Integumentary System
A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? 1 Client with shock 2 Client with anemia 3 Client with epilepsy 4 Client with peripheral vascular disease
3. Client with epilepsy A client with epilepsy does not have any circulatory inadequacy. Therefore the capillary refill time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-positive result). A client with shock has decreased oxygen saturation levels that further prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood circulation for clients with anemia, peripheral vascular disease, or diabetes.
A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which should the nurse conclude is an appropriate classification for these burns? 1 Eschar 2 Full-thickness 3 Deep partial-thickness 4 Superficial partial-thickness
3. Deep partial-thickness In deep partial-thickness burns, destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis occur. Eschar, a dry, leathery covering of denatured protein, occurs with full-thickness burns. In full-thickness burns, total destruction of the epidermis, dermis, and some underlying tissue occurs. In superficial partial-thickness burns, the epidermis is destroyed or injured, and a portion of the dermis may be injured.
The registered nurse is teaching the student nurse about precautions to take when treating a client with open burn wounds. Which statement made by the student nurse indicates the need for further teaching? 1 "I should use non-sterile gloves when applying ointments." 2 "I should use non-sterile, disposable gloves when removing old dressings." 3 "I should wear personal protective equipment before caring for the client." 4 "I should remove personal protective equipment before leaving one client to treat another."
1. "I should use non-sterile gloves when applying ointments." Sterile gloves are used when applying ointment to the open burn wounds. When removing contaminated dressings and washing the dirty wound, non-sterile, disposable gloves are used. When treating the client, personal protective equipment like disposable gowns and gloves are used. To prevent cross-contamination, the nurse should remove the personal protective equipment before leaving one client to treat another.
While assessing the skin of an older adult, the nurse finds redundant flesh around the eyes. Which changes in the skin are responsible for this condition? Select all that apply. 1 Decrease in muscle laxity 2 Increase in capillary fragility 3 Decrease of subcutaneous fat 4 Decrease of extracellular water 5 Increase in focal melanocytes in basal layer
1. Decrease in muscle laxity 3. Decrease of subcutaneous fat Redundant flesh around the eyes is due to a decrease in muscle laxity and a decrease of subcutaneous fat. Bruising is due to an increase in capillary fragility. Dry, flaking skin with possible signs of excoriation is due to a decrease of extracellular water. Solar lentigines on the face and backs of hands are due to an increase in focal melanocytes in the basal layer.
The registered nurse (RN) delegates the tasks of caring for a client with pressure ulcers. The client suffers further tissue necrosis during treatment. What could be the reason for this condition? 1 Cleaning of the wound by the registered nurse (RN) 2 Performing irrigation of the wound by the patient care associate (PCA) 3 Administering of oral analgesics by the licensed practical nurse (LPN) 4 Repositioning the client every 1-2 hours by the licensed practical nurse (LPN)
2. Performing irrigation of the wound by the patient care associate (PCA) The patient care associate (PCA) is not authorized to irrigate the wound as improper technique can lead to tissue damage. The RN is qualified to perform wound care; therefore, cleaning the wound is not likely to lead to tissue necrosis. Pressure ulcers are associated with pain. The LPN administering oral analgesics may relieve the pain, but it will not cause tissue necrosis. Having the licensed practical nurse (LPN) reposition the client every 1 or 2 hours will minimize the risk of tissue necrosis due to pressure ulcers.
Which topical immunomodulator is used to treat a client with atopic dermatitis? 1 Mupirocin 2 Tacrolimus 3 Clindamycin 4 Erythromyci
2. Tacrolimus Tacrolimus is used to treat atopic dermatitis. Mupirocin is used to treat impetigo. Clindamycin and erythromycin are used to treat acne vulgaris.
When changing a postoperative client's dressing, the nurse is careful not to introduce microorganisms into the incision. What type of asepsis includes this principle? 1 Wound asepsis 2 Medical asepsis 3 Surgical asepsis 4 Concurrent asepsis
3. Surgical asepsis A surgical incision is a portal of entry, so a technique that requires the absence of all microorganisms (surgical asepsis) is essential. Wound asepsis is incorrect terminology. Medical asepsis uses clean technique to minimize the spread of microorganisms; this is insufficient when there is a break in the skin. Intact skin is the first line of defense against the entry of microorganisms. Concurrent asepsis is incorrect terminology. Concurrent disinfection refers to measures initiated to control the spread of infection while an infection is present.
A carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scarred forever." What is the nurse's best initial response? 1 "The staff is taking steps to minimize scarring." 2 "Think about how lucky you are. You are alive." 3 "Try not to worry for now. Concentrate on your range-of-motion exercises." 4 "I know you're worried, but it is too early to tell how much scarring will occur."
4. "I know you're worried, but it is too early to tell how much scarring will occur." The response "I know you're worried, but it is too early to tell how much scarring will occur" is a truthful answer and validates the client's feelings. Although true, the response "The staff is taking steps to minimize scarring" shuts off communication and further ventilation of feelings. The response "Think about how lucky you are. You are alive" denies the client's fears. The response "Try not to worry for now. Concentrate on your range-of-motion exercises" denies the client's feelings.
A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching? 1 Placing the old dressing in a plastic bag 2 Changing the dressing without wearing a mask 3 Donning nonsterile gloves for removing the old dressing 4 Using a back-and-forth motion while cleaning the wound
4. Using a back-and-forth motion while cleaning the wound Each swipe with sterile gauze should be discarded, and another sterile gauze should be used for the next swipe. Placing the old dressing in a plastic bag confines the soiled dressing to a leakproof bag, which prevents contamination of the environment or others. A mask is not necessary. Nonsterile gloves are acceptable for dressing removal because the dressing is contaminated.
A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. Considering this finding, what should the nurse assess the client for? 1 Dehydration 2 Dry brittle hair 3 Prolonged wound healing 4 Clubbing of the fingertips
1. Dehydration Adequate intake of protein, carbohydrates, vitamin C, and minerals is necessary for tissue building and wound healing. There are no data to conclude that dehydration has occurred; 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 providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Select all that apply. 1 Eat foods high in vitamin C. 2 Take your temperature daily. 3 Balance periods of rest and activity. 4 Use a strong soap when washing the skin. 5 Expose the skin to the sun as often as possible.
1. Eat foods high in vitamin C. 2. Take your temperature daily. 3. Balance periods of rest and activity.
A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply. 1 Scaly lesions 2 Pruritic lesions 3 Reddened papules 4 Multiple petechiae 5 Erythematous macules
1. Scaly lesions 2. Pruritic lesions 3. Reddened papules Psoriasis is characterized by dry, scaly lesions that occur most frequently on the elbows, knees, scalp, and torso. Pruritus is generally mild. Sharply defined reddened papules or plaques covered by scales occur because of dermal inflammation; the inflammation occurs because of an abnormal growth of epidermal cells related to an autoimmune reaction. Petechiae are not characteristic of psoriasis. Macules are erythematous flat spots on the skin, as in measles.
Which fungal infection in a client is commonly referred to as athlete's foot? 1 Tinea pedis 2 Tinea cruris 3 Tinea corporis 4 Tinea unguium
1. Tinea pedis Tinea pedis is a fungal infection commonly known as athlete's foot. Tinea cruris is jock itch. Tinea corporis is ringworm. Tinea unguium is onychomycosis.
A client with systemic lupus erythematosus is taking prednisone. The nurse anticipates that the steroid may cause hypokalemia. Taking into consideration food preferences, the nurse encourages the client to eat which food? 1 Broccoli 2 Oatmeal 3 Fried rice 4 Cooked carrots
1. Broccoli Potassium is plentiful in green leafy vegetables; broccoli provides 207 mg of potassium per half cup. Oatmeal provides 73 mg of potassium per half cup. Rice provides 29 mg of potassium per half cup. Cooked fresh carrots provide 172 mg of potassium per half cup; canned carrots provide only 93 mg of potassium per half cup.
A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care? 1 Cool, moist towels 2 Dry, sterile dressings 3 Analgesic sunburn spray Incorrect4 Vitamin A and D ointment
1. Cool, moist towels Cool, moist towels will decrease edema and minimize pain. Dry dressings, when removed, may further damage the burn site. Although pain is temporarily alleviated, removal of the spray is necessary before further treatment can be instituted; removal may cause injury. Ointments are contraindicated on burns because they have an oil base.
The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue? 1 Red and swollen 2 Blistered and wet 3 Charred and white 4 Leathery and black
2. Blistered and wet Deep partial-thickness burns involve some injury to the epidermis and dermis, characterized by fluid-filled vesicles that are red, shiny, and wet. Red and swollen describes a superficial partial-thickness burn. The characteristics charred and white, and leathery and black describe a full-thickness burn.
A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take? 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.
3. Elevate the affected leg above the level of the heart. 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 primary healthcare provider. Nothing should be inserted under the cast; this can cause tissue injury.
Which description could be related to zosteriform-type lesions? 1 Wide distribution 2 Diffuse distribution 3 Bilateral distribution 4 Band-like distribution
4. Band-like distribution Band-like distribution of lesions would be termed as zosteriform-type lesions. Diffuse-type lesions are described as the wide distribution of the lesions. Generalized-type lesions are identified by the diffused distribution of the lesions. Symmetric-type lesions are the bilateral distributions of the lesions.
A nurse is caring for a client with chronic occlusive arterial disease. Which precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions? 1 Emotional stress, which is short lived 2 Poor hygiene and adequate protein intake 3 Stimulants such as coffee, tea, or cola drinks 4 Trauma from mechanical, chemical, or thermal sources
4. Trauma from mechanical, chemical, or thermal sources Diminished sensation decreases awareness of injury. Injured tissue cannot heal properly because of cellular deprivation of oxygen and nutrients; ulceration and gangrene may result. Emotional stress does not cause tissue injury; however, because of vasoconstriction, it may prolong healing. Inadequate hygiene is only one stress that may cause tissue trauma; adequate protein is not related to this disease. Although caffeine stimulates the peripheral vessels to constrict, limiting oxygen to cells, it is not the major cause of ulceration.
A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? 1 Vitamin C aids in the process of epithelialization. 2 Vitamin C helps in the synthesis of immune factors. 3 Vitamin C increases the metabolic energy required for inflammation. 4 Vitamin C is required for collagen production by fibroblasts.
4. Vitamin C is required for collagen production by fibroblasts. Vitamin C aids in capillary synthesis and collagen production by fibroblasts. Vitamin A aids in the process of epithelialization. Protein helps in the synthesis of immune factors. Carbohydrates increase the metabolic energy required for inflammation.
A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at what angle? 1 30 degrees 2 45 degrees 3 60 degrees 4 90 degrees
1. 30 degrees Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. Forty-five degrees, 60 degrees, and 90 degrees raise the head of the bed too high, which contributes to the client sliding down in bed.
A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? (Select all that apply.) 1 Butterfly facial rash 2 Firm skin fixed to tissue 3 Inflammation of the joints 4 Muscle mass degeneration 5 Inflammation of small arteries
1. Butterfly facial rash 3. 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 malar 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.
The nurse is teaching a client about self-management to prevent dry skin. Which statement made by the client indicates the need for further teaching? 1 "I should use nonalkaline soap for a bath." 2 "I should apply rubbing alcohol to the skin." 3 "I should avoid clothing that continuously rubs the skin." 4 "I should use a room humidifier during the winter months."
2. "I should apply rubbing alcohol to the skin." To prevent dry skin, rubbing alcohol is contraindicated because alcohol increases skin dryness. Use of nonalkaline soap for bathing prevents dry skin. Avoid clothing that continuously rubs the skin such as tight belts and nylon stockings. Use room humidifiers during winter months because skin is drier in winter.
After surgery for cancer, a client is to receive chemotherapy. When teaching the client about the side effects of chemotherapy, the nurse emphasizes what about the occurrence of alopecia? 1 It is usually rare 2 It is not permanent 3 It is frequently prolonged 4 It is sometimes preventable
2. It is not permanent Once the drugs that interfere with cell division are stopped, the hair will grow back; sometimes the hair will be a different color or texture. Alopecia is a common side effect of chemotherapy. Hair loss persists while the drugs are being received; once the drugs are withdrawn, the hair grows back. Although ice caps on the head and rubber bands around the scalp have been used to try to limit alopecia, they have not been particularly effective.
During a physical assessment, the nurse notes cutaneous fibromas and Lisch nodules (yellow elevations) on a client's irises. What genetic condition might this client have? 1 Phenylketonuria 2 Neurofibromatosis 3 Huntington disease 4 Myotonic dystrophy
2. Neurofibromatosis Cutaneous fibromas and Lisch nodules (yellow elevations on the iris) are signs of neurofibromatosis. Growth failure, frequent vomiting, irritability, hyperactivity, and erratic behavior are signs of phenylketonuria. Huntington disease is a progressive neurodegenerative disease. Muscle weakness, wasting, myotonia, and cardiac conduction abnormalities are signs of myotonic dystrophy.
A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? 1 Bananas 2 Strawberries 3 Green beans 4 Sweet potatoes
2. Strawberries Strawberries contain 88 mg of vitamin C (ascorbic acid) per cup. One banana contains 12 mg of ascorbic acid. One cup of green beans contains 21 mg of ascorbic acid. One baked sweet potato contains 25 mg of ascorbic acid.
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 what happens? 1 Blisters appear 2 Urinary output decreases 3 Edema and redness occur 4 Low-grade fever develops
2. 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 low-grade fever are expected with deep partial-thickness burns.
A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching? 1 "I should inspect the client's skin daily." 2 "I should manage the client's incontinence as quickly as possible." 3 "I should properly dispose of the client's contaminated dressings." 4 "I should not worry about what the client eats."
4. "I should not worry about what the client eats." The nurse should teach the caregiver about the role that good nutrition plays in enhancing a client's healing to correct this misconception. All the other statements are correct and require no further teaching. The nurse should teach the caregiver to conduct daily skin inspections. The nurse should instruct the caregiver about how to manage a client's incontinence and how to properly dispose of contaminated dressings.
The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person that suffers extensive burns. An appropriate response by the nurse is to call 911 and do what? 1 Apply ice to burned areas; the intervention will decrease pain 2 Use first aid cream to burned areas 3 Do nothing; attempting to treat the burned areas may cause further damage 4 Cover the burned areas with a bed sheet
4. Cover the burned areas with a bed sheet A bed sheet is not fuzzy and is nonadhering, and will keep the person warm. 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.
A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What should the nurse expect to identify when assessing this client? 1 Weight loss 2 Hypoglycemia 3 Decreased blood pressure 4 Inadequate wound healing
4. Inadequate wound healing Because the anti-inflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention, but also alterations in fat, carbohydrate (CHO), and protein metabolism. Persistent hyperglycemia (steroid diabetes) occurs because of altered glucose metabolism. Hypertension, not hypotension, occurs as a result of sodium and fluid retention.
