurse would expect which characteristic of this type of lesion to be documented in the clients record.

- an irregular shaped lesion

A nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to do which of the following next in the care of this client?

-administer an opioids analgesics last taken 6 hours ago

A nurse is preparing a client for skin grafting and notes that the health care provider has documented that the client is scheduled for a heterograft. The nurse understands that a heterograft used for the burn client is skin from:

-another species

A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing a problem with which of the following?

-appearance

A new student nurse, whose mother recently died from malignant melanoma, asks the faculty member" what can I do prevent malignant melanoma from developing?" the best response by the faculty member is

- avoiding excessive sun exposure will decrease risk

A parent tells the dermatologist that her daughter seems to be losing interest in school. which medication could have caused the patient's change in behavior

-Isotretinoin (accutane)

a nurse is reviewing the history for a patient who has been admitted with cellulitis. Which condition would predispose the patient to cellulitis?select all that apply

-Malnutrition and substance abuse -treatment with steroids or chemotherapy

A 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?

-applied cold compress to the affected area

a black patient is being seen with impending shock after an accident. How would the nurse expect the skin to appear during the assessment of the patient

-ashen, gray or dull

A client comes to a health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick?

-bullseye rash

An older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. Which combination of dietary items would the nurse encourage the client to eat to promote wound healing?

-chicken breast, broccoli, strawberries, milk

A nurse is assigned to care for a client with herpes zoster. Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection?

-clustered skin vesicles

A client who sustained an inhalation injury arrives in the emergency department. On data collection of the client the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing:

-hypoxia

On admission, a patient is noted to have impaired skin integrity related to severe dermatitis. Which nursing intervention to enhance patient comfort should be included when planning the patient care. select all that apply

-keeping the environment cool -using cool compress -using bath oils to decrease dryness.

The nurse's assessment shows that the patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. In the documentation, the nurse would chart this as a

-papule

when inspecting the skin. the nurse remembers that the skin provides a primary

-protective device against microorganisms

A patient admitted with partial thickness burns on his upper chest and face. It would be most important for the nurse to initially monitor the patient for

-respiratory problems

A patient who has developed a severe contact dermatitis of the lower extremities states" the itching is terrible, I just cannot keep from scratching" which statement should the nurse include in teaching patient. Select all that apply

-take cool or tepid baths several times daily to decrease pruritus -use cool, wet cloths or dressing to reduce itching -use an OTC antihistamine with sedative effects to reduce scratching

a 28 year old electrical lineman is brought to the emergency department after coming in contact with a live overhead wire. He has two quarter size burns on his right hand. He is admitted to the hospital. What is the most important rationale for admission to the hospital?

-the evident skin injury seldom represents the full extent of the damage

when teaching home care to a patient with concurrent herpes simplex genitalis infection, it is important to include that

-the patient will need to use protection even when no lesions are evident

when teaching a patient to care for herpes zoster lesion at home, the most important instruction for the nurse to give is

-wash hands for at least 1-2 mins before applying the medication

The nurse planning a care for the patient who has impetigo expects to administer which topical drug to the patient?

retapamulin

A nurse is checking the skin on a client who is immobile and notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents this finding as a pressure ulcer of which stage?

-stage 2

A patient with thermal burns over 30% of his body has maintained a urinary output of 250 mL for the past 8 hours. From this information, the nurse might suspect that the

-stage of hypovolemic burn shock is resolving

A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which action is contraindicated as the nurse delivers care to this client?

-keeping the client in a supine position

A nurse prepares to care for a client with acute cellulitis of the lower leg. Which of the following would the nurse anticipate being prescribed for the client?

-warm compresses to the affected area

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition?

-white skin that is sensitive to the touch

A nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse would anticipate which of the following signs in the client?

-tachycardia

A patient is admitted with partial and full thickness burns on his right lower extremity. Plan for the patient to have a

-temporary skin cover

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse makes which response to the client?

-the local anesthetic may cause a burning stinging sensation

A nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full thickness burn injuries of the back and legs. The nurse understand that which of the following would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?

- Urine output

A nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burn to the face and chest. The nurse notes a hoarse cough and that the client is expectorating sputum with black flecks. The client's eyelashes and eyebrows are singed, and the eyelids are swollen. The client suddenly becomes restless, and his color becomes dusky. The nurse interprets this data as indicating which of the following?

- The burn has probably caused laryngeal edema which has occluded that airway.

A client is brought to the emergency department immediately following a smoke inhalation injury. The initial nursing action is to prepare the client to receive:

- a 100% humidified oxygen by face mask

Which of the following individuals is least likely at risk for the development of psoriasis?

- a 32 year old african american

A patient complains of a burning pain on his lower thoracic area. On inspection, the area is found to be very erythematous and edematous with a cluster of vesicles. the nurse suspect the patient has:

-herpes zoster

A nurse prepares to help a health care provider examine the client's skin with a Wood's light. Which of the following would be included in the plan for this procedure?

-darken the room for the examination

A nurse notes that the health care provider has documented a diagnosis of herpes zoster in the client's chart. On the basis of an understanding of the cause of this disorder, the nurse would determine that this diagnosis was made after the use of which diagnostic test?

-culture of the lesion