Chapter 75 - Skin Disorders complete
Which of the following clients would be the most likely candidate for a pedicle graft? A) A client with a stage II decubitus ulcer B) A client with third-degree burns on his hand C) A client with severe eczema D) A client with a keloid behind the ear
B
A client is brought to the community health clinic after he was rescued from a burning building. The client has minor burns on 20% of his head and neck. What is the priority nursing intervention for this client? A) Dress the burns with salve. B) Wrap the burns with sterile bandages. C) Monitor the client's respiratory status. D) Insert a feeding tube before edema sets in.
C
A client presents at the emergency room with a cut on his hand caused by using a serrated knife to cut a bagel. What is another term for this type of skin alteration? A) Abrasion B) Excoriation C) Laceration D) Desquamation
C
A client presents with skin that is moist and pinkish with blisters and some blanching. What degree of burns would the nurse document? Group of answer choices a) Second degree: deep thermal, partial thickness b) First degree: superficial, partial thickness c) Second degree: superficial, partial thickness d) Third degree: full thickness
C
A nurse is caring for a client with full-thickness burns on the entire left side of the body following an accidental oil spill. Which of the following complications can occur during the recovery period from a burn injury? A) Asthma B) Hay fever C) Anemia D) Leukemia
C
The American Cancer Society has developed a helpful ABCD rule for evaluating a mole. Which of the following is one of these guidelines? A) Asymmetry: one-half the mole matches the other half B) Border: edges are regular and defined C) Color: color is not uniform and has varying shades D) Diameter: size is smaller than that of a pencil eraser
C
The nurse is preparing a therapeutic bath for a patient recovering from third-degree burns. Which of the following is a recommended guideline for this procedure? A) Give the bath in a standard tub, not a whirlpool tank. B) Use water that is as hot as the client can tolerate. C) Use medicated bath oil instead of soap. D) Rub the client's skin dry after the therapeutic bath.
C
The nurse is providing discharge teaching for a client who suffered minor burns using a steam cleaner. Which of the following are accurate teaching points for this client? A) Use ice to cool the area for 10 minutes or until the pain diminishes. B) If blisters occur, puncture the blisters with a sterile needle. C) Cover the burn loosely with sterile gauze. D) Do not use over-the-counter NSAIDs for pain; use only prescribed drugs.
C
The nurse is using wet-to-moist dressing to debride a client's decubitus ulcer. Which of the following types of debridement is the nurse employing? A) Autolysis B) Enzymatic debridement C) Mechanical debridement D) Surgical debridement
C
The nurse recognizes the signs and symptoms of angioedema when treating a client in the emergency room and documents "swelling around the eyes and dyspnea (difficulty breathing)." With what condition is angioedema associated? A) Vitiligo B) Warts C) Urticaria D) Folliculitis
C
What teaching should the nurse impart to clients with eczema? A. Use soaps that are more alkaline B. Use lotions containing lanolin C. Use a lotion containing menthol D. Take starch baths daily
D
Which is a precautionary measure to be followed to prevent an accident when handling electric equipment? Group of answer choices A. Always use multiple outlet plugs B. Tape the frayed cord of equipment before use C. Ensure cords are concealed under a rug D. Keep water heater's thermostat set lower than 120F
D
Which types of diet would be prescribed for a client with a third-degree, full thickness burn on 30% of the body? Group of answer choices a) High calorie, high carbohydrate b) Low calorie, high protein c) Low calorie, high carbohydrate d) High calorie, high protein
D
Which would be the most likely candidate for a pedicle graft? Group of answer choices a) A client with a stage II decubitus ulcer b) A client with a keloid behind the ear c) A client with severe eczema d) A client with third-degree burns on his hand
D
The nurse is teaching a patient who has severe skin allergies how to treat and prevent rashes. Which of the following are recommended teaching guidelines? Select all that apply. A) Take hot baths or showers. B) Do not use make-up. C) Wear clothing made of wool. D) Rinse clothes in clear water. E) Lightly slap the itching area. F) Keep fingernails short.
D, E, F
Radiation
How would the nurse classify the source of a sunburn?
chronic skin condition producing red lesions covered with silvery scales; chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches.
Psoriasis
Tinnitus
Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client knowing that which would indicate the presence of systemic toxicity from this medication?
Apply warm compresses to the affected areas.
A nurse is reinforcing teaching with a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include?
Administer psoralen medication before the treatment
A nurse is reinforcing teaching with a client who has a history psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instruction should the nurse include in the teaching?
Place the child in a bath with with colloidal oatmeal.
A nurse is reinforcing teaching with the parent of a child who has contact dermatitis. Which of the following information should the nurse include?
Color: color is not uniform and has verying shades
The American Cancer Society has developed a helpful ABCDE rule for evaluating a mole. Which is one of these guidelines?
Warts
A client with a skin disorder is undergoing electrodesiccation. For which disorder is this a common treatment?
What makes the eyebrows a common site for seborrheic dermatitis to develop? Group of answer choices a) Large concentration of sebaceous glands b) Large number of hair follicles c) Thicker dermal tissue d) Increased number of pigment cells
A
A client arrives at the healthcare facility with complaints of purplish-blue discoloration of the skin on his arm that developed after an accident. Which of the following terms should the nurse use to document the skin lesion? A) Purpura B) Desquamation C) Laceration D) Dermatitis
A
A client has been admitted to a healthcare facility with extensive burns. Which should the nurse perform soon after admission? A. Assessment of vital signs B. Application of synthetic dressing C. Preparation for wound debridement D. Preparation for whirlpool treatment
A
A client is admitted to a healthcare facility with 30% full-thickness burns. What should be the goal when caring for the client with these burns during the resuscitative phase? A) Achieve physiologic stability. B) Focus on managing the burn wound. C) Focus on physical repair of the tissue. D) Psychological restoration of the individual.
A
A client with a skin disorder is undergoing electrodesiccation. For which of the following disorders is this a common treatment? A) Warts B) Impetigo C) Carbuncle D) Scabies
A
A client with psoriasis is prescribed a topical application of Dovonex (calcipotriene). Which his achieved through the use of Dovonex? A. It slows the development of skin cells B. It softens the scales C. It reduces the skin edema D. It retards skin inflammation
A
A client with severe burns is undergoing a skin graft made from cadaver skin. What is the term for this type of graft? A) Homograft B) Autograft C) Isograft D) Xenograft
A
A nurse is caring for a client with a filiform wart. The nurse understands that filiform warts are nonmalignant. Which of the following is another type of nonmalignant tumor of the skin of which the nurse should be aware? A) Angioma B) Varicose veins C) Ganglion D) Ecchymosis
A
The nurse is applying a moist dressing on the arm of a patient with acute dermatitis. Which of the following nursing interventions would be appropriate when performing this procedure? A) Follow standard procedures. B) Premoisten the area with alcohol. C) Use a bed cradle when applying the dressing. D) Medicate with analgesics following the procedure.
A
The nurse performing a physical examination of a client with pruritus suspects the client has urticaria. Which of the following symptoms would the nurse document in this situation? A) Edematous, raised pink wheals that itch and burn B) Areas of the skin that are completely lacking in pigmentation C) Small vesicles with reddened and pruritic skin that is sometimes crusted D) Small, scaly patches of skin
A
A client is prescribed the antihistamine fexofenadine (Allegra) for severe seasonal allergies. Which of the following teaching points are appropriate for this client? Select all that apply. A) Warn the client not to drive or work around machinery. B) Urge the client to avoid using alcohol and other sedatives. C) Encourage the client to drink only water when taking the medication. D) Discontinue the antihistamine for 2 weeks before allergy testing. E) Use sunscreen to avoid photosensitivity reactions. F) Warn older adults that a larger dose may be required owing to the effects of aging.
A, B ,E
22.5%
An adult client trapped in a burning house 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, the nurse determines the extent of the burn injury to be which percentage?
A nurse is caring for a client with severe burns who has developed skin ulcers. Which of the following are other complications associated with burn injury? Select all that apply. A. Hypostatic pneumonia B. Kidney failure C. Asthma D. Curling ulcers E. Angioma
ABD
tumor composed of blood vessels; birthmark, vascular skin tumors, involving underlying tissues and blood vessels
angioma
Sanguineous
bloody
Serous
clear, watery plasma
debridement
to remove loose skin, crusts, or denuded tissue
Cryotherapy
treatment of applying liquid nitrogen to remove warts
localized loss of skin pigmentation characterized by milk-white patches; areas of skin that completely lack pigmentation
vitiligo
Follow standard precaution procedures.
The nurse is applying a moist dressing on the arm of a client with acute dermatitis. Which nursing intervention would be appropriate?
Axilla
The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication is being applied to which body area?
"I should apply an antibiotic ointment to the area."
A nurse is reinforcing discharge instructions with a client who had a skin biopsy with sutures. Which of the following client statements indicates that the teaching has been effective?
What is the priority observation of the nurse caring for a client diagnosed with psoriasis? Group of answer choices a) Skin infections b) Pigment changes c) Low self-esteem d) Difficulty breathing
A
Intravenous
A nurse is assisting with the care of a client who sustained deep partial-thickness and full-thickness burns over 60% of his body 24 hr ago and is requesting pain medication. The nurse should ensure the medication is administered using which of the following routes to administer medication?
Urinary retention
A nurse is caring for a client who has contact dermatitis and a new prescription for diphenhydramine. For which of the following adverse effects should the nurse monitor?
Inhalation injury
A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Most of the burns are full thickness burns on the arms, face, neck, and shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. These findings are indications of which of the following? Carbon monoxide poisoning
A client admitted to a healthcare facility with urticaria has developed angioedema. Which of the following findings should the nurse notify the healthcare provider of? Select all that apply. A. Small pruritic vesicles B. Respiratory distress C. Scaly patches on the skin D. Swelling around the eyes E. Extreme swelling of the lips
ADE
Ambulation three times daily
After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings?
Write the correct sequence order of actions to take in the ER for a client with a burn injury.
Assess for airway patency Administer oxygen as prescribed Obtain vital signs Assist to initiate an IV line and begin fluid replacement as prescribed Elevate the extremities Keep the client warm and place the client on NPO status
A client with a skin disorder is undergoing electrodessication. For which disorder is this a common treatment? Group of answer choices a) Carbuncle b) Warts c) Impetigo d) Scabies
B
A client with atopic dermatitis has intense pruritus. Which of the following should the nurse explain as an intervention to prevent pruritus? A) Do not wash new clothes before wearing them. B) Apply lotion on dry skin. C) Wear nylon gloves and socks at night. D) Avoid activities that cause the body to be chilled.
B
A nurse is preparing a dressing to be applied to the first-degree burns on a client's face. Which of the following should the nurse use as a topical agent in the dressing? A) Methotrexate B) Bacitracin C) Psoralen D) Calcipotriene
B
A nurse is providing enteral tube feedings for a client with third-degree burns to prevent the development of Curling's ulcer. Which of the following mechanisms is involved in the development of Curling's ulcer? A) Depletion of hydrogen ions in the gastric mucosa B) Occurrence of ischemic changes in the gastric mucosa C) Effect of medication such as cimetidine on gastric mucosa D) Proliferation of gastric mucosal cells in excess
B
A teenage client is diagnosed with psoriasis. Which of the following would be the highest priority observation of the nurse who is caring for this client? A) Difficulty breathing B) Low self-esteem C) Pigment changes D) Skin infections
B
The American Cancer Society has developed a helpful ABCDE rule for evaluating a mole. Which is one of these guidelines? Group of answer choices a) Asymmetry: one-half of the mole matches the other half b) Color: color is not uniform and has varying shades c) Border: edges are regular and defined d) Diameter: size is smaller than that of a pencil eraser
B
The nurse examining the skin of a client notices small fluid-filled blisters around the client's mouth and suspects they are caused by the herpesvirus. What test would be performed to confirm this suspicion? A) Wood's light examination B) Tzanck's smear C) Biopsy D) Scabies scraping
B
The nurse is assessing a client who arrives at the emergency room with burns on her hands from a malfunctioning coffee pot. The client's skin is moist and pinkish with blisters and some blanching. What degree of burns would the nurse document in this situation? A) First degree: superficial, partial thickness B) Second degree: superficial, partial thickness C) Second degree: deep dermal, partial thickness D) Third degree: full thickness
B
The nurse is caring for a client who has third-degree burns on 25% of her body. Which of the following is a goal for this client when managing fluid and electrolyte balance during burn care management? A) Urinary output of 1 to 1.5 mL/kg/hour B) Heart rate less than 120 beats per minute C) Systolic blood pressure greater than 150 mm Hg D) Decreased sodium levels
B
The nurse is providing discharge teaching for a client who suffered minor burns using a steam cleaner. Which teaching points should the nurse include? Group of answer choices a) Use ice to cool the area for 10 minutes or until the pain diminishes. b) Cover the burn loosely with sterile gauze. c) Do not use over-the-counter NSAIDs for pain; use only prescribed drugs. d) If blisters occur, puncture the blisters with a sterile needle.
B
Which method is used for the removal of filiform warts? A. Debridement B. Electrodessication C. Escharotomy D. Photochemotherapy
B
A client with second-degree burns has been prescribed moist dressing applications. Given below, in random order, are the steps undertaken during the application of moist dressings for a client with burn injury. Write the correct sequence. a. Apply dressing according to specific protocol b. Premedicate with analgesics and anxiolytics c. Document the observations made during the procedure d. Premoisten existing dressings with normal saline
BDAC
Indicate which are malignant (M) or benign (B) for the following neoplasms: (5 points)
Basal cell carcinoma M Pigmented nevi B Angiomas B Squamous cell carcinoma M Keloids B
A 5-year-old client is brought to a healthcare facility with complaints of head lice infestation. Which characteristic of lice manifestation should the nurse monitor this client for? A. Row of blackish dots with tiny vesicles B. Groups of eight to nine nodules C. Presence of nits inhabiting the hair D. Presence of red macular lesions
C
A client is admitted to a healthcare facility with third-degree burns. Which of the following is the extent of tissue damage seen in third-degree burns? A) Epidermis with minimal dermis involvement B) Entire epidermis and a portion of dermis C) Entire epidermis, dermis, and subcutaneous fat D) Minimal damage of the epidermis
C
A client diagnosed with basal cell carcinoma arrives at the healthcare facility along with her 16-year-old daughter. The client is worried that her daughter is also susceptible. The client's daughter asks the nurse if skin cancer is preventable. Which of the following interventions should the nurse emphasize with regard to the prevention of skin cancer? A) Avoid direct early morning sunlight exposure. B) Use sunscreen with a sun protective factor (SPF) of 12. C) Regularly use sunlamps and tanning beds rather than direct sunlight. D) Consult healthcare provider if changes in moles occur.
D
A client with complaints of itching is prescribed diphenhydramine HCI (Benadryl) by the healthcare provider. What client teaching should the nurse provide with regard to the use of antihistamine? A. Limit intake of fluids B. Avoid taking with milk C. Avoid use of sunscreen D. Avoid intake of alcohol
D
A client with seborrheic dermatitis complains of itching and large white scales over the eyebrows. Which of the following makes the eyebrows a common site for seborrheic dermatitis? A) Thicker dermal tissue B) Increased number of pigment cells C) Large number of hair follicles D) Large concentration of sebaceous glands
D
A nurse is caring for a client with full-thickness burns on the entire left side of the body. For which complications should the nurse monitor during the client's recovery period? Group of answer choices a. Leukemia b. Hay fever c. Asthma d. Anemia
D
The nurse consults a nutritionist to help plan a diet for a client who has third-degree, full-thickness burns on 30% of his body. Which of the following types of diets would the nutritionist recommend? A) Low calorie, high carbohydrate B) High calorie, high carbohydrate C) Low calorie, high protein D) High calorie, high protein
D
The school nurse is caring for a teenager who developed sunburn after being out in the sun without sunscreen at a school trip. How would the nurse classify this type of burn? A) Thermal B) Electrical C) Chemical D) Radiation
D
Deep full thickness
Damage to all layers of the skin; extends to muscle; tendons; and bones.
Deep partial thickness
Damage to the entire epidermis and deep into the dermis.
Full thickness
Damage to the entire epidermis and dermis; can extend into subq tissue; nerve damage
superficial partial thickness
Damage to the entire epidermis and some parts of the dermis
Triglyceride level
Isotretinon (Amenesteem, Clavaris.) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?
Serosanguineous
Pink-colored due to presence of a small amount of blood cells/mixed with serous
Apply a dressing that allows oxygen to pass through
The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure ulcer in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure ulcer?
The burn has probably caused laryngeal edema, which has occluded the airway.
The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless, and his color becoming dusky. The nurse should interpret this data as indicating which?
Heart rate less than 120 beats per minute
The nurse is caring for a client who has third-degree burns on 25% of her body. Which is a goal for this client when managing fluid and electrolyte balance?
Nails for shape, contour, color, thickness and cleanliness. Facial and body hair for distribution, color, quantity and hygiene. Skin for color, integrity, scars, lesions, and signs of breakdown.
The nurse is conducting a focused evaluation on a postoperative client's integumentary system. Which priority objective physical examination assessments are related to inspection? (Select all that apply.)
Use medicated bath oil instead of soap
The nurse is preparing a therapeutic bath for client recovering from third-degree burns. Which guideline is recommended for this procedure?
Wear a gown and gloves
The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?
Write the correct sequence that is undertaken during management of a burn injury. (Read carefully, Sequence may be different from the workbook) Wound dressing Physical therapy Vital signs assessment Pain management
Vital signs assessment Pain management Wound dressing Physical therapy
Monitor the client's respiratory status.
What is the priority nursing intervention for a client with minor burns on 20% of his head and neck?
Low self-esteem
What is the priority observation of the nurse caring for a client diagnosed with psoriasis?
Large concentration of sebaceous glands.
What makes the eyebrows a common site for seborrheic dermatitis to develop?
laceration
What term is used to identify a soft tissue cut caused by a serrated knife?
Lightly slap the itching area Keep fingernails short. Rinse the clothes in clear water
Which interventions should be introduced to a client for the treatment and prevention of rashes? (Select all that apply.) (1 point)
Feet Eyes Lips Tongue
Which locations on the body would the nurse assess to confirm the presence of angioedema? (Select all that apply.) (1 point)
High calorie, high protein
Which types of diet would be prescribed for a client with a third-degree, full thickness burn on 30% of the body?
A client with third-degree burns on his hand
Which would be the most likely candidate for a pedicle graft?
purulent
Yellow, gray or green drainage due to infection
Superficial thickness
damage to epidermis
boil; suppurative inflammatory skin lesion due to infected hair follicle
furuncle
pruritis
itching
neoplasm
means new growth
folliculitis
staphylococcal infection starting around the fair follicle
