Chapter 12 Integumentary Disorders

The client diagnosed with stage 4 infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?

"Stool will come out an opening in my abdomen so it wont get in the sore."

The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response?

"The graft will come from an animal, probably a pig."

The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer.

Adequate peripheral circulation to both feet ensured.

The nurse is caring for a client who has developed stage 4 pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority.

Altered nutrition.

The nurse in the long-term care facility must delegate a nursing task to an UAP. Which nursing task would be most appropriate to delegate?

Comb the nits out of the client's hair.

The paraplegic client is being admitted to a medical unit from home with a stage 4 pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?

Complete the Braden Scale

The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychological problem of "fear." Which nursing interventions should be included in the plan of care?

Encourage the client to verbalize the feeling of being afraid.

The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement?

Encourage the client's family to bring favorite foods.

The client is complaining of burning, lancinating, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement?

Ask the client if he or she has ever had chickenpox.

The nurse writes the problem "impaired skin integrity" for a client with stage 4 pressure ulcers Which intervention should be included in the plan for care? Select all that apply.

Ask the dietitian to consult.

The male client diagnosed with acquired immunodeficiency syndrome (AIDS) states that he has developed a purple-brown spot on his calf. Which action should the nurse do first?

Asses the lesion for size, color, and symmetry.

The nurse is teaching a class on hoe to prevent Lyme disease. Which intervention should be included in the discussion?

Avoid dense undergrowth when in a wooded area.

The ICU burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority?

High risk for infection.

The nurse writes the nursing diagnosis "impaired skin related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis?

Clean the clients wounds, body, and hair daily.

The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client?

Place hand in cool water.

The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which intervention should the nurse implement? Select all that apply.

Place the client in contact isolation, administer a corticosteriod IVP, asses the client;s pain on a 1-to-10 scale, and ensure that only nurses who have had chickenpox care for this client.

The nurse observes the UAP squeezing the "blackheads" on an elderly client. Which action should the nurse implement first?

Instruct the assistant to stop this behavior.

The female client calls the clinic and tells the nurse that she has a really big "boil" in the perineal area that is causing a lot of pain. Which intervention should the nurse implement?

Instruct the client to apply warm water, moist compresses to the area.

The female teacher comes to the school nurse's office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement?

Instruct the teacher to go to her HCP today.

The public health nurse is providing a class on skin disorders in the African American community. Which information should the nurse include in the presentation?

People with dark skin suffer the same skin conditions as people with light skin.

Which nursing intervention should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.

Perform meticulous hand hygiene, use sterile gloves for wound care, wear gown and mask during procedures, and administer antibiotics as prescribed.

The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?

Replace fluids and electrolytes.

Which skin condition would most likely occur in the areas underneath the armpits, and high between the legs?

Scabies

The nurse is admitting an 88 year old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the UAP?

Set up the isolation equipment for the client.

The client has tinea pedis. Which intervention should the nurse teach to the client?

Soak feet in a vinegar-and-water solution.

The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health?

Tell the client to remember that changes in lifestyle take time.

The nurse is caring for clients on a medical unit. After the shift report, which client should the asses first?

The 78-year-old client with the pressure ulcers who has a temperature of 102.3 degrees Fahrenheit.

The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?

The UAP asks to take a meal break before turning the clients at the 2 hour time limit.

The client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse?

The client is unable to remove the wedding ring.

Which client is at the greatest risk for the development of skin cancer?

The client with fair complexion who cannot get a tan.

With deep thickness and partial burns to the chest area. Which one should notify hcp?

The client's urinary output is 50 mL in two(2) hours.

The client is diagnosed with herpes simplex 2 and prescribed the antiviral medication valacyclovir (Valtrex) Which instructions should the nurse teach?

This medication will suppress symptoms but does not cure the disease.

The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate?

Use a magnifying glass and a penlight to visualize the skin.

The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?

Use a pillow to keep the heels off the bed when supine.

The 55 year old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox?

Varicella pneumonia

The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is "tired of it all" Which is the nurse's best therapeutic response?

"Are you tired of the treatment and needing to be cared for?"

The school nurse s discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, "How can I prevent getting impetigo?" Which statement would be the most appropriate response.

"Do not touch any affected area without gloves."

The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?

"I had to fix my daughter's hair with my brush."

The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220lbs. and the order reads 10mg per kilogram per day to be administered in equally divided doses every 6 hours. How many milligrams will be administered in one dose?

250 mg

Which individual would most likely experience the skin disorder pseudofolliclitis barbae (shaving bumps)?

A male African American soldier.

The client with thick, crusty, yellow toenails is diagnosed with tinea unguium (onychomycosis) and asks the clinic nurse what happens if he cant afford to take the medication the physician prescribed. The nurse's response will be based on which scientific rationale?

The toenail plate will separate and the entire toenail may be destroyed.

The client comes to the clinic complaining of sudden onset of high fever, chills, and a headache. The nurse assesses a patchy macular rash on the trunk and a circular type of rash that looks like an insect bite. Which question would be most appropriate for the nurse to ask during the interview?

"Have you been deer hunting in the last week."

Which statement by the client diagnosed with chickenpox indicates that the client understands the teaching?

"I should not scratch myself if at all possible. It might lead to scarring."

The client has had a squamous cell carcinoma removed from the lip. Which discharge instructions should the nurse provide?

Notify the HCP if a nonhealing lesion develops around the mouth.

The client is diagnosed with acne vulgaris. Which psychosocial problem is priority?

Body image disturbance.

The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to touch, and the client has a temperature of 100.8 degrees Fahrenheit. Which condition would the nurse suspect the client is experiencing?

Cellulitis

The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers?

Constant perineal moisture.

The nurse is assessing a young mother who came to the clinic complaining of sores on her skin. Which assessment data would support that the client has chickenpox?

Crops of lesions that have pus and reddened base.

The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?

Deep partial thickness

The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include?

Demonstrate care of the surgical site.

The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP?

Discuss problems the client and position the clients for the examination.

The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement?

Discuss the need to dry the groin area thoroughly after bathing.

The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client?

Do not engage in oral sex if you have a cold sore on the mouth.

The nurse writes the client problem of "acute pain and itching secondary to bacterial skin lesions." Which intervention should be included in the care plan? Select all that apply.

Maintain a cool environment, use a mild soap for sensitive skin, and apply skin lotion after bathing.

The HCP prescribed Kwell lotion to be applied to the entire body. Which instructions should the nurse teach the client concerning this medication?

Make sure that the skin is completely dry before applying it to the body.

The female client admitted for an unrelated diagnosis asks the nurse to check her back because :it itches all the time in one spot."When the nurse assesses the client's back, the nurse notes an irregular-shaped lesion with some scabbed over areas surrounding the lesion. Which action should the nurse implement first?

Measure the lesion and note the color.

The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?

Perform a through skin check monthly.

The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client's fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data?

Scabies

The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first?

The client scheduled for a skin biopsy who is crying.

The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal?

The client will not develop a secondary bacterial infection.

Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion?

The client will state a diminished level of pain?

The long-term care nurse has received the a.m. shift report. Which client should the nurse assess first?

The client with a stage I pressure ulcer.

The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse?

The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.

The wound care nurse documented a client's pressure ulcer on admission as 3.3 cm x 4.0 cm stage 2 on the coccyx. Which information would alert the nurse the the client's pressure ulcer is getting worse?

The coccyx wound extends to the subcutaneous layer and there is drainage.

Which client would most likely be at risk for the development of a carbuncle?

The female diagnosed with diabetes mellitus.

The nurse participating in a health fair is discussing malignant melanoma with a group of clients. Which information regarding the use of sunscreen is important to include?

The higher the number of the sunscreen, the more it blocks UV rays.

The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma?

The lesion is asymmetrical and has irregular borders.

What is the scientific rationale for placing lift pads under an immobile client?

The pads will help prevent friction shearing when repositioning the client.

The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?

Turn client who are immobile at least every two (2) hours.

The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain is at a "5" on a 1-to-10 scale. Which intervention should the nurse implement?

Turn on soft music and shut the blinds.

There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of the parasitic infection?

Wear gloves when providing hands-on care for a client with scabies.

The nurse in a dermatology clinic is taking the history of a client. Which questions should the dermatology nurse ask the client? Select all the apply.

When did you first notice the skin problem., What cosmetics or skin products do you use, have you experienced any loss of sensation, do you experience any itching, burning, or tingling?