2.5-Integumentary System Saunders Review Questions
The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. [] 1. Lesion has a waxy border [] 2. An irregularly shaped lesion [] 3. Papule, with a red, central crater [] 4. A small papule with a dry, rough scale [] 5. A firm nodular lesion topped with a crust
1. Lesion has a waxy border 2. An irregularly shaped lesion Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Test-Taking Strategy: Focus on the subject, basal cell carcinoma. Recall characteristic and etiology of basal cell cancer to direct you to the correct option. Review: the characteristics of basal cell carcinoma.
The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? 1. "I need to wear sunscreen when participating in outdoor activities." 2. "I need to avoid sun exposure before 10: 00 am and after 4: 00 pm." 3. "I need to wear a hat, opaque clothing, and sunglasses when in the sun." 4. "I need to examine my body monthly for any lesions that may be suspicious."
2. "I need to avoid sun exposure before 10: 00 am and after 4: 00 pm." Rationale: The client should be instructed to avoid sun exposure between the hours of approximately 10: 00 am and 4: 00 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or precancerous lesions. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. A careful reading of the question will direct you to the correct option. Review: client teaching for the prevention of skin cancer.
The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? 1. A staff member who has never had roseola 2. A staff member who has never had mumps 3. An unlicensed assistive personnel who has never had chickenpox 4. An unlicensed assistive personnel who has never had German measles
3. An unlicensed assistive personnel who has never had chickenpox Rationale: Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox. Options 1, 2, and 4 are not associated with the herpes zoster virus. Test-Taking Strategy: Note the subject, safe assignment-making. Recalling that herpes zoster is caused by a reactivation of the varicella zoster virus will assist you with answering the question. Review: the relationship between herpes zoster and chickenpox.
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply. [] 1. Metastasis is rare. [] 2. It is encapsulated. [] 3. It is highly metastatic. [] 4. It is characterized by local invasion. [] 5. Lesion is a nevus that has changed in color.
3. It is highly metastatic 5. Lesion is a nevus that has changed in color. Rationale: Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis. Test-Taking Strategy: Focus on the subject, a melanoma, and use knowledge regarding the various types of skin cancers. Recalling that melanomas are highly metastatic will direct you to the correct option. Review: the characteristics of skin cancers.
An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank. Answer: _____%
36% Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This totals 36%. Test-Taking Strategy: Focus on the subject, the rule of nines. Knowledge of this rule is necessary in order to answer this question. According to the rule, the entire head equals 9%, each arm equals 9% (both arms, 18%), the anterior and posterior torsos each equal 18% (entire torso, 36%), each leg equals 18% (both legs, 36%), and the perineum equals 1%. Remember the following: 9% (head) + 18% (arms) + 36% (torsos) + 36% (legs) + 1% (perineum) = 100%. Review: the rule of nines.
A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color of the skin which is insensitive to touch.
4. A white color of the skin which is insensitive to touch. Rationale: The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days. Test-Taking Strategy: Focus on the subject, diagnosis of frostbite. The words, insensitive to touch, should assist with directing you to the correct option. Review: the characteristics associated with frostbite.
