MedSurg Integumentary Test

Client arrives in ED after being burned in house fire. Client's burns cover face & left forearm. What extent of burns does client most likely have, measured as a percentage?

ANS: 18, 18% Rationale: When estimating % of body area or burn surface area that has been burned, Rule of Nines is used: face is 9% & forearm is 9%, for total of 18% in this client.

Nurse on a burn unit is caring for client who experienced burn injuries 2 days ago. Client now showing s/s of airway obstruction, despite appearing stable since admitted. How should client's change in status be best understood? A. Client likely exper delayed onset of respiratory complications B. Client likely developed a systemic infect C. Client's respiratory complications likely r/t psychosocial stress D. Client likely experiencing an anaphylactic react to med

ANS: A Rationale: Airway obstruction caused by upper airway edema can take as long as 48hrs to develop. Systemic infect would be less likely to cause resp complications. This problem more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but is less likely than a response to initial injury.

Nurse is caring for client in emergent/resuscitative phase of burn injury. During this phase, te nurse should monitor for evidence of what alteration in lab values? A. Sodium deficit B. Decreased prothrombin time(PT) C. Potassium deficit D. Decreased HCT

ANS: A Rationale: Anticipated fluid & electrolyte changes that occur during emergent/resuscitative phase of burn injury=sodium deficit, potassium excess, & elevated hematocrit. PT does not typically decrease.

A burn client is transitioning from acute phase of injury to rehabilitation phase. Client tells nurse, "I can't wait to have Sx to reconstruct my face so I look like I used to." What would be nurse's best response? A. "That's something you & your doctor will likely talk abt after your scars mature." B. "That's something for you to talk to your doctor abt bc it's not a nursing responsibility." C. "I know this is really imp to you, but you have to realize no one can make you look like you used to." D. "Unfortunately, it's likely these scars will look like this for rest of your life."

ANS: A Rationale: Burn reconstruction is Tx option after all scars have matured & discussed w/in 1st few yrs after injury. Even tho this is not nursing responsibility, nurse should still respond appropriately to client's query. It is true client will not realistically look like he/she used to, but this does not instill hope.

An unresponsive client w/a light complexion brought to ED by EMS. While assessing client, nurse notes client's face is a cherry-red color. What should nurse suspect? A. Carbon monoxide poisoning B. Anemia C. Jaundice D. Uremia

ANS: A Rationale: Carbon monoxide poisoning causes bright cherry red color in face & upper torso w/light-skin ppl. In dark skin ppl, will be cherry-red color in nail beds, lips, & oral mucosa. When anemia occurs w/light-skin ppl, skin has generalized pallor. Anemia w/dark-skin ppl manif as yellow-brown coloration. Jaundice appears as yellow coloration of sclerae. Uremia gives yellow-orange tinge to skin.

55yr-old woman is scheduled to have chemical face peel. Nurse is aware client is likely seeking tx for which of following? A. Wrinkles near lips & eyes B. Removal of acne scars C. Vascular lesions on cheeks D. Real or perceived misshaping of eyes

ANS: A Rationale: Chemical face peeling is esp useful for wrinkles at upper & lower lip, forehead, & periorbital areas. Chemical face peeling does not remove acne scars, remove vascular lesions, or reshape eyes.

Nurse in an ambulatory care center is admitting older adult client w/bright red moles on skin. What benign changes in skin of older adult appear as bright red moles? A. Cherry angiomas B. Solar lentigines C. Seborrheic keratoses D. Xanthelasmas

ANS: A Rationale: Cherry angiomas appear as bright red "moles," while solar lentigines commonly called "liver spots." Seborrheic keratoses=described as crusty brown "stuck on" patches, while xanthelasmas appear as yellowish, waxy deposits on upper eyelids.

Client has been dx w/psoriasis & freq has lesions around his right eye. What should nurse teach client abt topical corticosteroid use on these lesions? A. Cataract devel is possible. B. Ointment likely to cause weeping. C. Corticosteroid use contraindicated on these lesions. D. Client may develop glaucoma.

ANS: A Rationale: Clients using topical corticosteroid preparations repeatedly on face & around eyes should be aware cataract devel is possible. Weeping & glaucoma less likely. There is no consequent risk of glaucoma.

Client w/HIV sought care bc of recent devel of new skin lesions. Nurse should interpret these lesions most likely suggestive of what situation? A. Reduction in client's CD4 count B. Reduction in client's viral load C. Adverse effect of antiretroviral therapy D. Virus-induced changes in allergy status

ANS: A Rationale: Cutaneous signs may be 1st manifest of HIV, appearing in>90% of HIV-infected ppl as immune funct deteriorates. These skin signs correlate w/low CD4 counts & may become very atypical in immunocompromised ppl. Viral load^, not decreases, as disease progresses. Antiretrovirals not noted to cause cutaneous changes, & viruses don't change individual's allergy status.

Client has been admitted to burn ICU w/extensive full thickness burns over 25% of body. After ensuring cardiopulmonary stability, what would be nurse's immediate, priority concern when planning this client's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

ANS: A Rationale: During early phase of burn care, nurse most concerned w/fluid resuscitation, to correct large-volume fluid loss thru damaged skin. Infect control & early nutrit support are imp, but fluid resuscitation is immediate priority. Coping is higher priority later in recovery period.

Nurse conducting health interview & assessing for integumentary condit known to have genetic component. What assessm question is most appropriate? A. "Does anyone in your family have eczema or psoriasis?" B. "Have any of your family been dx w/malignant melanoma?" C. "Do you have family hx of vitiligo or port-wine stains?" D. "Does any member of your family have hx of keloid scarring?"

ANS: A Rationale: Eczema & psoriasis known to have a genetic component. This isn't true of any of other listed integumentary disorders.

Client in emergent/resuscitative phase of burn injury had blood work & ABGs drawn. Upon analysis of client's lab studies, nurse will expect results to indicate what findings? A. Hyperkalemia, hyponatremia, elevated HCT B. Hypokalemia, hypernatremia, decreased HCT C. Hyperkalemia, hypernatremia, decreased HCT D. Hypokalemia, hyponatremia, elevated HCT

ANS: A Rationale: Fluid & electrolyte changes in emergent/resuscitative phase of burn injury=hyperkalemia r/t release of K+ into extracellular fluid, hyponatremia from large amounts of Na lost in trapped edema fluid, & hemoconcentration that leads to increased HCT.

Nurse in ED is triaging 5yr-old brought to ED by parents for an outbreak of urticaria. What would be most appropriate question to ask this client's parents? A. "Has your child eaten any new foods today?" B. "Has your child bathed in past 24hrs?" C. "Did your child go to a friend's house today?" D. "Was your child digging in dirt today?"

ANS: A Rationale: Foods can cause skin reactions, esp in children. In most cases, this is more plausible cause of urticaria than bathing, contact w/other children, or soil-borne pathogens.

Client's blistering disorder has resulted in formation of multiple lesions in client's mouth. What intervention should be included in client's plan of care? A. Provide chlorhexidine solut for rinsing client's mouth. B. Avoid providing regular mouth care until client's lesions heal. C. Liaise w/primary provider to arrange for parenteral nutrit. D. Encourage client to gargle w/hypertonic solut after each meal.

ANS: A Rationale: Freq rinsing of mouth w/chlorhexidine solut prescribed to rid mouth of debris & soothe ulcerated areas. Hypertonic solut likely to cause pain & further skin disruption. Meticulous mouth care should be provided & there's no reason to provide nutrition parenterally.

Client who is in acute phase of recovery from burn injury has yet to experience adeq pain control. What pain management strategy is most likely to meet this client's needs? A. Client-controlled analgesia(PCA) system B. Oral opioids supplemented by NSAIDs C. Distraction & relaxation techn supplemented by NSAIDs D. Combo of benzodiazepines & topical anesthetics

ANS: A Rationale: Goal of Tx=prov long-acting analgesic that will prov even coverage for long-term discomfort. Helpful to use escalating doses when initiating med to reach level of pain control acceptable to client. Use of client-controlled analgesia(PCA)gives control to client & achieves goal. Clients cannot nrmlly achieve adeq pain control w/o use of opioids, & parenteral admin usually required.

Client is brought to ED w/a burn injury. Nurse knows the first systemic event after a major burn injury is what event? A. Hemodynamic instability B. GI hypermotility C. Respiratory arrest D. Hypokalemia

ANS: A Rationale: Initial syst event after major burn injury=hemodynamic instability, which results from loss of capillary integrity & subseq shift of fluid, Na, & protein from intravascular space into interstitial spaces. This precedes GI changes. Resp arrest may or may not occur, largely depending on presence or absence of smoke inhalation. Hypokalemia doesn't take place in initial phase of recovery.

While waiting to see HCP, client shows nurse skin areas that are flat, nonpalpable, & have had change of color. Nurse recognizes client is demonstrating: A. macules. B. papules. C. vesicles. D. pustules.

ANS: A Rationale: Macule=flat, nonpalpable skin color change, Papule=elevated, solid, palpable mass. Vesicle=circumscribed, elevated, palpable mass containing serous fluid, Pustule=pus-filled vesicle.

80yr-old client is brought to clinic by one of her children. Client asks nurse why she has gotten so many "spots" on skin. What would be an appropriate response by nurse? A. "As people age, nrmlly develop uneven pigmentation in skin." B. "These 'spots' are called 'liver spots' or 'age spots.'" C. "Older skin is more apt to break down & tear, causing sores." D. "These are usually result of nutritional deficits earlier in life."

ANS: A Rationale: Major changes in skin of older ppl=dryness, wrinkling, uneven pigmentat, & various proliferat lesions. Stating names of spots & IDing older adults' vulnerability to skin damage don't answer question. Lesions aren't nrmlly result of nutrit imbal.

Nurse is providing self-care education to client receiving tx for acne vulgaris. What instruction should nurse provide to client? A. "Wash face w/water & gentle soap each morning & evening." B. "Before bedtime, clean face w/rubbing alcohol on cotton pad." C. "Gently burst new pimples b4 they form a visible 'head'." D. "Set aside some time each day to squeeze blackheads & remove plug."

ANS: A Rationale: Nurse should inform client to wash face & other affected areas w/mild soap & water twice each day to remove surface oils & prev obstruction of oil glands. Cleansing w/rubbing alcohol not recommended & all forms of manipulation should be avoided.

ED nurse has just received a client w/burn injuries brought in by ambulance. Paramedics have started a large bore IV & covered burn in cool towels. Burn is estimated as covering 24% of client's body. How should nurse best address pathophysiologic changes resulting from major burns during initial burn-shock period? A. Admin IV fluids. B. Admin broad-spectrum antibiotics. C. Admin IV potassium chloride. D. Admin packed RBCs.

ANS: A Rationale: Pathophysiologic changes resulting from major burns in initial burn-shock period=massive fluid losses. Addressing losses=major priority w/initial phase of Tx. Abx & PRBCs not nrmlly given. K+ chloride would exacerbate client's hyperkalemia.

Public health nurse is educating group of administrators about decreasing hospitalizations for burns. Which population will nurse note as target population for burn injuries? A. Older adults B. Women more than men C. Adults 35-40yrs of age D. School-aged teenagers

ANS: A Rationale: Population most at risk for hospitalization=older adults. Statistically men have higher incidence of burns over women. Adults from 35-40yrs of age not shown to have high prevalence. School-aged teenagers don't have higher prevalence of burns w/hospitalization than aging population.

Nurse is caring for client dx w/psoriasis. Nurse is creating education plan for client. What info should be included in this plan? A. Lifelong management is likely needed. B. Avoid public places until sympt subside. C. Wash skin freq to prevent infect. D. Liberally apply corticosteroids as needed.

ANS: A Rationale: Psoriasis usually requires lifelong management. Psoriasis isn't contagious. Many clients need reassurance that condition isn't infectious, not reflection of poor personal hygiene, & not skin cancer. Excessive freq washing of skin produces more soreness & scaling. Overuse of topical corticosteroids can result in skin atrophy, striae, & med resistance.

Client presents at free clinic w/black, wart-like lesion on his face, stating, "I've done some research, & I'm pretty sure I have malignant melanoma." Subsequent diagnostic testing results in dx of seborrheic keratosis. Nurse should recognize what significance of this Dx? A. Client requires no tx unless he finds lesion to be cosmetically unacceptable. B. Client's lesion will be closely observed for 6mths before plan of tx is chosen. C. Client has one of few dermatologic malignancies that respond to chemo. D. Client will likely require wide excision.

ANS: A Rationale: Seborrheic keratoses are benign, wart-like lesions of various sizes & colors, ranging from light tan to black. There's no harm in allowing these growths to remain bc there's no medical signif to their presence.

Client w/Vit D defic is receiving education from nurse. What would be an appropriate recommendation by nurse? A. Spend time outdoors at least twice per wk. B. Increase intake of leafy green vegetables. C. Promote intake of clear fluids. D. Eat red meat at least once per wk.

ANS: A Rationale: Skin exposed to UV light can convert subst necessary for synthesizing Vit D(cholecalciferol). It's estimated most ppl need 5-30mins of sun exposure twice a wk in order for synthesis to occur. ^intake of water not r/t resolving VitD defic. VitD is unrelated to meat & vegetable intake.

Nurse is preparing to assist surgeon in skin grafting procedure. What can a skin graft can be used for? A. Denuded skin after burns. B. Slow healing wounds. C. Uncomplicated wound closure. D. Infected wounds.

ANS: A Rationale: Skin grafts commonly used to repair surgical defects like those that result from excision of skin tumors, to cover areas denuded of skin(e.g., burns), & to cover wounds in which insufficient skin is available to permit wound closure. Are also used when primary closure of wound increases risk of complications or when primary wound closure would interfere w/funct. Not used for uncomplicated wound closure. Skin grafts not used for infected wounds.

Outer layer of epidermis provides most effective barrier to penetration of skin by environmental factors. Which of following is an example of penetration by an environmental factor? A. An insect bite B. Dehydration C. Sunburn D. Excessive perspiration

ANS: A Rationale: Stratum corneum(outer layer of epidermis)provides most effective barrier to both epidermal water loss & penetration of environmental factors(chemicals, microbes, insect bites, & other trauma) Dehydration, sunburn, & excessive perspiration not examples of penetration of an environmental factor.

ED nurse learns from paramedics the team is transporting a client who has suffered injury from a scald from hot kettle. What variables will nurse consider when determining depth of burn? A. Causative agent B. Client's pre-injury health status C. Client's prognosis for recovery D. Circumstances of the accident

ANS: A Rationale: The following factors considered in determining depth of burn=how injury occurred, causative agent(flame or scalding liquid), temp of burning agent, duration of contact w/agent, & thickness of skin. Client's pre-injury status, circumstances of accident, & prognosis for recovery are imp, but not considered when determining depth of burn.

Nurse is caring for client w/dx of bullous pemphigoid & being tx on medical unit. Nurse knows that systemic tx will most likely include which element? A. Corticosteroid therapy B. Skin biopsy C. Topical corticosteroids D. Penicillin therapy

ANS: A Rationale: Tx for bullous pemphigoid includes system corticosteroid therapy. This wouldn't include skin biopsy as this is for diagnostics. Topical corticosteroids don't tx systemically. Goal of therapy=respond to inflam, not to tx infect.

As nurse expects, bite is elevated & has serous fluid contained in dermis. How would nurse classify this lesion? A. Vesicle B. Macule C. Nodule D. Wheal

ANS: A Rationale: Vesicle=primary elevated skin lesion & has fluid contained in dermis. Examples of vesicles=blister or insect bite. Wheals, macules, & nodules are not characterized by elevation & presence of serous fluid.

Nurse has reported for a shift at a busy burns & plastics unit in a large university hospital. Which client is most likely to have life-threatening complications? A. 4yr-old scald victim burned over 24% of body B. 27yr-old male burned over 36% of his body in car accident C. 39yr-old female client burned over 18% of body D. 60yr-old male burned over 16% of body in brush fire

ANS: A Rationale: Young children & older adults cont to have increased morbidity & mortality when compared to other age groups w/ similar injuries & present challenge for burn care. This is imp factor when determining severity of injury & poss outcome for client.

Client is admitted to burn unit after being transported a long distance. Client has burns to groin area & circumferential burns to both upper thighs. When assessing client's legs distal to wound site, nurse should be cognizant of risk of what complication? A. Ischemia B. Referred pain C. Cellulitis D. Venous thromboembolism(VTE)

ANS: A Rationale: As edema increases, pressure on small blood vessels & nerves in distal extremities causes obstruction of blood flow & consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, & VTE not noted complications that occur distal to injury site.

Client experienced an electrical burn & developed thick eschar over burn site. Which of following topical antibacterial agents will nurse expect HCP to order for the wound? A. Silver sulfadiazine 1%(Silvadene)water-soluble cream B. Mafenide acetate 10%(Sulfamylon)hydrophilic-based cream C. Silver nitrate 0.5% aqueous solution D. Acticoat

ANS: B Rationale: Mafenide acetate 10% hydrophilic-based cream is agent of choice when there's a need to penetrate thick eschar. Silver products do not penetrate eschar. Acticoat is a type of silver dressing.

Nurse educator is teaching group of nurses about Kaposi sarcoma. What would educator ID as characteristics of endemic Kaposi sarcoma? Select all that apply. A. Affects ppl predominantly in eastern half of Africa B. Affects men more than women C. Does not affect children D. Cannot infiltrate E. Can progress to lymphadenopathic forms

ANS: A, B, E Rationale: Endemic(African)Kaposi sarcoma affects ppl predominantly in eastern half of Africa, near equator. Men affected more often than women, & children can be affected too. Disease may resemble classic KS or may infiltrate & progress to lymphadenopathic forms.

Client is in acute phase of burn injury. One of nursing Dx in plan of care is Ineffective Coping R/t Trauma of Burn Injury. What interventions appropriately address this Dx? Select all that apply. A. Promote truthful communication. B. Avoid asking client to make decisions. C. Teach client coping strategies. D. Admin benzodiazepines as prescribed. E. Provide positive reinforcement.

ANS: A, C, E Rationale: Nurse can assist client to devel effec coping strategies by setting specif expectations for behavior, promoting truthful communicat to build trust, helping client practice approp strategies, & giving positive reinforcement when approp. Client may benefit from being able to make decisions regarding his/her care. Benzos may be needed for short-term management of anxiety, but not used to enhance coping.

Client's burns have required a homograft. During nurse's most recent assessment, nurse observes the graft is newly covered w/purulent exudate. What is nurse's most appropriate response? A. Perform mechanical debridement to remove exudate & prev further infect. B. Inform PCP promptly bc graft may need to be removed. C. Perf ROM exercises to^perfusion to graft site & facilitate healing. D. Document this finding as an expected phase of graft healing.

ANS: B Rationale: An infected graft may need to be removed, thus, care provider should be promptly informed. ROM exercises will not resolve problem, & nurse would not independently perform debridement.

Nurse is caring for client whose skin cancer will soon be removed by excision. Which of following actions should nurse perform? A. Teach client about early signs of secondary blistering diseases. B. Teach client about self-care after tx. C. Assess client's risk for recurrent malignancy. D. Assess client for adverse effects of radiotherapy.

ANS: B Rationale: Bc many skin cancers are removed by excision, clients usually tx in outpt surgical units. Role of nurse=teach client about prev of skin cancer & self-care after tx. Assessing client's risk for recurrent malignancy=primarily role of HCP. Blistering diseases don't result from cancer or subsequent excision. Excision not accompanied by radiotherapy.

During routine exam of client's fingernails, nurse notes horizontal depression in each nail plate. When documenting finding, nurse should use which term? A. Splinter hemorrhage B. Beau line C. Paronychia D. Clubbing

ANS: B Rationale: Beau line=horizontal depression in nail plate. Occurring alone or in multiples, depressions result from temp disturb in nail growth. Splinter hemorrhage=linear red or brown streak in nail bed. Paronychia=inflam of skinfold at nail margin. Clubbing=^ angle btwn nail plate & nail base.A young student comes to school nurse & shows nurse a mosquito bite.

An NP is seeing 16yr-old client who has come to dermatology clinic for Tx of acne. NP would know Tx may consist of which of following meds? A. Acyclovir B. Benzoyl peroxide & erythromycin C. Diphenhydramine D. Triamcinolone

ANS: B Rationale: Benzoyl peroxide & erythromycin gel is among topical tx's avail for acne. Acyclovir used in tx of herpes zoster as oral antiviral agent. Diphenhydramine=oral antihistamine used in tx of pruritus. Intralesional inj of triamcinolone=utilized in tx of psoriasis.

A young student is brought to school nurse after falling off swing. Nurse is documenting child has bruising on lateral aspect of right arm. What term will nurse use to describe bruising on skin in documentation? A. Telangiectasias B. Ecchymoses C. Purpura D. Urticaria

ANS: B Rationale: Telangiectasias consist of red marks on skin caused by stretching of superficial blood vessels. Ecchymoses=bruises, & purpura consists of pinpoint hemorrhages into skin. Urticaria=wheals or hives.

A gerontologic nurse is teaching group of nursing students about integumentary changes that occur in older adults. How should students best integrate these changes into care planning? A. By avoiding use of moisturizing lotions on older adults' skin B. By protecting older adults against shearing injuries C. By avoiding use of ice packs to tx muscle pain D. By protecting older adults against excessive sweat accumulation

ANS: B Rationale: Cellular changes assoc w/aging=thinning at junction of dermis & epidermis, which creates risk for shearing injuries. Moisturizing lotions can be safely used to address^dryness of older adults' skin. Ice packs can be used, provided skin is assessed reg & client possesses nrml sensation. Older adults perspire much less than younger adults, thus sweat accumulation rarely an issue.

Client who was burned in workplace accident has completed acute phase of Tx & plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of Tx? A. Monitoring fluid & electrolyte imbalances B. Providing education to client & family C. Treating infection D. Promoting thermoregulation

ANS: B Rationale: Client & family education is priority during rehabilitation. There should be no fluid & electrolyte imbalances in rehabilitation phase. Presence of impaired thermoregulation or infect would suggest client is still in acute phase of burn recovery.

Nurse who is taking care of a client w/burns is asked by family member why client is losing so much wt. Client is currently in intermediate phase of recovery. What would be nurse's most appropriate response to family member? A. "Client on calorie-restr diet to divert energy to wound healing." B. "Client's body has consumed fat deposits for fuel bc calorie intake is lower than normal." C. "Client actually hasn't lost wt. Instead, there's been a change in distribution of body fat." D. "Client lost many fluids while tx in emergency phase of burn care."

ANS: B Rationale: Clients lose great deal of wt during recovery from severe burns. Reserve fat deposits are catabolized as result of hypermetabolism. Clients are not placed on calorie restriction during recovery, & fluid losses would not account for wt loss later in recovery period. Changes in overall distribution of body fat do not occur.

Client is suspected of developing allergy to an environmental subst & given a patch test. During test, client develops fine blisters, papules, & severe itching. Nurse knows this is indicative of what strength reaction? A. Weak positive B. Moderately positive C. Strong positive D. Severely positive

ANS: B Rationale: Development of redness, fine elevations, or itching considered weak positive reaction. Fine blisters, papules, & severe itching indicate a moderately positive reaction. & blisters, pain, & ulceration indicate a strong positive reaction.

Client has received Dx of irritant contact dermatitis. What action should nurse prioritize in client's subsequent care? A. Teaching client to safely & effectively admin immunosuppressants B. Helping client ID & avoid offending agent C. Teaching client how to maintain meticulous skin hygiene D. Helping client perform wound care in home environment

ANS: B Rationale: Focus of care for clients w/irritant contact dermatitis is identifying & avoiding offending agent. Immunosuppressants not used to tx eczema & wound care not normally required, except in cases of open lesions. Poor hygiene has no correlation w/contact dermatitis.

An NP working in dermatology clinic finds an open lesion on a client being assessed. What should nurse do next? A. Obtain swab for culture. B. Assess characteristics of lesion. C. Obtain swab for pH testing. D. Apply test dose of broad-spectrum topical antibiotic.

ANS: B Rationale: If acute open wounds or lesions found on inspect of skin, comprehen assessm should be made & documented. Testing for culture & pH not necessarily req, & assessment should precede these actions. Antibiotics not applied on an empirical basis.

Client comes to dermatology clinic requesting removal of epidermal nevi on client's right cheek. Nurse knows procedure esp useful in tx such lesions is what? A. Skin graft B. Laser Tx C. Chemical face peeling D. Free flap

ANS: B Rationale: Lasers useful in tx cutaneous vascular lesions like epidermal nevi. Skin grafts, chemical face peels, & free flaps would not be used to remove this lesion.

Nurse is caring for client who devel pressure injury as result of decreased mobility. Nurse on prev shift provided client teaching about pressure injuries & healing promotion. Nurse determines client has understood teaching by observing client: A. Perform ROM exercises. B. Avoid placing body wt on healing site. C. Elevate body parts susceptible to edema. D. Demonstrate technique for massaging wound site.

ANS: B Rationale: Major goals of pressure injury Tx=relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutrit status, minimized friction & shear forces, dry surfaces in contact w/skin, & healing of pressure ulcer, if present. Other options don't demonstrate achievement of goal of client teaching.

Nurse is providing education to client scheduled for mechanical debridement of a wound. Nurse knows mechanical debridement involves which element? A. Spontaneous separation of dead tissue from viable tissue B. Removal of eschar until point of pain & bleeding occurs C. Shaving of burned skin layers until bleeding, viable tissue is revealed D. Early closure of wound

ANS: B Rationale: Mechanical debridement can be achieved thru use of surgical scissors, scalpels, or forceps to remove eschar until point of pain & bleeding occurs. Mechanical debridement can also be accomplished thru use of topical enzymatic debridement agents. Spontaneous separation of dead tissue from viable tissue=example of natural debridement. Shaving burned skin layers & early wound closure=examples of surgical debridement.

Nurse is doing shift assessment on group of clients after 1st taking report. An older adult client is having 2nd dose of IV antibiotics for dx of pneumonia. Nurse notices new rash on client's chest. Nurse should ask what priority question regarding presence of a reddened rash? A. "Is rash worse at particular time or season?" B. "Are you allergic to any foods or meds?" C. "Are you having any loss of sensation in that area?" D. "Is your rash painful?"

ANS: B Rationale: Nurse should suspect an allergic react to antibiotic therapy. Allergies can be signif threat to client's immediate health, thus questions addressing this possibility be prioritized over those addressing sensation. Asking abt prev rashes is imp, but should likely be framed in context of an allergy assessment.

Home care nurse is performing visit to client's home to perform wound care following client's hospital Tx for severe burns. While interacting w/client, nurse should assess for evidence of what complication? A. Psychosis B. Posttraumatic stress disorder C. Delirium D. Vascular dementia

ANS: B Rationale: Posttraumatic stress disorder(PTSD)=most common psychiatric disorder in burn survivors, w/prevalence that may be as high as 45%. As result, it's imp for nurse to assess for this complication of burn injuries. Psychosis, delirium, & dementia not among noted psychiatric & psychosocial complications of burns.

Assessment of a client's leg reveals presence of 1.5-cm circular region of necrotic tissue deeper than epidermis. Nurse should document presence of what type of skin lesion? A. Keloid B. Ulcer C. Fissure D. Erosion

ANS: B Rationale: Pressure ulcer that is stage2 or greater is one that extends past epidermal layer & can develop necrotic tissue. Keloids lack necrosis & consist of scar tissue. Fissure is linear, & erosions don't extend to dermis.

Client w/suspected malignant melanoma referred to dermatology clinic. Nurse knows to facilitate what diagnostic test to rule out skin malignancy? A. Tzanck smear B. Skin biopsy C. Patch testing D. Skin scrapings

ANS: B Rationale: Skin biopsy done to rule out malignancies of skin lesions. Tzanck smear to examine cells from blistering skin condit, like herpes zoster. Patch testing performed to ID subst to which client has devel an allergy. Skin scrapings done for suspected fungal infect.

Nurse is explaining imp of sunlight on skin to client w/decreased mobility & rarely leaves house. Nurse would emphasize UV light helps to synthesize what vitamin? A. E B. D C. A D. C

ANS: B Rationale: Skin exposed to UV light can convert subst necessary for synthesizing Vit D(cholecalciferol). Vit D essential for preventing rickets, condit that causes bone deformities & results from defic of Vit D, Ca, & Phos.

Wound care nurse is reviewing skin anatomy w/group of RNs. Which area of skin would nurse ID as providing cushion btwn skin layers, muscles, & bones? A. Dermis B. Subcutaneous tissue C. Epidermis D. Stratum corneum

ANS: B Rationale: Subcut tissue(hypodermis)=innermost layer of skin responsible for prov cushion btwn skin layers, muscles, & bones. Dermis=largest portion of skin, prov strength & structure. Epidermis=outermost layer of stratified epithelial cells & composed of keratinocytes. Stratum corneum=outermost layer of epidermis & prov barrier to prev epidermal water loss.

School nurse has sent home 4 children who show evidence of pediculosis capitis. What's an imp instruction nurse should include in note being sent home to parents? A. Child's scalp should be monitored for 48-72hrs b4 starting tx. B. Nits may have to be manually removed from child's hair shafts. C. Disease is self-limiting & symptoms will abate w/in 1wk. D. Efforts should be made to improve child's level of hygiene.

ANS: B Rationale: Tx for head lice should begin promptly & may require manual removal of nits following medicating shampoo. Head lice are not r/t a lack of hygiene. Tx is necessary bc condition will not likely resolve spontaneously w/in 1wk.

When caring for client w/toxic epidermal necrolysis(TEN), critical care nurse assesses freq for high fever, tachycardia, & extreme weakness & fatigue. Nurse is aware these findings are potential indicators of what condition(s)? Select all that apply. A. Possible malignancy B. Epidermal necrosis C. Neurologic involvement D. Increased metabolic needs E. Possible GI mucosal sloughing

ANS: B, D, E Rationale: Assessment for high fever, tachycardia, & extreme weakness & fatigue is essential bc these factors indicate process of epidermal necrosis, increased metabolic needs, & possible GI & respiratory mucosal sloughing. These factors less likely to suggest malignancy or neurologic involvement, as these not common complications of TEN.

A new client presents at clinic & nurse performs comprehensive health assessment. Nurse notes client's fingernail surfaces are pitted. Nurse should suspect presence of what health problem? A. Eczema B. Systemic lupus erythematosus (SLE) C. Psoriasis D. COPD

ANS: C Rationale: Pitted surface of nails is a definite indication of psoriasis. Pitting of nails does not indicate eczema, SLE, or COPD.

Current phase of client's tx for burn injury prioritizes wound care, nutrit support, & prev of complications like infect. Based on these care priorities, client is in what phase of burn care? A. Emergent B. Immediate resuscitative C. Acute D. Rehabilitation

ANS: C Rationale: Acute or intermediate phase of burn care follows emergent/resuscitative phase & begins 48-72hrs after burn injury. In this phase, attention directed toward cont assessment & maintenance of resp & circulatory status, fluid & electrolyte balance, & GI funct. Infect prev, burn wound care(wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, wound grafting), pain managem, & nutrit support priorities at this stage. Priorities in emergent or immediate resuscitative phase=first aid, prev of shock & resp distress, detection & Tx of concomitant injuries, & initial wound assessment & care. Priorities in rehabilitation phase=prev of scars & contractures, rehab, functional & cosmetic reconstruction, & psychosocial counseling.

Triage nurse in ED receives phone call from a frantic parent who saw their 4yr-old child tip a pot of boiling water onto themselves. Parent has called an ambulance. What should nurse in ED receiving the call instruct parent to do? A. Cover burn w/ice & secure w/a towel. B. Apply butter to area that is burned. C. Immerse child in cool bath. D. Avoid touching burned area under any circumstances.

ANS: C Rationale: After flames or heat source been removed or extinguished, burned area & adherent clothing are soaked w/cool water briefly to cool wound & halt burning process. Cool water is best first-aid measure. Ice & butter are contraindicated. Appropriate first aid necessitates touching the burn.

Nurse who provides care on burn unit is preparing to apply client's ordered topical antibiotic ointment. What action should nurse perform when admin this med? A. Apply new ointment w/o disturbing existing layer of ointment. B. Apply ointment using a sterile tongue depressor. C. Apply layer of ointment approximately 1/16in thick. D. Gently irrigate wound bed after applying antibiotic ointment.

ANS: C Rationale: After removing old ointment from wound bed, nurse should apply layer of ointment 1/16-in thick using clean gloves. Wound would not be irrigated after application of new ointment.

Client experienced 33% TBSA burn 72hrs ago. Nurse observes client's hourly urine output has been steadily increasing over past 24hrs. How should nurse best respond to this finding? A. Obtain order to reduce rate of client's IV fluid infusion. B. Report client's early signs of acute kidney injury(AKI). C. Recognize client is experiencing an expected onset of diuresis. D. Admin sodium chloride as prescribed to compensate for fluid loss.

ANS: C Rationale: As capillaries regain integrity, 48+ hrs after burn, fluid moves from interstitial to intravascular compartment & diuresis begins. This is an expected devel & doesn't require reduction in IV infusion rate or admin of NaCl. Diuresis not suggestive of AKI.

Client w/severe burns is admitted to ICU to stabilize & begin fluid resuscitation b4 transport to burn center. Nurse should monitor client closely for what signs of onset of burn shock? A. Confusion B. High fever C. Decreased BP D. Sudden agitation

ANS: C Rationale: As fluid loss continues & vascular volume decreases, CO continues to decrease & BP drops, marking onset of burn shock. Shock & accompanying hemodynamic changes not normally accompanied by confusion, fever, or agitation.

Nurse is providing care for client w/psoriasis. Following appearance of skin lesions, nurse should prioritize what assessment? A. Assessment of client's stool for evid of intestinal sloughing B. Assessment of client's apical heart rate for dysrhythmias C. Assessment of client's joints for pain & decreased ROM D. Assessment for cognitive changes resulting from neurologic lesions

ANS: C Rationale: Asymmetric rheumatoid factor-neg arthritis of multiple joints occurs in up to 42% of ppl w/psoriasis, most typically after skin lesions appear. Most typical joints affected=those in hands or feet, tho sometimes larger joints like elbow, knees, or hips may be affected. As such, nurse should assess for this musculoskeletal complication. GI, CV, & neurologic funct not affected by psoriasis.

Public health nurse is participating in health promotion campaign w/goal of improving outcomes r/t skin cancer in community. What action has greatest potential to achieve this goal? A. Educating participants abt relationship btwn general health & risk of skin cancer B. Educating participants abt tx options for skin cancer C. Educating participants abt early s/s of skin cancer D. Educating participants abt health risks assoc w/smoking & assisting w/smoking cessation

ANS: C Rationale: Best hope of decreasing incidence of skin cancer lies in educating clients abt early signs. There's relationship btwn general health & skin cancer but teaching ppl to ID early s/s more likely to benefit overall outcomes r/t skin cancer. Teaching abt tx options not likely to have major effect on outcomes of disease. Smoking not among major risk factors for skin cancer.

Client exper burns to upper thighs & knees. Following application of new wound dressings, RN should perform what nursing action? A. Instruct client to keep wound site in dependent position. B. Admin PRN analgesia as prescribed. C. Assess client's peripheral pulses distal to dressing. D. Assist w/passive ROM exercises to "set" new dressing.

ANS: C Rationale: Dressings can impede circulation if they're wrapped too tightly. Peripheral pulses must be checked freq & burned extremities elevated. Dependent positioning doesn't need to be maintained. PRN analgesics should be given prior to dressing change. ROM exercises don't normally follow dressing change.

Nurse is teaching client w/partial thickness wound how to wear the elastic pressure garment. How often should nurse instruct client to wear this garment? A. 4-6hrs/day for 6mths B. During waking hours for 2-3mths after injury C. Continuously D. At night while sleeping for a yr after injury

ANS: C Rationale: Elastic pressure garments are worn continuously (i.e., 24hrs/day)

When planning skin care of client w/decreased mobility, nurse is aware of varying thickness of epidermis. At what location is epidermal layer thickest? A. The scalp B. The elbows C. The palms of hands D. The knees

ANS: C Rationale: Epidermis is thickest over palms of hands & soles of feet.

35yr-old kidney transplant client comes to clinic exhibiting new skin lesions. Dx is Kaposi sarcoma. Nurse caring for client recognizes this is what type of Kaposi sarcoma? A. Classic B. AIDS related C. Iatrogenic D. Endemic

ANS: C Rationale: Iatrogenic/organ transplant-assoc Kaposi sarcoma occurs in transplant recipients & ppl w/AIDS. This form of KS characterized by local skin lesions & disseminated visceral & mucocutaneous diseases. Classic Kaposi sarcoma occurs predom in men of Mediter or Jewish ancestry bwtn 40-70yrs. Endemic KS affects ppl predom in eastern half of Africa. AIDS-related KS seen in ppl w/AIDS.

An older adult resident of long-term care facility been experiencing generalized pruritus that's become more severe in recent wks. What intervention should nurse add to resident's plan of care? A. Avoid application of skin emollients B. Apply antibiotic ointment, as prescribed, following baths C. Avoid using hot water during client's baths D. Admin acetaminophen 4x daily as prescribed

ANS: C Rationale: If baths prescribed, client reminded to use tepid(not hot)water & shake off excess water & blot btwn intertriginous areas (body folds)w/towel. Skin emollients applied to reduce pruritus. Acetaminophen & antibiotics do not reduce pruritus.

Nurse is performing initial assessment of client w/raised, pruritic rash. Client denies taking any prescription meds & denies any allergies. What would be an appropriate question to ask this client at this time? A. "Is anyone in your family allergic to anything?" B. "How long have you had this abrasion?" C. "Do you take any OTC drugs or herbal preparations?" D. "What do you do for a living?"

ANS: C Rationale: If suspicious areas noted, client is questioned abt nonprescription or herbal preps that might be in use. Estab family hx of allergies wouldn't give helpful info at this time. Client's lesion not described as an abrasion. Client's occupation may or may not be relevant. More imp to assess for herb or drug react.

Nurse is working w/family whose 5yr-old child has been dx w/impetigo. What educational intervention should nurse include in this family's care? A. Ensuring family knows impetigo not contagious B. Teaching about safe & effective use of topical corticosteroids C. Teaching about imp of maintaining high standards of hygiene D. Ensuring family knows how to safely burst child's vesicles

ANS: C Rationale: Impetigo is assoc w/unhygienic conditions, educational interventions to address this are appropriate. Disease is contagious, thus vesicles not be manually burst. Bc of bacterial etiology, corticosteroids ineffective.

Client is admitted to ICU w/what is thought to be toxic epidermal necrolysis(TEN). When assessing health hx of client, nurse would be alert to what precipitating factor? A. Recent heavy UV exposure B. Substandard hygienic conditions C. Recent admin of new meds D. Recent varicella infect

ANS: C Rationale: In adults, TEN usually triggered by reaction to meds. Antibiotics, anticonvulsant agents, butazones, & sulfonamides are most freq meds implicated. TEN is unrelated to UV exposure, hygiene, or varicella infect.

Nurse is performing comprehensive assessment of client's skin surfaces & intends to assess moisture, temp, & texture. Nurse should perform this component of assessment in what way? A. By examining client under Wood light B. By inspecting client's skin in direct sunlight C. By palpating client's skin D. By performing percussion of major skin surfaces

ANS: C Rationale: Inspection & palpation=techniq commonly used in examining skin. Client would only be examined under Wood light if indications could be diagnostic. Client examined in well-lit room, not direct sunlight. Percussion not techniq used in assessing skin.

Nurse is reviewing gerontologic considerations r/t care of clients w/dermatologic probs. What vulnerability results from age-related loss of subcut tissue? A. Decreased resistance to UV radiation B. Increased vulnerability to infection C. Diminished protection of tissues & organs D. Increased risk of skin malignancies

ANS: C Rationale: Loss of subcut tissue substances of elastin, collagen, & fat diminishes protection & cushioning of underlying tissues & organs, decreases muscle tone, & results in loss of insulating properties of fat. This age-related change doesn't correlate to^ vulnerability to sun damage, infect, or cancer.

Client dx w/stasis ulcer is hospitalized. There's an order to change dressing & provide wound care. Which activity should nurse first perform when providing wound care? A. Assess drainage in dressing. B. Slowly remove soiled dressing. C. Perform hand hygiene. D. Don nonlatex gloves.

ANS: C Rationale: Nurse & HCP must adhere to standard precautions & wear gloves when inspecting skin or changing dressing. Use of standard precautions & proper disposal of any contaminated dressing is carried out according to Occupational Safety & Health Administration(OSHA)regulations. Hand hygiene must precede other aspects of wound care.

A new client comes to dermatology clinic to be assessed for reddened rash on abd. For what diagnostic test should nurse prepare client to ID the causative allergen? A. Skin scrapings B. Skin biopsy C. Patch testing D. Tzanck smear

ANS: C Rationale: Patch testing performed to ID subst to which client has devel an allergy. Skin scrapings done for suspected fungal lesions. Skin biopsy completed to rule out malignancy & estab exact dx of skin lesions. Tzanck smear used to examine cells from blistering skin condit, like herpes zoster.

Client w/squamous cell carcinoma scheduled for tx of this malignancy. Nurse should anticipate tx for this type of cancer will primarily consist of what intervention? A. Chemotherapy B. Radiation therapy C. Surgical excision D. Biopsy of sample tissue

ANS: C Rationale: Primary goal of surgical management of squamous cell carcinoma=remove tumor entirely. Radiation therapy reserved for older client, bc x-ray changes may be seen after 5-10yrs, & malignant changes in scars may be induced by irradiation 15-30yrs later. Obtaining biopsy would not be goal of tx, may be assessment. Chemo & radiation generally reserved for clients who are not surgical candidates.

Nurse in dermatology clinic is reading EHR of new client. Nurse notes client has hx of a primary skin lesion. What skin lesion may this client have? A. Crust B. Keloid C. Pustule D. Ulcer

ANS: C Rationale: Pustule=example of primary skin lesion. Primary skin lesions are original lesions arising from prev normal skin. Crusts, keloids & ulcers are secondary lesions.

Client has dx of seborrhea & been referred to dermatology clinic, where nurse contributes to care. When planning client's care, nurse should include what nursing dx? A. Risk for deficient fluid volume r/t excess sebum synthesis B. Ineffective thermoregulation r/t occlusion of sebaceous glands C. Disturbed body image r/t excess sebum production D. Ineffective tissue perfusion r/t occlusion of sebaceous glands

ANS: C Rationale: Seborrhea causes highly visible manifest likely to have neg effect on client's body image. Seborrhea doesn't nrmlly affect fluid balance, thermoregulation, or tissue perfusion.

Client requires a full-thickness graft to cover a chronic wound. How is the donor site selected? A. Largest area of body w/o hair is selected. B. Any area not normally visible can be used. C. Area matching color & texture of skin at surgical site is selected. D. Area matching sensory capability of skin at surgical site is selected.

ANS: C Rationale: Site where intact skin is harvested is called donor site. Selection of donor site made to match color & texture of skin at surgical site & to leave as little scarring as possible.

While assessing 25yr-old female, nurse notes client has hair on lower abd. Earlier in health interview, client stated her menses are irregular. Nurse should suspect what type of health problem? A. A metabolic disorder B. A malignancy C. A hormonal imbalance D. An infectious process

ANS: C Rationale: Some women w/higher levels of testosterone have hair in areas generally thought as masculine, like face, chest, & lower abd. Often a normal genetic variation, but if appears along w/irregular menses & wt changes, may indicate hormonal imbalance. This combo of irregular menses & hair distribut is inconsistent w/metabolic disorders, malignancy, or infect.

Nurse is leading health promotion workshop focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma(BCC)? A. Teaching participants to improve overall health thru nutrition B. Encouraging participants to ID their family hx of cancer C. Teaching participants to limit their sun exposure D. Teaching participants to control exposure to environmental & occupational radiation

ANS: C Rationale: Sun exposure is best known & most common cause of BCC. BCC not commonly linked to general health debilitation, family hx, or radiation exposure.

Nurse is developing care plan for client w/partial thickness burn & determines an appropriate goal is to maintain position of joints in alignment. What is best rationale for this intervention? A. Prevent neuropathies B. Prevent wound breakdown C. Prevent contractures D. Prevent heterotopic ossification

ANS: C Rationale: To prevent complication of contractures, nurse will estab goal to maintain position of joints in alignment. Gentle ROM exercises & consult to PT/OT for exercises & positioning recommendations also appropriate interventions for prev of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

Client presents at dermatology clinic w/suspected herpes simplex. Nurse knows to prepare what diagnostic test for this condit? A. Skin biopsy B. Patch test C. Tzanck smear D. Examination with a Wood light

ANS: C Rationale: Tzanck smear=test to examine cells from blistering skin condit(herpes zoster, varicella, herpes simplex)& all forms of pemphigus. Secretions from susp lesion applied to glass slide, stained, & examined. Not accomplished by biopsy, patch test, or Wood light.

Client just told he has deep malignant melanoma. Nurse caring for this client should anticipate client will undergo what Tx? A. Chemotherapy B. Immunotherapy C. Wide excision D. Radiation therapy

ANS: C Rationale: Wide excision is primary Tx for malignant melanoma, which removes entire lesion & determines level & staging. Chemo may be used after melanoma excised. Immunotherapy is experimental & radiation therapy is palliative.

Client w/partial thickness burn injury had xenograft applied 2wks ago. Nurse notices xenograft is separating from burn wound. What is nurse's most appropriate intervention? A. Reinforce xenograft dressing w/another piece of Biobrane. B. Remove xenograft dressing & apply new dressing. C. Trim away separated xenograft. D. Notify HCP for further emergency-related orders.

ANS: C Rationale: Xenografts adhere to granulation tissue. As tissue heals xenograft will become removed from scar tissue. Applying more of xenograft will not continue to heal wound(as it is already healed). Not an emergency & reinforcement not necessary.

Nurse is preparing to perform physical assessment of newly admitted client. During which of following components of assessment should nurse wear gloves? Select all that apply. A. Palpation of nailbeds B. Palpation of client's upper extremities C. Palpation of a rash on client's trunk D. Palpation of a lesion on client's upper back E. Palpation of client's finger joints

ANS: C, D Rationale: Gloves are worn during skin exam if rash or lesions are to be palpated. Not nrmlly necessary to wear gloves to palpate client's extremities or fingers unless contact w/body fluids is reasonably foreseeable.

Nurse is planning care of client w/herpes zoster. What med, if given w/in first 24hrs of initial eruption, can arrest herpes zoster? A. Prednisone B. Azathioprine C. Triamcinolone D. Acyclovir

ANS: D Rationale: Acyclovir, if started early=effective in signif reducing pain & halting progression of disease. There's evidence that infect is arrested if oral antiviral agents given w/in first 24hrs. Prednisone=anti-inflammatory agent used in variety of skin disorders, but not in Tx of herpes. Azathioprine=immunosuppressive agent used in Tx of pemphigus. Triamcinolone=utilized in Tx of psoriasis.

Client's health assessm resulted in dx of alopecia areata. What nursing dx should nurse most likely assoc w/this health prob? A. Chronic pain B. Impaired skin integrity C. Impaired tissue integrity D. Disturbed body image

ANS: D Rationale: Alopecia areata causes hair loss in smaller defined areas. As such, it's common for client to exper disturbed body image. Hair loss doesn't cause pain & doesn't affect skin or tissue integrity.

65yr-old man presents at clinic reporting nodules on both legs. Man tells nurse that his son, who is in med school, encouraged him to seek prompt care & told him the nodules are r/t fact he is Jewish. What health prob should nurse suspect? A. Stasis ulcers B. Bullous pemphigoid C. Psoriasis D. Classic Kaposi sarcoma

ANS: D Rationale: Classic Kaposi sarcoma occurs predom in men of Mediterr or Jewish ancestry btwn 40-70yrs of age. Most clients have nodules or plaques on lower extremities that rarely metastasize beyond this area. Classic KS is chronic, relatively benign, & rarely fatal. Stasis ulcers don't create nodules. Bullous pemphigoid characterized by blistering. Psoriasis presents w/silvery plaques.

While performing client's ordered wound care for Tx of a burn, client has made series of sarcastic remarks to nurse & criticized nurse's technique. How should nurse best interpret this client's behavior? A. Client may be exper adv drug react affecting cognition & behav. B. Client may be experiencing neurologic or psychiatric complications of client's injuries. C. Client may be exper inconsistencies in care being provided. D. Client may be experiencing anger abt current circumstances the client is deflecting toward nurse.

ANS: D Rationale: Client may experience feelings of anger. Anger may be directed outward toward those who escaped unharmed or toward those now providing care. While drug react, complications, & frustrating inconsistencies in care can't be automatically ruled out, it is not uncommon for anger to be directed at caregivers.

Nurse is assessing skin of client dx w/bacterial cellulitis on dorsal portion of great toe. When reviewing client's health hx, nurse should ID what comorbidity as increasing client's vulnerability to skin infections? A. COPD B. Rheumatoid arthritis C. Gout D. Diabetes

ANS: D Rationale: Clients w/DM particularly susceptible to skin infect. COPD, RA, & gout are less commonly assoc w/integumentary manif.

Nurse is working w/a client dx w/Cushing syndrome. When completing physical assessment, nurse should specifically observe for what integumentary manifestation? A. Alopecia B. Yellowish skin tone C. Patchy, bronze pigmentation D. Hirsutism

ANS: D Rationale: Cushing syndrome causes excessive hair growth, esp in women. Alopecia=hair loss from scalp & other parts of body. Jaundice causes yellow discoloration in light-skin clients but doesn't accompany Cushing syndrome. Clients w/Addison disease exhibit bronze discoloration to skin due to^melanin production.

Nurse is assessing teenage client w/acne vulgaris. Client's mother states, "I keep telling him this is what happens when you eat as many French fries as he does." What aspect of pathophysiology of acne should inform nurse's response? A. Sudden change in client's diet may exacerbate, rather than alleviate, client's sympt. B. French fries are one of foods known to directly cause acne. C. Elimination of fried foods from client's diet likely lead to resolution w/in sev mths. D. Diet is thought to play minimal role in devel of acne.

ANS: D Rationale: Diet not believed to play major role in acne therapy. Change in diet not known to exacerbate sympt. However, does appear to be correlation btwn foods high in refined sugars & acne, therefore, these foods should be avoided.

Nurse caring for client who is recovering from full-thickness burns is aware of client's risk for contracture & hypertrophic scarring. How can nurse best reduce this risk? A. Apply skin emollients as prescribed after granulation occurred. B. Keep injured areas immobilized when poss to promote healing. C. Admin oral or IV corticosteroids as prescribed. D. Encourage physical activity & ROM exercises.

ANS: D Rationale: Exercise & promotion of mobility can reduce risk of contracture & hypertrophic scarring. Skin emollients not nrmlly used in Tx of burns, & do not prevent scarring. Steroids not used to reduce scarring, as they also slow healing process.

A client is brought to ED from site of chemical fire, where client suffered burn that involves epidermis, dermis, & muscle & bone of right arm. On inspection, skin appears charred. Based on these assessment findings, what is depth of burn on client's arm? A. Superficial partial thickness B. Deep partial thickness C. Full partial thickness D. Full thickness

ANS: D Rationale: Full-thickness burn=involves total destruction of epidermis & dermis &, sometimes, underlying tissue too. Wound color ranges widely from white to red, brown, or black. Burned area is painless bc nerve fibers destroyed. Wound can appear leathery, hair follicles & sweat glands destroyed. Edema may also be present. Superficial partial-thickness burns=involve epidermis & possibly portion of dermis. Client will exper pain that's soothed by cooling. Deep partial-thickness burns=involve epidermis, upper dermis, & portion of deeper dermis. Client will report pain & sensitivity to cold air. Full partial thickness not a depth of burn.

Client comes to clinic reporting red rash of small, fluid-filled blisters & is suspected of having herpes zoster. What presentation is most consistent w/this Dx? A. Grouped vesicles occurring on lips & oral mucous membs B. Grouped vesicles occurring on genitalia C. Rough, fresh, or gray skin protrusions D. Grouped vesicles in linear patches along a dermatome

ANS: D Rationale: Herpes zoster(shingles)=acute inflam of dorsal root ganglia, causing localized, vesicular skin lesions following a dermatome. Herpes simplex type1=viral infect affecting skin & mucous membs, usually producing cold sores or fever blisters. Herpes simplex type2=primarily affects genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray skin protrusions.

Dark-skin client is admitted to medical unit w/liver disease. To correctly assess this client for jaundice, on what body area should nurse look for yellow discoloration? A. Elbows B. Lips C. Nail beds D. Sclerae

ANS: D Rationale: Jaundice, yellowing of skin, is directly r/t elevations in serum bilirubin & often 1st observed in sclerae & mucous membs.

Nurse is providing care for client who devel Kaposi sarcoma secondary to HIV infect. Nurse should be aware this form of malignancy originates in what part of body? A. Connective tissue cells in diffuse locations B. Smooth muscle cells of GI & respiratory tract C. Neural tissue of brain & spinal cord D. Endothelial cells lining small blood vessels

ANS: D Rationale: Kaposi sarcoma(KS)=malignancy of endothelial cells that line small BV's. It doesn't originate in connective tissue, smooth muscle cells of GI & respiratory tract, or in neural tissue.

30yr-old client just returned from OR after having "flap" done following a motorcycle accident. Client's spouse asks nurse about major complications following this type of Sx. What would be nurse's best response? A. "Major complication is when client develops chronic pain." B. "Major complication is when client loses sensation in flap." C. "Major complication is when pedicle tears loose & flap dies." D. "Major complication is when blood supply fails & tissue in flap dies."

ANS: D Rationale: Major complication of flap=necrosis of pedicle or base as result of failure of blood supply. This is more likely than tearing of pedicle & chronic pain & more serious than loss of sensation.

While performing initial assessment of client admitted w/appendicitis, nurse observes elevated blue-black lesion on client's ear. Nurse knows this lesion is consistent w/what type of skin cancer? A. Basal cell carcinoma B. Squamous cell carcinoma C. Dermatofibroma D. Malignant melanoma

ANS: D Rationale: Malignant melanoma presents itself as superficial spreading melanoma which may appear in combo of colors, w/hues of tan, brown, & black mixed w/gray, blue-black, or white. Lesion tends to be circular, w/irregular outer portions. BCC usually begins as small, waxy nodule w/rolled, translucent, pearly borders, telangiectatic vessels may be present. SCC appears as rough, thickened, scaly tumor & may be asymptomatic or may involve bleeding. Dermatofibroma presents as firm, dome-shaped papule or nodule that may be skin colored or pinkish brown.

Nurse is providing educational presentation addressing topic of "Protecting Your Skin." When discussing anatomy of skin, nurse should state what cells are responsible for producing pigmentation of skin? A. Islets of Langerhans B. Squamous cells C. T cells D. Melanocytes

ANS: D Rationale: Melanocytes=special cells of epidermis primarily responsible for producing pigment melanin. Islets of Langerhans= clusters of cells in pancreas. Squamous cells=flat, scaly epithelial cells. Tcells funct in immune response.

Client has just undergone Sx for malignant melanoma. Which of following nursing actions should be prioritized? A. Maintain client on bed rest for first 24hrs postop. B. Apply distraction techniques to relieve pain. C. Provide soft or liquid diet high in protein to assist w/healing. D. Anticipate need for, & admin, appropriate analgesic meds.

ANS: D Rationale: Nursing interventions after Sx for malignant melanoma center on promoting comfort, bc wide excision Sx may be necessary. Anticipating need for & admin appropriate analgesic meds are imp. Distraction techn may be appropriate for some clients, but not substitute for analgesia. Bed rest & modified diet not necessary.

An occupational health nurse is called to floor of factory where worker has sustained flash burn to right arm. Nurse arrives & the flames have been extinguished. Next step is to "cool the burn." How should nurse cool the burn? A. Apply ice to site of burn for 5-10mins. B. Wrap client's affected extremity in ice until help arrives. C. Apply an oil-based subst to burned area until help arrives. D. Wrap cool towels around affected extremity intermittently.

ANS: D Rationale: Once burn has been sustained, application of cool water is best first-aid measure. Soaking burn area intermittently in cool water or applying cool towels gives immediate & striking relief from pain, & limits local tissue edema & damage. However, never apply ice directly to burn, never wrap person in ice, & never use cold soaks or dressings for longer than sev mins- such procedures may worsen tissue damage & lead to hypothermia in ppl w/large burns. Oils are contraindicated.

Nurse is caring for client who has sustained deep partial-thickness burn injury. In prioritizing nursing Dx for plan of care, nurse will give highest priority to what nursing Dx? A. Activity intolerance B. Anxiety C. Ineffective coping D. Acute pain

ANS: D Rationale: Pain is inevitable during recovery from any burn injury. Pain in burn client described as one of most severe types of acute pain. Management of often-severe pain is one of most difficult challenges facing burn team. While other nursing Dx listed are valid, presence of pain may contribute to these Dx. Management of client's pain is priority, as it may have direct correlation to other listed nursing Dx.

Nurse is caring for client w/burns who is in later stages of acute phase of recovery. Plan of nursing care should include which of following nursing actions? A. Maintenance of bed rest to aid healing B. Choosing appropriate splints & functional devices C. Admin of beta adrenergic blockers D. Prev of VTE

ANS: D Rationale: Prev of DVT=imp factor in care. Early mobilization of client is imp. Nurse monitors splints & functional devices, but these are selected by OT & physical therapists. Hemodynamic changes accompanying burns don't nrmlly req use of beta blockers.

Client who sustained third-degree facial burns & facial fx is undergoing reconstructive Sx & implantation of prosthesis. Nurse has ID'd nursing Dx of Low Self Esteem r/t use of facial prosthetic secondary to reconstructive surgery. Which nursing intervention would be appropriate for this Dx? A. Referring client to a speech therapist B. Gradually adding soft foods to diet C. Admin analgesics as prescribed D. Teaching client how to use & care for prosthesis

ANS: D Rationale: Process of facial reconstruction often slow & tedious. Bc person's facial appearance affects self-esteem so greatly, this type of reconstruction often very emotional experience for client. Reinforcement of client's successful coping strategies improves self-esteem. If prosthetic devices used, client taught how to use & care for them to gain sense of greater independ. This is an intervention that r/t Disturbed Body Image in these clients. None of other listed interventions relate directly to dx of Disturbed Body Image.

Nurse is performing home visit to client recovering following long course of inpt Tx for burn injuries. When performing home visit, nurse should do which of following? A. Assess client for signs of electrolyte imbalances. B. Admin fluids as prescribed. C. Assess risk for injury recurrence. D. Assess client's psychosocial state.

ANS: D Rationale: Recovery from burns can be psychologically challenging, nurse's assessments must address this reality. Fluid & electrolyte imbalances are infrequent during rehabilitation phase of recovery. Burns not typically health prob that tends to recur. Experience of being burned tends to foster vigilance.

Nurse is caring for client whose chemical injury has necessitated skin graft to client's left hand. Which statement is true regarding skin graft use? A. This use is not a type of reconstruction. B. Skin grafts form their own blood supply. C. They are only transplanted from another doner. D. Skin is transferred from distant site to graft site.

ANS: D Rationale: Skin grafting=techn where section of skin detached from its own blood supply & transferred as free tissue to distant (recipient)site. Skin grafting can be used to repair almost any type of wound & is most common form of reconstructive Sx.

An older adult client, who is bedridden, is admitted to unit bc of pressure injury that can no longer be tx in community setting. During assessment, nurse finds ulcer extends into muscle & bone. At what stage should nurse document this injury? A. I B. II C. III D. IV

ANS: D Rationale: StageIII & IV pressure injuries characterized by extensive tissue damage. In addition to interventions listed for stageI, these advanced draining, necrotic pressure injuries must be cleaned(debrided)to create area that will heal. StageIV=ulcer that extends to underlying muscle & bone. StageIII=ulcer that extends into subcut tissue. W/this type of ulcer, necrosis of tissue & infect may develop. StageI=area of erythema that doesn't blanch w/pressure. StageII involves break in skin that may drain.

Client w/exceptionally low BMI been admitted to ED with s/s of hypothermia. Nurse should know this client's susceptibility to heat loss is r/t atrophy of what skin component? A. Epidermis B. Merkel cells C. Dermis D. Subcutaneous tissue

ANS: D Rationale: Subcut tissues & amnt of fat deposits are imp factors in body temp regulation. Epidermis=outermost layer of stratified epithelial cells. Merkel cells=receptors that transmit stimuli to axon thru chemical synapse. Dermis makes up largest portion of skin, prov strength & structure. It's composed of 2 layers: papillary & reticular.

ED nurse has just admitted client w/a burn. What characteristic of burn will primarily determine whether client experiences a systemic response to this injury? A. Length of time since the burn B. Location of burned skin surfaces C. Source of burn D. Total body surface area(TBSA) affected by burn

ANS: D Rationale: Systemic effects are result of several variables. However, TBSA & wound severity considered major factors that affect presence or absence of systemic effects.

Client is brought to ED by paramedics, who report the client has partial thickness burns on chest & legs. Client has also suffered smoke inhalation. What is priority in care of a client who has been burned & suffered smoke inhalation? A. Pain B. Fluid balance C. Anxiety and fear D. Airway management

ANS: D Rationale: Systemic threats from a burn are greatest threat to life. ABCs of all trauma care apply during early post-burn period. While all options should be addressed, pain, fluid balance, & anxiety & fear do not take precedence over airway management.

While assessing a dark-skin client at clinic, nurse notes presence of patchy, milky-white spots. Nurse knows this finding is characteristic of what dx? A. Cyanosis B. Addison disease C. Polycythemia D. Vitiligo

ANS: D Rationale: W/cyanosis, nail beds are dusky. W/polycythemia, nurse notes ruddy blue face, oral mucosa, & conjunctiva. A bronzed appearance, or "external tan," is assoc w/Addison disease. Vitiligo=condition characterized by destruction of melanocytes in circumscribed areas of skin & appears in light or dark skin as patchy, milky-white spots, often symmetric bilaterally.

82yr-old client being tx in hospital for sacral pressure ulcer. What age-related change is most likely to affect client's course of tx? A. Increased thickness of subcut skin layer B. Increased vascular supply to superficial skin layers C. Changes in character & quantity of bacterial skin flora D. Increased time required for wound healing

ANS: D Rationale: Wound healing becomes slower w/age, req more time for older adults to recover from surgical & traumatic wounds. There are no changes in skin flora w/increased age. Vascular supply & skin thickness both decrease w/age.

Client's burns are estimated at 36% of total BSA, fluid resuscitation has been ordered in ED. After establishing IV access, nurse should anticipate admin of what fluid? A. 0.45%NaCl w/20mEq/L KCl B. 0.45%NaCl w/40mEq/L KCl C. Normal saline D. Lactated Ringer

ANS: D Rationale: Fluid resuscitation w/lactated Ringer should be initiated using American Burn Association's(ABA) fluid resuscitation formulas. LR=crystalloid of choice bc its composition & osmolality most closely resemble plasma & bc use of normal saline is assoc w/hyperchloremic acidosis. Potassium chloride solutions would exacerbate hyperkalemia that occurs following burn injuries.

Nurse is aware the outer layer of skin consists of dead cells that contain large amounts of keratin. Physiologic functions of keratin include which of following? Select all that apply. A. Producing antibodies B. Absorbing electrolytes C. Maintaining acid-base balance D. Physically repelling pathogens E. Preventing fluid loss

ANS: D, E Rationale: Dead cells of epidermis contain large amounts of keratin(insoluble, fibrous protein that forms outer barrier of skin) Keratin has capacity to repel pathogens & prev excessive fluid loss from body. Doesn't contrib directly to antibody production, acid-base balance, or electrolyte levels.