Integumentary EAQ Level 1 and 2
A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aide station. The nurse encourages the client to seek medical attention but the client refuses. The nurse advises the person to go to a health care provider if: 1 Blisters appear. 2 Urinary output decreases. 3 Edema and redness occur 4 Low-grade fever develops.
Decreasing urinary output indicates hypovolemia that results from a fluid shift from the vascular space to the burned area. Blisters, edema and redness, and low-grade fever are expected with deep partial-thickness burns.
A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. For which clinical indicators associated with unresolved severe peripheral edema should the nurse assess the client? 1 Proteinemia 2 Contractures 3 Tissue ischemia 4 Thrombus formation
Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia. Proteinemia, contractures, and thrombus formation are not complications resulting from long-term edema.
Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client three days after admission? 1 Severe pain 2 Maintenance of sterility 3 Alteration in body image 4 Frequent dressing changes
The severe pain experienced by the client during débridement of burns places an emotional strain on the relationship. Maintaining sterility is not a problem if the nurse follows principles of surgical asepsis. According to Maslow, basic needs of survival and safety take precedence over higher-level needs. Pain becomes all-encompassing, and the nurse must help the client cope with it. Frequent dressing changes are not complete.
A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? 1 Oral 2 Topical 3 Intravenous 4 Intramuscular
Topical antibiotics are applied directly to the wound and are effective against many gram-positive and gram-negative organisms found on the skin. Although oral, intravenous, and intramuscular antibiotics may be administered, they are most effective for systemic rather than local infections; the vasculature in and around a burn is impaired and the medication may not reach the organisms in the wound.
A client with scleroderma complains of numbness and tingling in the hands followed by blanching of the fingers. The nurse concludes that the client has Raynaud's phenomenon, a condition commonly associated with scleroderma. The nurse plans to advise the client to: 1 Soak the hands frequently in hot water 2 Keep the hands warm by wearing gloves 3 Rub the hands briskly to increase circulation 4 Take the prescribed anticoagulants to prevent exacerbations
Raynaud's phenomenon is caused by vasospasm, precipitated by exposure to cold or emotional stress. Keeping the hands warm helps to limit episodes of Raynaud's phenomenon. Raynaud's phenomenon commonly is associated with scleroderma, a connective tissue disorder. Vasodilators, not anticoagulants, are prescribed to counteract vasospasm and increase blood flow.
A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should: 1 Cover the cast with plastic wrap until dry 2 Assist with weight bearing when the client ambulates 3 Elevate the affected leg above the level of the heart 4 Insert a finger inside the edges of the cast to check for skin abrasions
Elevating the affected leg will help reduce the formation of edema via the principle of gravity. Plastic wrap holds moisture and will interfere with drying of the cast. Full weight bearing should not start until prescribed by the health care provider. Nothing should be inserted under the cast; this can cause tissue injury.
A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. Considering this finding, the nurse should assess the client for: 1 Dehydration 2 Dry brittle hair 3 Prolonged wound healing 4 Clubbing of the fingertips
Adequate intake of protein, carbohydrates, vitamin C, and minerals is necessary for tissue building and wound healing. There are no data to conclude dehydration; although the client is not eating, the client may be drinking fluids. Dry brittle hair will take a prolonged period of time; it will not occur during a short period. Clubbing of the fingertips is associated with prolonged hypoxia.
A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data? 1 Weights every day 2 Urinary output every hour 3 Blood pressure every 15 minutes 4 Extent of peripheral edema every 4 hours
A client with extensive burns has an indwelling urinary catheter so that urine output can be measured hourly. Urinary output reflects circulating blood volume; it is the most reliable, immediately available information to assess fluid needs. Although daily weights reflect fluid retention or loss, they are not as immediately accurate as hourly urine measurements. A blood pressure reading may indicate hypervolemia or hypovolemia, but it is not as accurate an indicator of fluid replacement as hourly urine output. Peripheral edema may have many causes; it is not an effective indicator of fluid balance.
The nurse is planning the care for a client with a body surface burn injury of 55%. The nurse understands that clients with burn injuries: 1 Are prone to poor healing because of a hypermetabolic state. 2 Have a decreased risk of infection when in a hypermetabolic state. 3 Need a cool environment to decrease caloric need. 4 Will need 20 calories/kg during the healing process.
Burn injuries cause a hypermetabolic state. This results in lipid and protein catabolism, which in turn can inhibit wound healing. A hypermetabolic state does not cause a risk for wound healing directly; if a person in a hypermetabolic state does not receive enough calories and protein, it predisposes them to poor wound healing, which in turn would place them at risk for infection. Cooling the environment would cause an increase in caloric need as the body tries to warm to core temperature. Clients with burn injuries require increased calories and protein to promote wound healing. For an adult client, 20 calories/kg does not provide an adequate increase of calories/protein.
A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. What is the best nursing intervention when providing wound care? 1 Use a consistent approach to care and encourage participation. 2 Prepare equipment while doing the procedure and explain the treatment to the client. 3 Heat the water to 105º F to prevent loss of body temperature and prepare the equipment before starting. 4 Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done.
Client participation provides for a sense of control, and a consistent approach provides a routine with no surprises; these approaches may limit pain and promote adherence to the regimen. Preparation of the equipment and explanation of the procedure should be performed before the procedure; when performed during the procedure, it wastes time, which can prolong pain and increase anxiety. Heating the water to 105º F to prevent loss of body temperature is too hot; the water should be approximately 100º F. Changing staff disrupts the client's routine and sense of trust.
A health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. What principle does the nurse determine is in operation when the application of local heat transfers temperature to the body? 1 Radiation 2 Insulation 3 Convection 4 Conduction
Conduction is the conveyance of energy such as heat, cold, or sound by direct contact. Direct contact is not necessary to convey heat by radiation. Insulation refers to retention of heat, not its transfer. Convection is the transfer of heat by air circulation (e.g., by fans or open windows).
When the exposure method of treatment is used for burns, the nurse explains to the client that: 1 Bathing will not be permitted 2 Dressings will be changed daily 3 Isolation precautions will be required while hospitalized 4 Room temperature will be kept below 72° F
Isolation precautions are essential for the prevention of infection in clients with burns; policies and procedures include specific interventions related to standard and transmission-based precautions, medical asepsis, surgical asepsis, and room assignments. Hydrotherapy in a large tank tub may be used to clean burn wounds. Dressings are not used with the exposure method. Clients are more comfortable with a room temperature of 85° F.
For which clinical manifestation should the nurse assess a client with metastatic melanoma? 1 Oily skin 2 Nikolsky sign 3 Lymphadenopathy 4 Erythema of the palms
Lymphadenopathy occurs in clients with malignancies that have metastasized. The skin generally is dry and itchy. Nikolsky sign (external layer of the skin becomes detached from the basal layer when rubbed by slight friction) occurs in clients with pemphigus, not melanoma. Erythema of the palms is not a symptom of melanoma (Cirrhosis).
The nurse is caring for a client who returns from surgery with a catheter that is attached to a portable wound drainage system exiting from the surgical site. The principle underlying the function of a portable drainage system is: 1 Gravity 2 Osmosis 3 Active transport 4 Negative pressure
The negative pressure of a portable wound drainage system exerts a sucking force that pulls fluid toward the collection chamber. Gravity is the environmental force that pulls weight toward the center of the earth. An indwelling urinary catheter uses the principle of gravity to draw fluid from the bladder to the collection bag held below the level of the bladder. Osmosis occurs when a solvent moves from a solution of lesser concentration to one of greater solute concentration when the two solutions are separated by a semipermeable membrane; fluid moving from the interstitial compartment into the intracellular compartment uses osmosis. Active transport occurs when ions move across a cell membrane against a concentration gradient with the assistance of metabolic energy; sodium and potassium ions move into and out of cells via active transport (sodium-potassium pump).
A client is scheduled to receive irradiation to the chest wall after a tumor was removed from the client's lung. When teaching skin care to the client, the nurse emphasizes: 1 Keeping the skin dry to protect it from excoriation 2 Massaging the skin four times a day to increase circulation 3 Using skin lotion twice daily to keep the skin supple 4 Washing the area frequently to remove desquamated cells
The skin is the first line of defense; keeping it dry and safe from injury promotes skin integrity. Massage is traumatic because irradiated skin is fragile and subject to blistering and sloughing. The skin should be free of emollients because they change the angle or degree of radiation. Irradiated skin is fragile; if soap is used, a film left after rinsing can change the angle and intensity of radiation.
A client is admitted to the burn unit with partial-thickness burns over 30% of the body surface area. Twenty-four hours later, the client, who has an IV of 5% dextrose in saline running, has tremors, twitching, and signs of disorientation. During the past hour the urinary output was 110 mL. What should the nurse do next? 1 Slow the IV rate and notify the health care provider. 2 Slow the IV rate and check the last chest x-ray film. 3 Increase the IV rate and assess the arterial blood gases. 4 Increase the IV rate and request a prescription for calcium gluconate.
Tremors, twitching, and signs of disorientation are signs of water intoxication, which may proceed to pulmonary edema; the health care provider should be notified. During the resuscitation/emergent phase of burn recovery the client will experience hyperkalemia, hyperchloremia, and hyponatremia.
A client is admitted with 50% of the body surface area burned after an industrial explosion and fire. The client's serum albumin is 1.5 g/dL, the hematocrit is 30%, the urine specific gravity is 1.025, and the serum globulin is 3 g/dL. When evaluating the client's response to fluid replacement, the nurse should prepare to administer a colloid when the: 1 Globulin is 3 g/dL 2 Albumin is below 2 g/dL 3 Hematocrit is below 32% 4 Urine specific gravity is 1.018
Administration of a colloid is indicated when the serum albumin decreases below 2 g/dL; then, albumin must be administered to increase the level to the expected range of 3.5 to 5.5 g/dL. This increases the oncotic pressure and prevents the shift of fluid out of the intravascular compartment. A globulin of 3 g/dL is within the expected parameters of 2.3 to 3.4 g/dL. A hematocrit level of 32% is low and indicates overhydration; administration of a colloid will increase this problem. The urine specific gravity is within the expected limits of 1.010 to 1.030.
A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent? 1 Colitis 2 Gastritis 3 Stress ulcer 4 Metabolic acidosis
An ulcer of the upper gastrointestinal tract is related to excessive secretion of stress-related hormones, which increases hydrochloric acid production. Histamine H2 antagonists decrease acid secretion. Colitis is not a complication of burns. Gastritis is not a complication of burns. Metabolic acidosis is not a complication of burns unless hypermetabolism or renal failure occurs; metabolic acidosis is not treated with H2 antagonists.
A nurse is caring for a client admitted for removal of basal cell carcinoma and reconstruction of the nose. About which contributing factor should the nurse question the client when collecting a health history? 1 Dietary patterns 2 Familial tendencies 3 Amount of tobacco use 4 Ultraviolet radiation exposure
Basal cell carcinoma, the most common type of skin cancer, is linked most closely to solar ultraviolet radiation. Diet is not a risk factor. Although skin type is a genetically determined risk factor, it cannot be altered and it is influenced by solar ultraviolet radiation. Smoking is not a risk factor.
A female client arrives in the emergency department with partial-thickness burns on the chest, abdomen, and leg. The priority nursing intervention is to: 1 Carefully remove the client's clothing 2 Evaluate for inhalation injury 3 Apply sterile saline dressings on burned surfaces 4 Calculate total body surface area that has been burned
Heat inhalation can cause edema of the respiratory lumina, interfering with oxygenation; evaluation of respiratory status is a priority. The health care provider first assesses the client's adaptations to the burn injury and then prescribes the appropriate therapies. Only then would the nurse apply sterile saline dressings if they were prescribed. Carefully removing the client's clothing and calculating total body surface area that has been burned are done after the client's respiratory status is evaluated.
A client was admitted with full-thickness burns two weeks ago. Since admission, the client has lost an average of a pound of weight each day. The nurse expects the client's diet to be adjusted to include: 1 Low-sodium milk 2 High-protein drinks 3 Foods that are low in potassium 4 Ten percent more calories in the form of fats
High-protein drinks have twice the calories per volume of other fluids and provide protein for wound healing. Low-sodium milk does not contain adequate calories to help meet the high metabolic rate associated with burns. Potassium is restricted during the first 48 to 72 hours after a burn injury, not two weeks after the injury. Increased calories in the form of protein and carbohydrates, not fats, are needed.
A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. The nurse's best response is: 1 "This type of schedule gives noncancerous cells time to recover." 2 "The department only operates from Monday through Friday." 3 "Your energy level will be increased greatly by a five-day schedule." 4 "Side effects are eliminated when treatment is administered for five rather than seven days."
Both malignant and healthy cells are affected by radiation; time between courses of treatments allows normal cells to repair. Staff are available if necessary for a treatment protocol; many facilities operate seven days a week. Fatigue occurs in either a five- or seven-day schedule. Some side effects are inevitable, although they vary with each individual.
