integumentary EAQ 2

Which teaching point would the nurse provide to help an aging client prevent skin complications related to decreased sebum gland production?

do not squeeze

Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct.

all

Which instructions would be taught to a client who is diagnosed with psoriasis and is prescribed corticosteroids? Select all that apply. One, some, or all responses may be correct.

apply the medication directly apply the medication using

A client reports fever, redness, skin breakdown, and inflammation on the leg. Upon assessment, the nurse finds the area to be tender and edematous with diffused borders. The nurse would anticipate teaching the client about which condition?

cellulitis

When teaching an older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding?

i should apply

A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary health care provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action would the nurse take?

refuse

Which abnormal condition would the nurse suspect when assessing a client with dermatitis on overlying surfaces of the skin?

intertrigo

Twelve hours after sustaining full-thickness burns to the chest and thighs, a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/h for the past 10 hours. No bowel sounds are heard. Which action would the nurse take?

moisten the client's lips

Which dressing technique promotes autolysis in the spontaneous separation of necrotic tissue?

moisture-retentive covering

A client who has smoked tobacco for many years has noticed lesions on the mouth and lips. Which condition would the nurse suspect?

squamous cell

The nurse is providing postoperative care for a client and assesses that the skin around the client's T-tube is raw and excoriated. Which intervention would the nurse implement?

use a skin barrier around

The nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly?

cantaloupe

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. Which is the nurse's best response?

this type of schedule

Which disorder would the nurse suspect in the client who has blue nail beds?

cardiopulomary

A client who underwent spinal surgery reports pain at bony prominences and has skin breakdown and tears. Which interventions performed by the nurse would be included in the plan of care? Select all that apply. One, some, or all responses may be correct.

cleansing removing changing

The nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse is observing the dressing change procedure. Which initial action would the observing nurse take?

discuss the incident

How would the nurse arrange the order of steps in normal wound healing in the proliferative phase?

formation contraction buildup formation migration growth

For which medication would the nurse monitor the serum creatinine and blood urea nitrogen (BUN) levels, when administered to a client receiving therapy for extensive burn wounds?

gentamicin sulfate

The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow?

high caloric intake, liberal potassium intake, and 3g protein/kg

Which technology will be used for the treatment of electrical burns?

hyperbaric oxygen

The nurse has instructed the client about effective ways of reducing burn injury. Which statement made by the client shows ineffective learning?

i will set the bathing water

A client with third-degree burns asks the nurse, "Why do I need a temporary pigskin graft?" Which response by the nurse is appropriate?

it promotes rapid

A client with a full-thickness burn receives an allograft. Several days later the client points out that the graft is coming off at the edges. Which response by the nurse is accurate?

its a temporary

Which action would the nurse implement for a client who has a portable wound drainage system in place after surgery?

maintain compression

Which type of gauze and technique would the nurse use when changing the dressings on a client's hand that has deep partial-thickness burns?

non cotton backed; placing a hand roll

How would the nurse prepare a client for cranial surgery?

obtain

The nurse asked the student nurse to care for a client whose dermal-epidermal junction is flattened. On assessing the client, the registered nurse observes that the risk for skin tears is increased. Which action of the student nurse may have resulted in this condition?

taping the client

The nurse is teaching the student nurse about vascular changes of the skin. Which statement would the nurse use while describing the image shown below?

these are normal markings

A pregnant client is noted to have a yellow-orange discoloration of the ears and nose and an increased level of serum carotene. Which condition might be affecting the client?

thyroid

Which information may be obtained by palpation? Select all that apply. One, some, or all responses may be correct.

turgor texture lesions moisture

The nurse observes the student nurse caring for the skin of the client who recently underwent radiation therapy. Which actions made by the student nurse would the nurse correct? Select all that apply. One, some, or all responses may be correct.

using a washcloth drying the irradiated removing the ink markings

Which figure would the nurse identify as a primary skin lesion?

3

While assessing the skin of a light-skinned client, the nurse concludes that the client has ecchymosis. Which skin color variation would confirm this diagnosis?

dark red

Which body part would be examined to assess for jaundice in a dark-skinned client?

hard palate

A client admitted with a burn injury has erythema and mild swelling. Which type of burn would the nurse suspect?

1st

Which image shows wound healing by secondary intention?

2

The nurse is caring for a client with burns receiving opioid analgesics and who is sedated. Which medications would the nurse anticipate to be prescribed to overcome this side effect of the opioid analgesics? Select all that apply. One, some, or all responses may be correct.

pregabalin gabapentin

Which integumentary manifestation would the nurse identify in a client with CD4+ count of 180/mm3 (200/uL)?

delayed wound

Which physiological abnormality might occur in the client diagnosed with a dysfunction of the eccrine glands? Select all that apply. One, some, or all responses may be correct.

drying of surface cells decreased efficiency decreased excretion

Which instruction would the nurse include in a teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma?

empty the pouch

A client has a diagnosis of superficial partial-thickness burns. The client asks which layers of skin are involved with this type of burn. Which response by the nurse is appropriate?

the epidermis

A client with a reddish-blue generalized skin alteration is hospitalized. Laboratory findings show an increase in the overall amount of hemoglobin. The nurse would expect to teach the client about which condition?

polycythemia

The nurse is preparing to administer preoperative medication to a client scheduled for incision and drainage of a wound abscess. Which action is essential before the nurse administers the medication?

verify consent

Which intervention relieves integumentary itching, promoting comfort of the client exposed to poison ivy?

wet

When teaching a client with pruritus about personal care interventions, which client statement indicates understanding of the interventions?

i will trim my fingernails

Which action would be the nurse's first priority when receiving a client with major burns?

assessing airway patency

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first?

evaluate whether the client

The nurse is caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. Which primary short-term outcome established by the nurse and client will be added to the care plan?

the client's pain

Which finding would the nurse identify as normal inflammation versus an infection when assessing a client's wound that was sutured 72 hours ago?

a slight red border

Which information would the nurse include in a teaching plan for a client whose burns are being treated with the exposure (open) method?

aseptic

A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which response by the nurse would be the best explanation to give to the client?

bed rest limits muscle

A primary health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. The application of local heat transferring temperature to the body is which principle?

conduction

Which client actions may worsen the symptoms of decreased eccrine and apocrine gland function? Select all that apply. One, some, or all responses may be correct.

frequent bathing with hot water applying moisturizer

A client has burn injuries from an electrical current. Which interventions would be used as first aid until the client is transferred to a health care facility? Select all that apply. One, some, or all responses may be correct.

leave wrap remove

The primary health care provider advises the client to apply 0.9% spinosad topical suspension to scalp and hair. Which causative organism would the nurse anticipate for the client's condition?

lice

Which lesion may alter skin turgor?

lichenification

Which personal protective equipment will the nurse plan to wear when providing central venous access device site care?

mask

A client develops sepsis after severe burn injuries. For which complication is the client at high risk?

paralytic ileus

The nurse is caring for a client with a body surface burn injury of 55%. Which information will the nurse consider when planning care for this client?

is prone to poor healing

Identify the type of bacterial infection from the figure.

cellulitis

Which action would the nurse take to assess a client for a fungal infection of the toenails?

determining

What would the nurse infer from this image?

herpes

Which etiology is associated with intertrigo in clients?

obesity

Which normal vascular markings on the skin can be identified in the image?

cherry

A client with a skin infection in the axilla reports a small, red lesion filled with pus. Upon assessment, the nurse notices the area to be erythematous and tender on palpation with noticeable pus. The nurse would anticipate teaching the client about which condition?

furuncle

An older adult client with postherpetic neuralgia reports deep tissue pain. Which skin infection does the nurse expect to observe in the client's electronic medical record?

herpes zoster

The nurse is assessing a client who is suspected of having candidiasis. Which questions asked by the nurse would help confirm the diagnosis? Select all that apply. One, some, or all responses may be correct.

do you have cheesy do you have red do you have white

Which common complications could be seen in a client who has undergone surgery for bags under the eyes? Select all that apply. One, some, or all responses may be correct.

ectorpion hematoma corneal injury

Which clinical findings would support the primary health care provider's conclusion of actinic keratosis?

elevated, dry, hyperkeratotic

While assessing the skin of an older adult, the nurse observes that the skin has a dry and uneven color. Which change is responsible for this condition?

decreased activity

Which medications used for the treatment of plaque psoriasis will the nurse administer subcutaneously? Select all that apply. One, some, or all responses may be correct.

etanercept adalimumab ustekinumab

While assessing the skin of a client, the nurse notices edema at the dorsum of the foot and ankle. Which predisposing condition would the nurse anticipate in the client?

CHF

Which items would the nurse include in assessment of the integumentary system for a preoperative client? Select all that apply. One, some, or all responses may be correct.

assess examine question

The student nurse provides follow-up care instructions to a client who recently underwent a biopsy procedure. Which statement made by the student nurse requires correction?

avoid using tap water

A client is admitted after incurring electrical burns to both hands while playing golf during a lightning storm. When assessing the entrance and exit wounds, which information would the nurse need to consider about electrical burns?

cause severe nervous

The nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority?

extent of burn

Which action would the nurse implement when caring for a client with burns who is prescribed polymyxin?

apply

Which wound care is given to a client with severe burn injuries during the acute phase?

assess

A client with vesiculopustular lesions with honey-colored crusts on the face visits a primary health care provider. Which bacterial condition is suspected?

impetigo

While assessing a client, the nurse observes solar lentigines on the face and back of the hands. What changes in the skin would the nurse suspect to be the reason for the client's symptoms?

increased focal melanocytes

Which etiologies would the nurse associate with a client who has the skin disorder telangiectasia? Select all that apply. One, some, or all responses may be correct.

liver sun

The nurse is caring for a client who returns from surgery with a drain that is attached to a portable wound drainage system exiting from the surgical site. Which principle underlying the function of a portable drainage system will the nurse consider when planning care for this client?

negative pressure

The nurse is caring for a client during the emergent phase after the client sustained serious burns that involved a large surface of the skin. Which nursing intervention is the priority during this phase?

restoring fluid volume