Burns

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy

2.Urine output Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

An adult client with a burn injury just arrived at the emergency department. Place the nursing actions in the care of this client in order of priority. All options must be used.

1,3,2,6,4,5 The primary goals for a burn injury are to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and to maintain a patent airway. The nurse then prepares to administer oxygen. The type of oxygen delivery system is prescribed by the primary health care provider. Oxygen is necessary to perfuse tissues and organs. Vital signs should be assessed so that a baseline is obtained, which is needed for comparison of subsequent vital signs once fluid resuscitation is initiated. The nurse then initiates an IV line and begins fluid replacement as prescribed. The extremities are elevated (if no obvious fractures are present) to assist in preventing shock. The client is kept warm (using sterile linens) and is placed on NPO status because of the altered gastrointestinal function that occurs as a result of the burn injury. A Foley catheter may be inserted so that the response to the fluid resuscitation can be carefully monitored. Once these actions are taken, the nurse performs a complete assessment, stays with the client, and monitors the client closely. In addition, tetanus toxoid may be prescribed for prophylaxis.

The nurse suspects herpes zoster (shingles) when which assessment finding is noted?

1.Clustered skin vesicles The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because the lesions follow nerve pathways, they do not cross the midline of the body. Options 2, 3, and 4 are incorrect descriptions of herpes zoster.

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin?

1.Clustered skin vesicles The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Options 2, 3, and 4 are incorrect descriptions.

The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure?

1.Ensure that the consent form has been signed. A punch biopsy involves use of a punch instrument that punctures the skin and is rotated to obtain some of the dermis and fat. It is used for diagnostic purposes. A signed consent form is required for this procedure. A Foley catheter is not indicated and should be avoided if possible for any condition or procedure due to the risk for catheter-associated urinary tract infection. Chlorhexidine wipes are not specifically indicated for this procedure; usually an antibacterial such as povidone-iodine is used. There is not typically a lot of bleeding with this procedure; therefore, units of blood are not typically made available for the client undergoing punch biopsy.

The nurse in the postanesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring?

1.Frequent swallowing The client should be assessed for frequent swallowing, which may be the only sign of bleeding. Bleeding may not always be externally visible after rhinoplasty because blood may run down the back of the client's throat. The surgical procedure and the packing may be uncomfortable, so discomfort is expected and analgesics would be prescribed. The area around the client's eyes is expected to be edematous and ecchymotic, and ice compresses are applied. Some blood on the external nasal dressing is expected.

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and should plan to question which prescription?

1.Gastric lavage The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

A client taking calcium carbonate chewable tablets and ranitidine is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment?

1.Gastric pH of 3 The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.

The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease?

1.It is caused by a tick bite. Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from 1 person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused from the inhalation of cysts from contaminated cat feces or the consumption of rare or raw meat.

The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client?

1.Keep the test sites dry. The nurse instructs the client to keep the test sites dry at all times. The nurse also discourages excessive physical activity that will result in sweating. If the client reapplies patches that come loose, this can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later.

Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain

2.A skin infection of the dermis and underlying hypodermis Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis.

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client?

2.Foam pad The client who cannot shift weight unassisted should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for this purpose are those that have a tendency to equalize the client's weight on the pad. These include foam, water, gel, and alternating air products. A pillow provides cushion but does not distribute weight equally. A plastic-lined pad and folded blankets provide no pressure relief.

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type?

2.Full-thickness Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation?

2.Heart rate of 95 beats/minute When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition?

2.Hypertrophy of collagen fibers Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve.

The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"?

2.Leave the dressing intact for 3 to 5 days. After surgery, graft sites are immobilized with bulky cotton pressure dressing for 3 to 5 days to allow vascularization, or "take," of the newly grafted skin. Dressings should not be disturbed. Elevation and complete rest of the grafted area is required to allow blood vessels to connect the graft with the wound bed. Any activity that might cause movement of the dressing against the body and separation of the graft from the wound is prohibited, such as application of an ice pack. Additionally, cold promotes vasoconstriction.

The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for?

2.Lesions with well-defined geometric margins Contact dermatitis findings include skin lesions with well-defined geometric margins. Option 1 describes a medication eruption. Option 3 describes nonspecific eczematous dermatitis. Option 4 describes atopic dermatitis.

The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client?

2.Oral mucosa In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa and in areas of lighter melanization such as the abdomen and buttocks. Jaundice would best be noted in the sclera of the eye. Cyanosis is best noted on the palms of the hands and soles of the feet.

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe?

2.Pink or red color Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold.

The clinic nurse notes that the primary health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

2.Positive culture results With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

The clinic nurse notes that the primary health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

2.Positive culture results With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

A client is admitted to the hospital with a partial-thickness skin loss and blister on the sacrum. The nurse should develop a plan of care for which stage of pressure ulcer? Refer to figure.

2.Stage II ulcer A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage I ulcer is characterized by a reddened area and intact skin. Stage III ulcers are full-thickness lesions of the skin. Stage IV ulcers also are full-thickness lesions, with exposed muscle, bone, or supportive tissue.

The nurse has been working with the client diagnosed with candidiasis (thrush). What should the nurse assess for in this client?

2.The presence of white patches Assessment of the client with candidiasis (thrush) will reveal white patches on the tongue, palate, and buccal mucosa. The lesions adhere firmly to the tissues and are difficult to remove. The lesions often are referred to as "milk curds" because of their appearance. Clients often describe the lesions as dry and hot. Options 1, 3, and 4 are not characteristics of thrush.

The nurse has provided home care instructions to a client after dermabrasion. Which statement by the client indicates a need for further instruction?

3."I need to keep my skin dry to allow it to heal." After dermabrasion, the client is instructed to implement measures that will prevent dry skin. The client will be instructed to use wet soaks and to use emollients when the wet soaks are not being used. The client should avoid exposure to the sun. If the client plans to be outdoors, a sunscreen needs to be applied, and protective clothing and items such as a hat should be worn.

A client has undergone laser surgery to remove 2 nevi. The nurse determines that the client has understood discharge instructions if the client makes which statement?

3."I need to protect the operated areas from direct sunlight for at least 3 months." After laser surgery to remove any type of skin lesion, the skin should be protected from direct sunlight for a minimum of 3 months. There should be minimal or no discomfort after the procedure, and, if present, the discomfort should be relieved easily with acetaminophen. The operated area should be cleansed gently with half-strength hydrogen peroxide twice a day after the dressing is removed (24 hours after the procedure). Redness and swelling are expected after this procedure.

The nurse is providing home care instructions to a client after rhinoplasty. Which statement by the client indicates a need for further instruction?

3."I should be sure to run a dehumidifier in my home." After rhinoplasty, the client is taught to sleep on at least 2 pillows; this elevates the head and reduces edema. The client also is told to avoid any activities, such as bending over, that would increase intracranial pressure and cause nasal bleeding. A humidifier (not a dehumidifier) decreases the dry throat associated with mouth breathing. The client should be instructed to sneeze through the mouth and not blow through the nose.

An adult client was burned in an explosion. The burn initially affected the client's entire face (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, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

3.36% 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 half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of the posterior torso, equaling 9%. This totals 36%.

The nurse prepares to assist a primary health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include in the plan for this procedure?

3.Darken the room for the examination. Examination of the skin under a Wood's light is always carried out in a darkened room. The procedure is painless. This is a noninvasive examination; therefore, an informed consent is not required. A hand-held, long-wavelength ultraviolet light or Wood's light is used. The skin does not need to be shaved and a local anesthetic is not necessary. Areas of blue-green or red fluorescence are associated with certain skin infections.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?

3.Immobilization of the affected leg Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing?

3.Liquefaction necrosis Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury.

The presence of which finding leads the home health nurse to suspect infestation of a client with scabies?

3.Multiple straight or wavy, thread-like lines beneath the skin Scabies can be identified by the presence of multiple straight or wavy, thread-like lines beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the skin and lays its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 4 are not characteristics of scabies.

The nurse is providing skin care instructions to a female client with acne vulgaris. What should the nurse instruct the client to do?

3.Remove cosmetics from her face at bedtime. The client should be instructed to wash her face 2 or 3 times daily with a mild cleanser. Vigorous rubbing of the face is avoided, and cosmetics need to be removed from the face at bedtime. The client is instructed to use only water-based cosmetics and to avoid exposure to skin products that contain oils because products that are oily may cause skin flare-ups

An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions?

3.Spider angioma Spider angiomas have a bright red center with legs that radiate outward. Spider angiomas are commonly seen in liver disease and vitamin B deficiency, although they occasionally can occur without underlying pathology. Purpura results from hemorrhage into the skin. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Cherry angioma occurs with increasing age and has no clinical significance. It appears as a small, round, bright red lesion on the trunk or extremities.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis?

4."This skin infection involves the deep dermis and subcutaneous fat." Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red erythema without sharp borders and spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular, and the infection extends beyond the epidermis. It is not a superficial infection, and it is not simply inflammation. Options 1, 2, and 3 are incorrect descriptions.

The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions?

4."You will need to wear dark eye goggles during the treatment. Safety precautions are required during UV light therapy. Protective dark eye goggles are required to prevent exposure of the eyes to the UV light; it may be necessary to wear the goggles for the remainder of the day following treatment. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Most UV light therapies require the client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UV light. Direct contact with the lightbulbs used for the treatment should be avoided to prevent burning of the skin.

The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder?

4.A client who tans in an indoor tanning bed Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme conditions can damage the skin, posing the highest risk for skin disorders. An athlete would be at low risk of developing an integumentary problem. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. An older client may be at a higher risk than a younger person.

In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem?

4.Altered body image Psoriasis is an autoimmune dermatitis that is expressed as silvery scales on reddish-colored skin on areas such as scalp, elbows, hands, and knees. Onset of the disease generally occurs before age 40, with symptoms varying in intensity from mild to severe. Skin disorders, particularly when experienced by young persons and particularly when visible on exposed body parts, can cause significant psychosocial distress. Altered body image is a priority client problem that should be considered when planning care for a client with psoriasis. The remaining options are not priority client problems associated with psoriasis.

The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder?

4.An outdoor construction worker Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. The outdoor construction worker would fit into a high-risk category for the development of an integumentary disorder. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. Immobility and lack of nutrition would increase the older client's risk, but the older client is not at as high a risk as the outdoor construction worker. The physical education teacher is at low or no risk of developing an integumentary problem.

The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record?

4.Appears to have cherry angiomas on trunk and thighs A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby-colored round lesions on the trunk and/or extremities. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology. Purpura results from hemorrhage into the skin.

A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse should tell the client to take which measure?

4.Avoid bathing in the shower or tub more than once daily. Several things may be done to promote hydration of the skin. The client should limit tub or shower bathing to once daily or every other day and should sponge bathe on the other days. Room humidity should be maintained at greater than 40%. Bath water should be between 95º F and 100º F (35º C to 37.8º C) (tepid) and not very hot or very cold. Harsh soaps should be avoided, and emollients should be applied generously to skin while it is still damp.

A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem?

4.Blotchy brown macules across the cheeks and forehead Chloasma is a condition caused by hormonal influences on melanin production and is characterized by blotchy brown macules across the cheeks and forehead. Options 1 and 2 refer to normal variations in skin color. Option 3 describes vitiligo.

A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint?

4.Chronic kidney disease Clients with chronic kidney disease often have pruritus, or itchy skin. This is because of impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with diabetes mellitus are at risk for skin infections and skin breakdown.

A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What should the nurse include in client teaching to maximize the effects of the treatment?

4.Cover the application with a warm, moist dressing and an occlusive outer wrap. Penetration of topical corticosteroid therapy can be enhanced by applying warm, moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or similar item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic adverse effects. The medication is applied but not rubbed into the skin. Dry sterile dressings are not used. A heat lamp can cause a burn injury.

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term?

4.Ecchymosis Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

4.Elevated hematocrit levels The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia, and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity?

4.Erythema Cellulitis presents with erythema (redness), which is localized inflammation. Options 1, 2, and 3 are not signs or symptoms of cellulitis.

An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area?

4.Greater trochanter The greater trochanter is at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position. When the client is lying supine, the heels, sacrum, and back of the head all are at risk, as are the elbows and scapulae.

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary?

4.High pressure alarm keeps sounding on the ventilator A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?

4.Keep the client on NPO (nothing by mouth) status The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.

The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present?

4.Multiple straight or wavy thread-like lines underneath the skin Scabies can be identified by the multiple straight or wavy thread-like lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.

The nurse is performing an assessment on a client with a diagnosis of pemphigus vulgaris. How should the nurse assess for the presence of Nikolsky's sign?

4.Note skin blistering and sloughing with finger pressure. Nikolsky's sign, epidermal blistering and sloughing precipitated by lateral finger pressure, commonly is present in pemphigus vulgaris. Option 3 identifies an assessment technique to determine the presence of a Candida infection in the mouth. Draining blisters are not characteristic of this disorder. Although a foul odor may be noted from the skin of a client with this disorder, this characteristic is not related to Nikolsky's sign.

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

4.Partial-thickness skin loss of the dermis In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulceration with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

4.Partial-thickness skin loss of the dermis In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition?

4.Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs Acute frostbite is treated ideally with rapid and continuous rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because they can contribute to increased cellular damage. Cold or hot water is not used. Thawing can cause considerable pain, and the nurse administers analgesics as prescribed.

A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound?

4.Semipermeable film dressing Semipermeable film dressings are used on superficial wounds, on ulcers, and occasionally on some deep, draining, or necrotic ulcers. These dressings have the advantage of staying in place for several days, allowing tissues to heal underneath. Dry sterile dressings would stick to the wound and are inappropriate. Wet to dry dressings are unnecessary because the tissue does not need debridement. Gelfoam sponge dressings are a type of enzyme dressing used in the treatment of necrotic tissue.

The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure.

4.Stage IV pressure ulcer In a stage IV pressure ulcer, there is full-thickness tissue loss with exposed bone, tendon, or muscle. Eschar or slough may be present in some parts of the wound. In a stage II pressure ulcer, there is partial-thickness loss of the dermis manifesting as a shallow open ulcer with a pink/red wound bed and no slough. In a stage III pressure ulcer, there is full-thickness tissue loss with subcutaneous fat visible but no exposure of tendon or muscle, and slough may be present. Deep tissue injury appears as localized areas of purple or maroon discolored intact skin or a blood-filled blister.

The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort?

4.Take baths twice daily using a dilute solution of alcohol and water. One bath or one shower per day for 15 to 20 minutes with warm water and a mild soap should be followed immediately by the application of an emollient to prevent evaporation of water from the hydrated epidermis. The client should avoid using a dehumidifier because this will further dry room air. The client should be instructed to avoid applying rubbing alcohol, astringents, or other drying agents to the skin. A bath using a dilute alcohol solution will cause further drying of the skin.

The nurse prepares to assist the primary health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care?

4.Tell the client that the procedure is painless. A Wood's light examination is a painless procedure. The skin does not need to be shaved, and a local anesthetic is not necessary. Examination of the skin under a Wood's lamp is always carried out in a darkened room. This is a noninvasive examination; therefore, an informed consent is not required. A hand-held long-wavelength ultraviolet light source or Wood's lamp is used. Areas of blue-green or red fluorescence are associated with certain skin infections.

Which information should the nurse include while providing education for a client scheduled for a rhinoplasty?

4.The nasal bone is fractured, and the cartilage and bone are remolded into the desired shape. In a rhinoplasty procedure, the nasal bone is fractured, excess tissue is removed, and cartilage and bone are remolded into the desired shape. The client usually receives a local anesthetic in combination with intravenous sedation or general anesthesia. The packing is removed on the day after the surgery, and the splint remains in place for 1 week. Incisions are made inside the nose, so scars are not visible.

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase?

4.The period from the time the burn was incurred to the time when the client is considered physiologically stable The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society.

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.

According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%.

An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply.

1,3,4,5 When the client is lying supine, the heels, sacrum, and back of the head are all at risk, as are the elbows and scapulae. The greater trochanter and ankles are at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position.

The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure?

2.Apply an emollient lotion to the skin to enhance softening. The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days; however, soaking for 1 hour 6 times daily is excessive and could lead to skin breakdown. The skin should not be scrubbed vigorously because this action also could lead to skin breakdown. The skin should be patted dry, and a lubricating lotion should be applied. The client should avoid overexposing the skin to the sunlight.

The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions?

3."I need to assess my skin for lesions that appear net-like." Reticular skin lesions resemble a net in appearance. Linear lesions appear in a straight line, whereas annular lesions are ring shaped. Arciform lesions are shaped like an arc.

The nurse has provided home care instructions to a client after blepharoplasty. Which statement by the client indicates a need for further instruction?

1."I need to keep ice on my eyes for at least 3 days." Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Home care instructions after blepharoplasty include the administration of cool compresses for 24 (not 72) hours. Vigorous activities, such as sports, need to be avoided for 1 month. Because lying on the side increases the possibility of swelling in the dependent eye area, the client should sleep supine with at least 2 pillows to elevate the head. The client should understand the importance of not bending over at the waist for the first 48 hours after the procedure. Bending would increase pressure to the operative area.

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn?

1.9600 mL of lactated Ringer's solution The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.

The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition?

1.Acne Acne is characterized by vesicles filled with cloudy or purulent fluid. Freckles are flat lesions less than 1 centimeter. Psoriasis is presented by elevated, plateaulike patches more than 1 centimeter. Sebaceous cysts are nodules filled with either liquid or semisolid material that can be expressed.

The nurse expects to note which prescription for a client with a skin infection that extends into the dermis?

1.Applying warm compresses to the affected area Warm compresses may be prescribed to decrease the discomfort, erythema, and edema associated with a skin infection that is characteristic of cellulitis. The nurse should also provide supportive care as prescribed to manage associated symptoms such as fever or chills. After tissue and blood are obtained for culture, antibiotics are initiated. Heat lamps can cause more disruption to already inflamed tissue. Iced compresses are not prescribed because they can damage tissue.

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply.

2,3 Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions are most commonly found on the upper back and legs and on the soles and palms of persons with dark skin.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply.

2,3 Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions may occur any place on the body, especially where birthmarks or new moles are apparent.

The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use?

2.Skin breakdown When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. Options 1, 3, and 4 are not complications.

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?

3."Take a shower immediately, lathering and rinsing several times." When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply.

4,5 Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.

An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank.

According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.

The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply.

1,2 Psoriasis lesions appear as red, raised papules that may coalesce into large plaques covered by silvery scales. Eczema can manifest as tiny red vesicles that weep serous or purulent material. Erythema noted mostly under the breast area is characteristic of seborrheic dermatitis. Pink to dark red, patchy eruptions on the skin may be indicative of exfoliative dermatitis.

The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply.

1,2,3,5 Acne is a chronic skin disorder that usually begins in puberty and is more common in males. Lesions develop on the face, neck, chest, shoulders, and back. Acne requires active treatment for control until it resolves. The types of lesions include comedones (open and closed), pustules, papules, and nodules. The exact cause is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes (and the enzymes that reduce lipids to irritating fatty acids). Exacerbations coincide with the menstrual cycle because of hormonal activity. Oily skin and a genetic predisposition may be contributing factors.

A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply.

1,2,3,5 Erythema (or redness) of the skin can be caused by vasodilation from high environmental temperatures, fever, or inflammation. The presence of deoxygenated hemoglobin is responsible for cyanosis of the skin.

The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply.

1,2,3,5 Unconscious clients are completely immobile, having lost the protective reflexes to shift body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours. Use of a bed cradle can protect the client's toes from breakdown due to weight from linens. Protective pads can be applied to the heels and elbows to reduce friction and shear. Appropriate perineal care is essential to keep waste products from excoriating the skin. The nurse can reduce skin dryness and irritation by adding a superfatty solution (i.e., baby oil or castile soap) to the daily bath water. Drying agents such as alcohol are avoided because dry skin can crack and break down.

A client with severe psoriasis has a problem of chronic low self-esteem. The nurse should incorporate which nursing action when working with this client?

1.Listening attentively Clients with chronic skin disorders may experience chronic low self-esteem because of the disorder itself and possible rejection by others. The nurse demonstrates acceptance of the client by using a quiet, unhurried manner and by using appropriate visual contact, facial expression, and therapeutic touch. Communications that seem brief and formal may reinforce the feelings of rejection, as well as avoidance of looking at the affected skin areas.

The nurse in the ambulatory care clinic is reviewing a plan of care for a client who will be returning from the postanesthesia care unit after a blepharoplasty. Which nursing interventions should be a component of the postoperative care plan for this client? Select all that apply.

1,2,4,5 Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Postoperatively, the client is assessed for swelling, bruising, bleeding, and eye pain. The head of the bed should be elevated, and cool eye compresses are applied to the area to reduce swelling. The client is instructed to avoid the Valsalva maneuver, which increases intracranial pressure and also pressure in the head and eye, thereby increasing the risk of hemorrhage. The function of extraocular eye muscles also is assessed. Gauze pads are not used because cotton is thick and pulls the skin when it is removed; in addition, warm compresses will increase the swelling.

The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply.

1,3 Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first?

1.Nails Paronychia is a fungal infection that most often is caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The affected area generally is tender to touch and has purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. A variety of disorders may involve the epithelial skin layer

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

1.Return of distal pulses Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

Which individuals are most likely to be at risk for development of psoriasis? Select all that apply.

2,3,4 Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. Various forms exist, with psoriasis vulgaris being the most common type. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a cause. The disorder also may be exacerbated by the use of certain medications. Psoriasis occurs equally among women and men, although the incidence is lower in darker-skinned races and ethnic groups.

The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply.

2,3,5 The client with a diabetic ulcer needs to take strict precautions and implement very specific measures to allow for wound healing. Interventions include washing the feet with warm (not hot) water daily with a mild soap, using lanolin to prevent drying and cracking, wearing closed-toed shoes that are well fitting and avoiding high-heel and open-toed shoes, and exercising the feet daily by walking and flexing at the ankle to promote circulation.

The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching?

2."I can sit in my favorite chair all day." Sitting in one position all day can be a risk factor for pressure ulcer development. Options 1, 3, and 4 are preventative measures for pressure ulcer development.

A client is seen in the health care clinic 2 weeks after rhinoplasty. The client tells the nurse that the upper lip is numb. Which nursing response would be appropriate?

2."In many cases the nose and upper lip are numb for up to 6 months." The nurse should instruct the client that after this procedure ecchymosis will last approximately 2 weeks, and the nose and upper lip may be numb for approximately 6 months. Options 1, 3, and 4 are inappropriate and inaccurate nursing responses.

Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction?

2."The UV light treatments are given on consecutive days." UV light treatments are limited to 2 or 3 times a week and are not given on consecutive days. Safety precautions are required during UV light therapy. It is best to expose only those areas requiring treatment to the UV light. Protective wraparound goggles prevent exposure of the eyes to UV light. The face should be shielded with a loosely applied pillowcase if it is unaffected. Direct contact with the lightbulbs of the treatment unit should be avoided to prevent burning of the skin.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?

2.A skin infection of the dermis and underlying hypodermis Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis.

A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound?

2.Autograft A full-thickness burn will require terminal coverage with an autograft-the client's own skin. Biobrane is porcine collagen bonded to a silicone membrane, which is temporary and lasts anywhere from 10 to 21 days. Homografts (cadaveric skin) and xenografts (pigskin) provide temporary coverage of the wound by acting as a dressing for up to 3 weeks before rejecting.

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply.

4,5 Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.

The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction

4."I should apply a lubricant to my skin after bathing when my skin is thoroughly dry." The client should be instructed that a lubricant is applied immediately after the bath, while the skin is still damp, to help increase hydration of the stratum corneum. Options 1, 2, and 3 are appropriate home care measures to control the symptoms associated with pruritus.

The nurse provides home care instructions to a client diagnosed with impetigo. Which statement by the client indicates the need for further instruction?

4."It is not necessary to separate my linens and towels from those of other household members." The client needs to separate his or her linens and towels from those of other household members. Thorough hand washing, separating linens and towels, and separate washing of the client's dishes are required because the infection is contagious so long as skin lesions are present. Antibiotics are administered and should be continued as prescribed.

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

4.A white color to the skin, which is insensitive to touch Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.