Chapter 23 - Integumentary System

a, petechiae - tiny, purple spots

During change-of-shift report, the outgoing nurse reports a new finding of petechiae in a new patient admitted with a yet-to-be diagnosed hematologic disorder. On assessment of this patient, the incoming nurse may expect to find A. Tiny, purple spots on skin. B. Large ecchymotic areas on skin. C. Hyperkeratotic papules and plaques. D. Small, raised red areas on the soles of the feet.

d

During the acute phase of a burn, the nurse in-charge should assess which of the following? a. Client's lifestyle b. Alcohol use c. Tobacco use d. Circulatory status

2

Giving discharge instructions to a burn patient, the topical agent she is to apply to her wound will cause permanent staining of clothes, linen, walls and floors. Which of the following will she be using: 1. mafenide acetate ( Sulfamylon) 2. silver sulfadiazine (Silvadene) 3. bacitracin ointment 4. silver nitrate 5. O-wutagufiam

b

Inspection of an obese, female patient reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. The nurse would suspect that the odor is most likely caused by A. Ecchymosis. B. Colonization by yeast or bacteria. C. Age-related integumentary changes. D. Atrophy of the skin under the abdominal folds.

4

The friend of a friend asks you if they should take antibiotics to help get rid of their shingles. You tell them: 1. what do I look like, a doctor? 2. a hammer would probably work better 3. yes they would work fine as shingles are a bacterial infection 4. no because shingles are a virus

b

The nurse documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing? a. Inflammatory b. Migratory c. Proliferation d. Maturation

b, e

The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which of the following locations should the nurse inspect for cyanosis (select all that apply)? A. Patient's sclera B. Patient's nail beds C. Soles of the patient's feet D. Palms of the patient's hands E. Conjunctiva of the patient's eyes

a, b, d

Your niece asks you about the rash she "has grossed out for about a year" on her arm. You have knowledge of chronic skin disorders and would suspect which of the following? (select all that apply) a. vitiligo b. dermatitis c. urticaria d. psoriasis

1

Your significant other has developed scaly, crusty areas on their lower leg. They tell you that "the itching is driving me batty!" Since you are so smart, you suspect which of the following: 1. eczema 2. psoriasis 3. impetigo 4. shingles

1, 3, 5

You are helping in an elementary school and the parents want to know what you are looking for when you are looking for parasitic skin infections. You would tell them (select all that apply) 1. scabies 2. carbuncles 3. lice 4. keloids 5. bed bugs

d

A 14-year-old female and her mother have presented to their nurse practitioner seeking treatment for the daughter's acne. The nurse would recognize that acne is characterized by the presence of multiple A. Ulcers. B. Wheals. C. Vesicles. D. Pustules.

a, b, d

A client has a pressure ulcer with a large amount of necrotic tissue. Which of the following physician's orders or nursing interventions might you carry out? (select all that apply) a. enzymatic debridement b. wet-to-dry or wet-to-moist dressings c. application of a closed dressing d. a therapeutic bath e. rub the skin vigorously with gauze

B

A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is. The appropriate response by the nurse is: a. "There is no pain associated with this procedure" b. "The local anesthetic may cause a burning or stinging sensation" c. A preoperative medication will be given so you will be sleeping and will not feel any pain" d. "There is some pain, but the physician will prescribe an opioid analgesic following the procedure"

a

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? a. Scale b. Crust c. Ulcer d. Scar

a

Which nursing intervention can help a client maintain healthy skin? a. Keep the client well hydrated. b. Avoid bathing the client with mild soap. c. Remove adhesive tape quickly from the skin. d. Recommend wearing tight-fitting clothes in hot weather.

c

Which of the following laboratory tests would be most important to check in a patient presenting with purpura? A. Urinalysis B. Serum electrolytes C. Coagulation studies D. White blood cell count

b

Which of the following medications are the most likely to have an effect on the patient's integumentary system? A. Diuretic B. Corticosteroid C. Benzodiazepine D. Calcium channel blocker

d, Wool is itchy!

Which of these statements by the client with pruritus requires the need for reteaching? a. "I will avoid using fabric softeners because harsh chemicals may irritate" b. "I will shower after I get out of the pool" c. "I will take only cool or lukewarm baths" d. "I will wear wool gloves to prevent scratching my skin"

2

You are assessing a baby and notice small, pimplelike protrusions on her cheeks. These protrusions are called: 1. pustules 2. papules 3. vesicles 4. macules

3, xenograft (1 is an autograft, 2 is an isograft, 4 is a homograft)

a recent recipient of a xenograft asked what the heck it was, so you told him: 1. we took a piece of your skin from somewhere else and put it where you needed it 2. we took a piece of skin from your twin and placed it where you needed it 3. we took a piece of skin from an animal and placed it where you needed it 4. we took a piece of skin from another person and placed it where you needed it

2, 91% = both arms (18), both legs (36), torso (36), groin (1)

the victim of a chemical burn received second and third degree burns both her arms, both her legs, her entire torso and her groin. what percentage of burn has she suffered? 1. 90% 2. 91% 3. 64% 4. 99%