integumentary, EAQ - Med-Surg
A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan?
"Avoid applying lotions and powders over the area."
A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan?
"Clean the mouth with a soft toothbrush or a gentle spray."
A client is found to have groups of isolated erythematous pustules on the scalp. Which statement made by the client is associated with the skin infection present in the client?
"I have no discomfort." Rationale: The presence of isolated erythematous pustules in groups on the scalp indicates folliculitis. A client with folliculitis may not feel any discomfort. A client with cellulitis has a fever. A client with herpes simplex infection feels itching, stinging, or pain. A client with candidiasis may have cracks at the corner of the mouth.
A registered nurse teaches a client about the self-care measures to be taken to prevent dry skin. Which statement made by the client indicates the nurse needs to follow up?
"I will use deodorant soap in place of alkaline soap."
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 gives noncancerous cells time to recover."
The nurse is caring for a client who underwent intestinal surgery 3 days ago and notices brownish pus with a fecal odor draining from the incision. What should the nurse infer from this finding?
1 Colonization with Proteus 2 Colonization with Pseudomonas 3 Colonization with Staphylococcus Correct4 Colonization with aerobic coliform and Bacteroides A client who underwent intestinal surgery is more susceptible to developing colonization of aerobic coliform and Bacteroides, which results in brown pus with a fecal odor. Beige pus that has a fishy odor is formed due to colonization with Proteus. Greenish-blue pus that has a fruity smell is formed due to colonization with Pseudomonas. Creamy-yellow pus indicates a colonization of Staphylococcus.
What could be the possible cause of a scald injury?
1 Contact with grease Correct2 Contact with hot liquids or steam 3 Contact with alkali in oven cleaners Incorrect4 Contact with open flame in house fires Scalding injuries usually result from contact with hot liquids or steam. Contact with grease and the alkali in oven cleaners may cause chemical injuries. An open flame in house fires may cause thermal injuries.
What is a clinical manifestation of hypernatremia in burns?
1 Fatigue Correct2 Seizures Incorrect3 Paresthesias 4 Cardiac dysrhythmias Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.
Which infection is caused due to fungus?
1 Furuncle 2 Folliculitis 3 Herpes zoster Correct4 Dermatophytosis Dermatophytosis is a fungal infection in which single or multiple patches appear on the skin. Furuncle is a bacterial infection in which small, tender, erythematous nodules filled with pus appear on the skin. Folliculitis is a bacterial infection in which erythematous pustules appear singly or in groups on the skin. Herpes zoster is a viral infection in which lesions are present on an erythematous base.
The primary healthcare provider instructs the nurse to monitor serum creatinine and blood urea nitrogen in a client who is on therapy for burn wounds. Which medication most likely has been prescribed to the client?
1 Nitrofurantoin 2 Mafenide acetate Incorrect3 Silver sulfadiazine Correct4 Gentamicin sulfate Gentamicin sulfate may cause nephrotoxicity in the client; therefore the client who is prescribed this drug should be carefully monitored for serum creatinine and blood urea nitrogen. The client on nitrofurantoin should be closely observed for signs of allergic reactions. Blood gas and serum electrolyte levels should be monitored in clients on mafenide acetate. In clients who are on silver sulfadiazine, wounds should be monitored for infections.
A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client?
1 This decreases catabolism to promote healing at the site of injury. 2 This lowers the metabolic rate in an attempt to help reduce the fever. Incorrect3 This reduces the energy demands on the body in the presence of infection. Correct4 This limits muscle contractions that may force causative organisms into the bloodstream. Exercise will promote extension of the local infection from the leg into the circulation, causing septicemia (sepsis). Although bed rest does decrease catabolism to promote healing at the site of injury, it is not the purpose for bed rest in this situation. Although bed rest does reduce the energy demands on the body in the presence of infection and lowers metabolic rate, it is not the purpose for bed rest in this situation.
Which complications does the nurse anticipate in the client who has blue-colored nail beds?
1 Thrombocytopenia 2 Polycythemia vera Incorrect3 Methemoglobinemia Correct4 Cardiopulmonary disease A bluish-color to the nail beds is due to an increase in deoxygenated blood that may be due to cardiopulmonary disease. When there is bleeding from the vessels into the tissues, small blue-colored spots are formed (petechiae), which may be due to thrombocytopenia (decreased numbers of platelets). Polycythemia vera is characterized by brown spots on the skin caused by increased melanin production. Methemoglobinemia is a complication in which the mucous membranes appear blue in color due to increased deoxygenated blood in the body.
What would the nurse state is a cause of systemic altered inflammatory response in impaired wound healing?
1 Uremia 2 Cirrhosis Correct3 Leukemia 4 Hypovolemia Leukemia is a cause of systemic altered inflammatory response in impaired wound healing. Uremia, cirrhosis, and hypovolemia are systemic impaired cellular proliferation responses in impaired wound healing.
Which type of allergic skin condition in a client is associated with immunological irregularity, asthma, and allergic rhinitis?
1 Urticaria 2 Psoriasis 3 Acne vulgaris Correct4 Atopic dermatitis Atopic dermatitis is an allergic skin condition that is a genetically influenced, chronic, relapsing disease. It is associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma. Urticaria is an allergic skin condition that results in a local increase in permeability of capillaries, causing erythema and edema in the upper dermis. Psoriasis is an autoimmune chronic dermatitis but not an allergic skin condition. Acne vulgaris is an inflammatory disorder of sebaceous glands.
What would the nurse state is a serious side effect of x-rays?
1 Vesicles 2 Papular Correct3 Desquamation 4 Plaque-like lesions X-ray is one of the radiologic diagnostic tests also used as therapy in some disease conditions. Desquamation is a serious side effect caused by x-rays. Vesicles, papules, and plaque-like lesions are serious effects caused by drug-induced photosensivity.
Which physiologic activity is associated with the "proliferative phase" of normal wound healing?
1 White blood cells migrate into the wound Correct2 Epithelial cells grow over the granulation tissue bed 3 Scar tissue gradually becomes thinner and pale in color 4 Vasodilation occurs with increased capillary permeability During the "proliferative phase" of normal wound healing, the epithelial cells grow over the granulation tissue bed. The white blood cells are migrated into the wound during the inflammatory phase. In the maturation phase, the scar tissues gradually become thinner and pale in color. The vasodilation with the increased capillary permeability may occur during the inflammatory phase.
A medical-surgical nurse is assisting a wound care with the debridement of a client's coccyx wound. What is the primary goal of this action?
: Removing dead or infected tissue to promote wound healing
how do you measure an open wound
A sterile, flexible applicator is the safest implement to use.
Which gastrointestinal (GI) change may be found in the client with burn injuries?
Abdominal distention
Which drug can cause chemical burns?
Anthralin Rationale: Anthralin is a strong irritant that has an action similar to tar. So this drug can cause chemical burns with topical use.
Which drug can cause chemical burns?
Anthralin is a strong irritant that has an action similar to tar. So this drug can cause chemical burns with topical use. Prednisone is a corticosteroid applied topically to treat psoriasis. Tazarotene and calcipotriene are teratogenic (cause birth defects).
A client who had a history of chicken pox arrived at the hospital complaining of itching and deep pain on the skin. Which assessment finding made by the nurse helps to confirm the diagnosis?
Appearance of multiple lesions in a segmental distribution on the skin Rationale: The client who had a history of chicken pox may have a chance of getting herpes zoster. Multiple lesions in a segmental distribution on the skin may be a viral infection such as herpes zoster.
Which type of laser is used in the treatment of vascular and other pigmented lesions?
Argon
The nurse is providing care for a client diagnosed with invasive pancreatic cancer. The client has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action should the nurse take postoperatively?
Cleanse the area around the insertion site to prevent skin breakdown
Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins?
Contact dermatitis Rationale: In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins.
When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?
Correct response: shearing force A shearing force results when one layer of tissue slides over another layer. Patients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces
A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes?
Correct1 Deep breathing exercises 2 Progressive muscle relaxation 3 Active range-of-motion exercises 4 Important elements of wound care Deep breathing exercises are an effective intervention in controlling pain; this is a positive coping skill. Muscle relaxation techniques generally include muscle contraction and then relaxation, which may increase the pain. Active range-of-motion exercises may increase the pain. Understanding important aspects of wound care will not reduce pain; health teaching should be initiated before, not during, a procedure.
Bacterial Infection?
Correct1 Impetigo Incorrect2 Candidiasis 3 Plantar warts 4 Verucca vulgaris Impetigo is the bacterial infection of skin caused by group A β-hemolytic streptococci or Staphylococcus aureus. Candidiasis is the fungal infection caused by Candida albicans. Plantar warts and verucca vulgaris are viral infections caused by the human papilloma virus.
Which does the nurse understand related to negative pressure wound therapy? Select all that apply.
Correct1 Using a suction pump Incorrect2 Treating necrotizing infections 3 Administering oxygen under high pressure 4 Application of a low-voltage current to a wound area Correct5 Reducing chronic ulcers by removing fluids from the wound In negative pressure wound therapy, a suction pump is used to treat the wounds. This therapy can reduce chronic ulcers by removing fluids from the wound. Necrotizing infections are treated by hyperbaric oxygen therapy. Hyperbaric oxygen therapy is the administration of oxygen under high pressure. Electrical stimulation is the application of a low-voltage current to a wound area.
Which integumentary change is associated with delayed wound healing in a client?
Decreased cell division
A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which classification should the nurse use to describe these burns?
Deep partial-thickness Rationale: In deep partial-thickness burns, upper layers of the dermis, and injury to deeper portions of the dermis occur.
Which infection is caused due to fungus?
Dermatophytosis
A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?
Directly proportional
cleaning a wound PPE
Don a mask, gown, and eye protection. Carefully remove the soiled dressing. Don sterile gloves. Fill the irrigation syringe with warmed irrigation solution. Gently direct a stream of solution into the wound. Dry the surrounding skin with gauze dressings.
A nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond?
Explain that the incision should not be immersed in water until it has healed
Which skin infection would cause facial paralysis?
Herpes zoster Rationale: Facial paralysis is the clinical sign of Bell's palsy, a complication of the herpes zoster infection. This is seen when the trigeminal nerve is infected by the varicella-zoster virus.
A physician orders a wound irrigation to apply local antiseptics to a patient's wound. Which of the following is a guideline for performing this procedure? :
If the wound is closed, clean technique may be used instead of sterile technique.
Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply.
Impetigo Erysipelas
A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?
In the preoperative period Rationale: Teaching for the postoperative period should begin as soon as the decision for surgery is made; knowledge of what to expect decreases anxiety and may improve adherence to the treatment regimen.
Which functions does the nurse associate with the epidermis?
Inhibits proliferation of microorganisms Allows the photoconversion of 7-dehydrocholesterol to vitamin D
Which characteristic does the nurse associate with a punch biopsy?
It is performed using a circular cutting instrument 2 to 6 mm in diameter.
What are the functions of a client's subcutaneous layer of skin?
It provides insulation. It acts as an energy reservoir. It acts as a mechanical shock absorber.
Which description describes a coalesced type of skin lesion configuration?
Lesions merge together and appear confluent.
Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue?
Moisture-retentive dressing
) A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which of the following interventions should the nurse include in the plan to prevent the development of pressure ulcers? Select all that apply.
Provide incontinent care every 2 hours and as needed • Turn client every 2 hours while client in bed • Encourage client to take fluids every 2 hours
What is the color of a client's wound caused by skin tears?
Red
Which surgery is used to treat excessive wrinkling or sagging of facial skin?
Rhytidectomy
A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply.
Scaly lesions Reddend papules
What is a clinical manifestation of hypernatremia in burns?
Seizures
The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?
Skin integrity
) A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which of the following stages should the nurse document for this wound?
Suspected deep tissue injury
(see full question) The nurse is caring for a patient who has a pressure ulcer on his back. What nursing intervention would the nurse perform? t
The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair. Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure.
What should the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn?
The risk of septicemia and its potential complications from treatment
The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing?
The scar is firm and inelastic on palpation.
When reestablishing a Jackson-Pratt drain after emptying its contents, the nurse squeezes the collection container and recaps the drain. What is the rationale for the nurse's action?
To restore suction Rationale: Closed suction drains such as Hemovac and Jackson-Pratt suction by means of compression and reexpansion of the system.
A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care?
Use a consistent approach to care and encourage participation
gunshot wound cleaning
Using sterile technique, clean the wound from the top to the bottom, and from the center to the outside. Dry the area with a gauze sponge in the same manner and apply ointment and dressing.
Radiation therapy negatively
affects fibroblastic activity.
Wounds healed by primary intention
are well approximated (skin edges tightly together).
The proliferative phase of wound healing
begins within two to three days of the injury.
The proliferation phase is characterized
by the formation of granulation tissue (highly vascular, red tissue that bleeds easily).
phagocytosis is the process
by which white blood cells consume pathogens, coagulated blood, and cellular debris
A contusion is a
closed wound with bleeding in underlying tissues.
(see full question) A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing to the client that has a highly absorbent nature. Which of the following types of dressing should the nurse use for this client?
gauze
A stage III wound will have
have subcutaneous tissue visible
. A stage IV wound will have
have tendons, muscles, or bones exposed.
Packing allows for
healing from the base of the wound to the surface, helping to prevent abscess formation.
regeneration or cell duplication, and scar formation
which is the replacement of damaged cells with fibrous tissues.
Staples are
wide metal clips that form a bridge to hold two wound margins together.
The inflammatory phase
lasts about four to six days, and white blood cells and macrophages move to the wound
Wounds healing by delayed primary intention or tertiary intention are
left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed.
the muscle layer
moves the skeleton
The registered nurse is teaching a student nurse about delegating tasks to the unlicensed assistive personnel (UAP) while caring for a client with a skin disease. Which delegation statement made by the student nurse requires a need for further teaching?
"I will advise the UAP to reinforce the client teaching." Rationale: Reinforcement of client teaching is a task to be performed by licensed practical nurses and licensed vocational nurses. This task should not be delegated to the UAP.
What is the source of an Integra graft?
1 Porcine skin 2 Cadaveric skin Correct3 Glycosaminoglycan bonded to silicone membrane Incorrect4 Porcine collagen bonded to silicone membrane Glycosaminoglycan bonded to silicone membrane is the source of an Integra artificial skin graft. Porcine skin is the source of a xenograft. Cadaveric skin is the source of an allograft. Porcine collagen bonded to silicone membrane is the source of a biobrane graft.
A registered nurse teaches a client about the self-care measures to be taken to prevent dry skin. Which statement made by the client indicates the nurse needs to follow up?
1 "I will decrease intake of caffeine and alcohol." 2 "I will avoid wearing tight outfits and tight belts." Correct3 "I will use deodorant soap in place of alkaline soap." 4 "I will wear splints at night to prevent scratching in deep sleep." Use of deodorant soap will make the skin dry further so the nurse needs to follow up to correct this misconception. Deodorant soap should be avoided in clients having dry skin. All of the other statements are correct and need no follow up. Avoiding caffeine and alcohol will prevent dry skin. Avoiding tight outfits will prevent the drying of skin. Wearing splints will prevent damage to dry skin caused by scratching during deep sleep due to pruritus.
A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up?
1 "I will leave the skin markings intact." 2 "I will protect the skin from sources of heat." 3 "I will wear soft clothing over the upper body." Correct4 "I will use an oatmeal-based lotion after each treatment." While undergoing radiation therapy, lotions, powders, and ointments should not be applied to the area. The skin markings should not be removed, because they form the parameters for the delivery of radiation. To protect the irradiated skin, sunlight and heat should be avoided. Nonirritating clothing should be worn over the area to prevent trauma to the delicate irradiated skin.
A client with third-degree burns asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse's best response?
1 "It helps debride necrotic tissue." Correct2 "It promotes rapid healing of the wound." 3 "When sutured in place, it provides better adherence." 4 "Topical lotions can be used concurrently with the graft." The graft provides a framework for granulation and speeds healing. The graft promotes epithelialization; enzymatic preparations or surgery may be used to debride the burned tissue. Pigskin grafts are not sutured. Using topical lotions on burn wounds can increase the likelihood of infections.
A client is diagnosed with psoriasis, and the nurse is providing health teaching concerning skin care at home. Which recommendation does the nurse include in the teaching?
1 "Shower twice a day." 2 "Soak the affected areas in hot water." Correct3 "Apply moisturizing lotion several times a day." 4 "Cover affected areas when in contact with others." Moisturizing lotions provide an occlusive film on the skin surface so that usual water loss through the skin is limited, allowing the trapped water to hydrate the stratum corneum. Excessive exposure to water, particularly hot water, increases irritation and scaling. Psoriasis is not a communicable disease, and affected areas do not need to be covered when in contact with others.
While assessing the skin of a client, the nurse observes a lesion that has a wavy border. Which type of lesion is present in the client?
1 Annular Incorrect2 Circinate 3 Coalesced Correct4 Serpiginous A lesion with a wavy border indicates a serpiginous lesion. A lesion that is ringlike with raised borders around a flat, clear center indicates an annular lesion. A circular lesion indicates a circinate lesion. A lesion that merges with another and appears confluent indicates a coalesced lesion.
A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client?
1 Bathing will not be permitted. 2 Dressings will be changed daily. Correct3 Personal protective equipment will be worn by staff. 4 Room temperature will be kept below 72° F (22.2° C). Personal protective equipment (disposable hats, masks, gowns, and gloves) are essential for the prevention of infection in clients with the open method of treatment. Hydrotherapy in a large tank tub may be used to clean burn wounds. Dressings are not used with the open method. Clients are more comfortable with a room temperature of 85° F (29.4° C).
Which changes to the client's skin are caused by the atrophy of eccrine sweat glands?
1 Bruises Correct2 Dry skin Incorrect3 Wrinkles 4 Skin shearing Atrophy of the eccrine sweat glands will result in dry skin and decreased body odor. Increased capillary fragility and permeability will result in bruising. Decreased subcutaneous fat, degeneration of elastic fibers, and stiffening of the collagen fibers will result in wrinkles. Decreased subcutaneous fat will result in shearing of the skin.
Which skin infection would cause facial paralysis?
1 Candidiasis Correct2 Herpes zoster 3 Herpes simplex 4 Dermatophytosis Facial paralysis is the clinical sign of Bell's palsy, a complication of the herpes zoster infection. This is seen when the trigeminal nerve is infected by the varicella-zoster virus. Candidiasis is a fungal infection not associated with Bell's palsy. Herpes simplex is a viral infection and may not cause Bell's palsy. Dermatophytosis is also a fungal infection not associated with Bell's palsy.
A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time?
1 Client with shock 2 Client with anemia Correct3 Client with epilepsy 4 Client with peripheral vascular disease A client with epilepsy does not have any circulatory inadequacy. Therefore the capillary refill time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-positive result). A client with shock has decreased oxygen saturation levels that further prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood circulation for clients with anemia, peripheral vascular disease, or diabetes.
Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue?
1 Continuous wet gauze Correct2 Moisture-retentive dressing 3 Topical enzyme preparations Incorrect4 -Wet-to-dry damp saline moistened gauze A moisture-retentive dressing is used to promote autolysis in the spontaneous separation of necrotic tissue in wound debridement. Continuous wet gauze is used in promoting dilution of viscous exudate and softening the dry scar. Topical enzyme preparation shows proteolytic action on thick, adherent eschar, causing the breakdown of denatured protein and a more rapid separation of necrotic tissue. In wet-to-dry damp saline-moistened gauze, necrotic debris is mechanically removed but with less trauma to healing tissue.
A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take?
1 Cover the cast with plastic wrap until dry. 2 Assist with weight bearing when the client ambulates. Correct3 Elevate the affected leg above the level of the heart. 4 Insert a finger inside the edges of the cast to check for skin abrasions. Elevating the affected leg will help reduce the formation of edema via the principle of gravity. Plastic wrap holds moisture and will interfere with drying of the cast. Full weight bearing should not start until prescribed by the primary healthcare provider. Nothing should be inserted under the cast; this can cause tissue injury.
Which change in the epidermis causes increased risk of sunburn?
1 Decreased cell division Correct2 Decreased melanocyte activity 3 Decreased vitamin D production 4 Decreased immune system cells Decreased melanocyte activity in the epidermis leads to increased risk of sunburn. Decreased cell division causes delayed wound healing. Decreased vitamin D production leads to increased risk for osteomalacia. Decreased immune system cells results in a decreased skin inflammatory response.
The dermis contains the
nerves, hair follicles, blood vessels, and glands. T
A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?
1 Decreased rate of glomerular filtration Incorrect2 Excessive blood loss through the burned tissues Correct3 Plasma proteins moving out of the intravascular compartment 4 Sodium retention occurring as a result of the aldosterone mechanism The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.
Which physical changes may cause longitudinal nail ridges?
1 Decreased rate of growth 2 Decreased cell division Correct3 Decreased blood flow 4 Decreased vitamin D production Longitudinal ridges may be due to decreased blood flow to the nail beds. Decreased cell division in the skin may cause a delay in wound healing. Increased risk of fungal infections is due to decreased rate of growth. Increased risk of osteomalacia is due to a decrease in vitamin D levels.
which clinical finding occurs due to thinning of the subcutaneous layer?
1 Decreased tone and elasticity 2 Decreased sensory perception Correct3 Increased risk for hypothermia 4 Increased susceptibility to dry skin Thinning of the subcutaneous layer results in increased risk for hypothermia. Degeneration of elastic fibers in the dermis results in decreased tone and elasticity. In the dermis, reduced number and function of nerve endings leads to decreased sensory perception. A decrease in dermal blood flow results in increased susceptibility to dry skin.
Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins?
1 Drug eruption 2 Atopic dermatitis Correct3 Contact dermatitis 4 Nonspecific eczematous dermatitis In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In drug eruption, bright-red erythematosus macules and papules are seen. In atopic dermatitis, lichenification with scaling and excoriation is observed. Lichenification with weeping papules and macules is seen in nonspecific eczematous dermatitis.
Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound?
1 Electrical stimulation 2 Topical growth factors 3 Hyperbaric oxygen therapy Correct4 Negative pressure wound therapy Negative pressure wound therapy is a new technology used to reduce chronic ulcers by removing fluids from the wound and enhancing granulation. Electrical stimulation is done by the application of low-voltage current to a wound area to increase blood vessel growth and promote granulation. Topical growth factors are the normal body substances that stimulate cell movement and growth. Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue oxygen concentration.
A client's burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare?
1 Enzymatic agents Correct2 Scissors and forceps Incorrect3 Autolytic semi-occlusive dressing 4 Continuous passive-motion device Mechanical debridement means to physically remove dirt, damaged or dead tissue, and cellular debris from a wound or burn so that infection is prevented and healing is promoted. Scissors, forceps, or scalpels may be used along with hydrotherapy. Enzymatic preparations are used to debride chemically by dissolving and removing necrotic tissue. A mechanical device that continually moves an extremity is called continuous passive range of motion and is used for knee surgery. Autolytic debridement includes semi-occlusive or occlusive dressings to soften dry eschar by autolysis.
A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?
1 Equal 2 Unrelated 3 Inversely related Correct4 Directly proportional There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.
Which benign tumor forms on the surface of the client's epithelium?
1 Fibroma 2 Adenoma Correct3 Papilloma 4 Chondroma A papilloma is a benign tumor that forms on the surface of the epithelium. A fibroma forms on the fibrous tissue. An adenoma forms on the glandular epithelium. A chondroma forms on the cartilage.
The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?
1 Fluid volume 2 Skin integrity 3 Physical mobility 4 Urinary elimination
The nurse is caring for a client who returns from surgery with a catheter 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?
1 Gravity 2 Osmosis 3 Active transport Correct4 Negative pressure The negative pressure of a portable wound drainage system exerts a sucking force that pulls fluid toward the collection chamber. An indwelling urinary catheter uses the principle of gravity to draw fluid from the bladder to the collection bag held below the level of the bladder. Osmosis occurs when a solvent moves from a solution of lesser concentration to one of greater solute concentration when the two solutions are separated by a semipermeable membrane; fluid moving from the interstitial compartment into the intracellular compartment uses osmosis. Active transport occurs when ions move across a cell membrane against a concentration gradient with the assistance of metabolic energy; sodium and potassium ions move into and out of cells via active transport (sodium-potassium pump).
During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for?
1 Hypokalemia and hyponatremia Correct2 Hyperkalemia and hyponatremia 3 Hypokalemia and hypernatremia 4 Hyperkalemia and hypernatremia Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.
During the proliferation phase,
new tissue is built to fill the wound space.
Gauze dressings do
not allow the nurse to visualize the site without partially or completely removing the dressing
Which drug is prescribed for the client to treat severe nodulocystic acne?
1 Imiquimod Correct2 Isotretinoin Incorrect3 Clindamycin 4 Corticosteroids Isotretinoin is used for nodulocystic acne and may provide lasting remission. Imiquimod is a topical immunomodulator used to treat plantar warts. Clindamycin is a topical antibiotic used to treat acne vulgaris to suppress new lesions and minimize scarring. Corticosteroids are contraindicated because use of corticosteroids may cause flare-ups in clients with acne.
A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve?
1 Increasing mobility 2 Preventing contractures 3 Limiting orthostatic hypotension Correct4 Preventing pressure on peripheral blood vessels The circulating air bed disperses body weight over a larger surface, which reduces pressure against the capillary beds, allowing for tissue perfusion. These beds are used for clients who are immobile; they do not increase mobility. Limiting orthostatic hypotension is achieved by dangling, not by this type of bed. Range-of-motion exercises, not the type of bed, will help prevent contracture.
Which description describes a coalesced type of skin lesion configuration?
1 Lesions are well defined with sharp borders. Correct2 Lesions merge together and appear confluent. 3 Lesions are ringlike around flat centers of skin. 4 Lesions have wavy borders that resemble a snake. Coalesced skin lesions merge with one another and appear confluent. Circumscribed skin lesions are well defined with sharp borders. Annular skin lesions are ringlike with raised borders around flat centers of the normal skin. Lesions with wavy borders that resemble a snake are described as serpiginous.
Which nursing assessment finding is associated with chronic eczema?
1 Localized edema Correct2 Rough and thick skin 3 Decreased skin turgor 4 Increased skin temperature Rough and thick skin may indicate chronic eczema. Localized edema is associated with trauma/inflammation. A decrease in skin turgor may indicate severe dehydration. An increase in skin temperature may be a sign of fever.
Which drug is a newer treatment option for treating metastatic melanoma?
1 Lomustin Correct2 Ipilimumab 3 Carmustine 4 Temozolomide Ipilimumab is a type of immunotherapy and is monoclonal antibody. It is a newer option of drug therapy used in the treatment of metastatic melanoma. Lomustin, carmustine, and temozolomide are established chemotherapy drugs in use for many years for the treatment of metastatic melanoma.
A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?
1 Loss of skin integrity caused by the burns 2 Potential infection as a result of the burn injury Correct3 Inadequate gas exchange caused by smoke inhalation 4 Decreased fluid volume because of the depth of the burns Maintaining a patent airway is the priority; because of the proximity of the chest and face to the nose and mouth, inhalation burns also may have occurred. Although loss of skin integrity caused by the burns is important, it is not the priority at this time. Although potential for infection as a result of the burn injury is important, it is not the priority. Although fluid needs are important, the gas exchange is priority.
The nurse is providing care for a client diagnosed with invasive pancreatic cancer. The client has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action should the nurse take postoperatively?
1 Maintain intermittent low suction to limit trauma. Correct2 Cleanse the area around the insertion site to prevent skin breakdown. 3 Attach the tube to a negative-pressure drainage system to promote drainage. 4 Reposition the client frequently to increase the flow of bile through the tube. Bile is irritating to the skin; cleansing the area around the T-tube to prevent skin breakdown is a priority. Suction is contraindicated; drainage is via gravity. The T-tube is attached to a bag for straight drainage via gravity, not suction that uses negative pressure. Repositioning the client is vital to prevent venous and pulmonary stasis, not for facilitating the drainage of bile.
A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet?
1 Milk Correct2 Tea 3 Orange juice 4 Tomato juice The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.
Which benign condition shows silver scaly plaques on the skin?
1 Nevi Correct2 Psoriasis 3 Urticaria 4 Acne vulgaris A silver scaly plaque on the skin is due to psoriasis and is most commonly seen on the elbows and scalp. Hyperpigmented areas that vary in form and color are due to nevi. Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to urticaria. Non-inflammatory lesions, including open comedones and closed comedones, are due to acne vulgaris.
A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall?
1 Partial-thickness burns require grafting before they can heal. Correct2 Partial-thickness burns are often painful, reddened, and have blisters. 3 Partial-thickness burns cause destruction of both the epidermis and dermis. 4 Partial-thickness burns often take months of extensive treatment before healing. Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the epidermis and only part of the dermis. Recovery from partial-thickness burns with no infection occurs in 2 to 6 weeks.
Which test would the client undergo to receive a diagnosis of systemic lupus erythematosus?
1 Patch test 2 Photo patch test Correct3 Direct immunofluorescence test 4 Indirect immunofluorescence test A direct immunofluorescence test is used in the diagnosis of systemic lupus erythematosus. The patch test and photo patch test are used to evaluate allergic dermatitis and photo allergic reactions. An indirect immunofluorescence test is performed on a blood sample.
Which practice would be suitable in the prevention of a pressure ulcer?
1 Positioning a client directly on the trochanter Correct2 Keeping the client's skin directly off plastic surfaces 3 Keeping the head of the bed elevated above 30 degrees Incorrect4 Placing a rubber ring or donut under the client's sacral area For the prevention of a pressure ulcer, the client's skin should be kept directly off plastic surfaces. While the client is positioned on his or her side, direct positioning on the trochanter should be avoided. The head of the bed should not be kept elevated above 30 degrees. This is to prevent shearing. A rubber ring or donut under the client's sacral area should be avoided.
Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor?
1 Proteus 2 Bacteroides Correct3 Pseudomonas 4 Staphylococcus The purulent exudates of greenish-blue pus with a fruity odor signifies the colonization of Pseudomonas. Proteus colonization causes pus with a fishy odor. The colonization of Bacteroides causes brownish pus with a fecal odor. Staphylococcus colonization results in purulent exudate of creamy yellow pus.
Which type of biopsy would the nurse identify as required for removal of entire lesions on the skin?
1 Punch biopsy 2 Shave biopsy Incorrect3 Incisional biopsy Correct4 Excisional biopsy An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.
The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." Which information should the nurse consider about rabies when planning care for this client?
1 Rabies is a bacterial infection characterized by encephalopathy and opisthotonos. 2 Rabies is an acute bacterial septicemia that results in convulsions and a morbid fear of water. Incorrect3 Rabies is a nonspecific immune response to organisms deposited under the skin by an animal bite. Correct4 Rabies is an acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system. Rabies is a viral infection that enters the body through a break in the skin and is characterized by convulsions and choking. Rabies is not caused by a bacteria; its outstanding symptoms are convulsions and choking. Rabies is not associated with a bacterial septicemia; it is caused by a virus. The virus specifically attacks nervous tissue and is carried in the saliva of infected animals.
Which skin color alteration may be observed in a client diagnosed with methemoglobinemia?
1 Red Correct2 Blue 3 White 4 Yellow-orange Blue discoloration of the skin may indicate an increase in deoxygenated blood, which is associated with methemoglobinemia. Red (erythema) may be associated with generalized inflammation. White (pallor) may indicate a decreased level of hemoglobin. It may signify a risk of anemia and shock. A yellow-orange skin discoloration may indicate jaundice and is associated with liver disorders.
Which surgery is used to treat excessive wrinkling or sagging of facial skin?
1 Rhinoplasty Correct2 Rhytidectomy 3 Dermabrasion 4 Blepharoplasty Rhytidectomy is the removal of excess skin and tissue from the face; this is the surgery used to treat wrinkling or sagging of facial skin. Rhinoplasty is the removal of excessive tissue or cartilage from the nose. Dermabrasion is the process of removing the facial epidermis or a portion of the dermis to treat acne scars. Blepharoplasty is the removal of bulging fat in the periorbital area; this is used to treat bags under the eyes.
Which secondary skin lesion may include athlete's foot as an example?
1 Scar Incorrect2 Scale 3 Ulcer Correct4 Fissure An example of a fissure-type secondary lesion is athlete's foot. Surgical incisions and healed wounds are examples of scar-type secondary lesions. A scale-type secondary lesion would include flaking of the skin following a drug reaction or sunburn. Ulcer-type lesions may include pressure ulcers or chancres.
The primary healthcare provider prescribed imiquimod to a client with a skin infection. What could be the possible condition of the client?
1 Shingles 2 Erysipelas Correct3 Plantar warts 4 Verucca vulgaris Imiquimod is a topical immunomodulator that stimulates the production of α interferon and other cytokines to enhance cell-mediated immunity. This medication is used for warts, actinic keratoses, and superficial basal cell carcinoma. Topical imiquimod may be used in the treatment of plantar warts, which are caused by a viral infection called the human papilloma virus. Shingles, caused by activation of varicella-zoster virus, is treated with antiviral agents such as acyclovir and famciclovir. Erysipelas is a bacterial infection treated with systemic antibiotics such as penicillin. Verucca vulgaris, also a viral infection, is treated with blistering agents such as cantharidin, keratolytic agents such as salicylic acid, and CO2 laser destruction.
The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches the most effective method for putting out the flames. Which information from the group members indicates successful learning?
1 Slap at the flames. Correct2 Log-roll the victim in the grass. 3 Pour cold liquid over the flames. 4 Remove the victim's burning clothes. Log-rolling the victim in the grass effectively extinguishes the flames and protects the client from additional injury. Slapping at the flames will not eliminate the oxygen that supports the fire and will fan the flames. Pouring cold liquid over the flames may extinguish the flames, but not as effectively as rolling in the grass. Removing the victim's burning clothes may or may not protect the client from further injury and is dangerous for the rescuer.
The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance?
1 T-tube movement increases. Correct2 Pain at the incision site increases. 3 The nasogastric tube gets irritating. 4 The bandage on the abdomen is constricting. The incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations.
Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs?
1 Tenting 2 Angioma 3 Varicosity Correct4 Telangiectasia Telangiectasia is a permanent condition characterized by cutaneous blood vessels that are superficial and visibly dilated. Tenting is the failure of the skin to immediately return to the normal position after a gentle pinch. Angioma is a tumor that consists of blood and lymph vessels. Varicosity is the increased prominence of superficial veins. Topics
A client's wound is healing. Which event occurs in the proliferative phase of wound healing?
1 Thinning of scar tissue 2 Strengthening of collagen Correct3 Formation of "granulation" tissue 4 Increase in capillary permeability "Granulation" tissue is formed in the proliferative tissue. Thinning of scar tissue and strengthening of collagen fibers is seen in the maturation phase of wound healing. The increase in capillary permeability occurs in the inflammatory phase of wound healing.
A client sustained minor skin injuries following an accident. Which event occurs close to the time of injury?
1 Thinning of the scar tissue 2 Formation of granulation tissue Correct3 Migration of leukocytes to the site of injury 4 Arrival of fibroblasts to the site of infection Beginning at the time of injury and lasting 3 to 5 days is the inflammatory phase in which migration of leucocytes takes place. Scar tissue is formed in the maturation phase. Formation of "granulation" tissue and migration of fibroblasts occurs in the proliferative phase.
Which fungal infection does the client refer to as jock itch?
1 Tinea pedis Correct2 Tinea cruris 3 Tinea corporis 4 Tinea unguium Tinea cruris is a fungal infection commonly referred to as jock itch. It clinically manifests with well-defined scaly plaque in the groin area. Tinea pedis is a fungal infection commonly referred to as athlete's foot. It is clinically manifested as interdigital scaling and maceration, scaly plantar surfaces, erythema, and blistering. Tinea corporis is a fungal infection commonly referred to as ringworm. It is clinically manifested as an erythematous annular, ringlike, scaly lesion with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.
Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity?
1 Utricaria 2 A drug reaction Incorrect3 Atopic dermatitis Correct4 Allergic contact dermatitis Allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens. Utricaria is an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis. A drug reaction may be caused by any drug such as penicillin that acts as antigen causing hypersensitivity reactions. Atopic dermatitis is a genetically influenced, chronic, relapsing disease associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.
Which description could be related to zosteriform-type lesions?
1 Wide distribution 2 Diffuse distribution 3 Bilateral distribution Correct4 Band-like distribution Band-like distribution of lesions would be termed as zosteriform-type lesions. Diffuse-type lesions are described as the wide distribution of the lesions. Generalized-type lesions are identified by the diffused distribution of the lesions. Symmetric-type lesions are the bilateral distribution of the lesions.
What factors put a client at risk for bacterial infections? Select all that apply.
1 Dry skin Incorrect2 Underweight Correct3 Atopic dermatitis Correct4 Diabetes mellitus Correct5 Systemic antibiotics Atopic dermatitis, diabetes mellitus, and systemic usage of antibiotics and corticosteroids are predisposing factors for bacterial infections. Dry skin may not cause bacterial infections, as moisture on the skin is important for bacterial growth. Being underweight may not cause bacterial infections, whereas obesity is a risk factor for poor wound healing and diabetes mellitus.
A client is diagnosed with a dysfunction of the eccrine gland. Which physiologic abnormality might occur in the client? Select all that apply.
1 Drying of hair Correct2 Drying of surface cells 3 Decreased synthesis of vitamin D Correct4 Decreased efficiency to cool the body Correct5 Decreased excretion of waste products through the skin The eccrine gland is a sweat gland, the main functions of which are to moisturize the surface cells, cool the body by evaporation, and excrete waste products through the pores of the skin. Therefore dysfunction of the eccrine gland may result in drying of surface cells, decreased efficiency to cool the body, and decreased excretion of waste products through the skin. The sebaceous gland secretes sebum, which prevents drying of hair and skin. Therefore dysfunction of the sebaceous gland may lead to drying of hair and skin. Endogenous synthesis of vitamin D occurs by the action of UV light on vitamin D precursors in epidermal cells. Therefore dysfunction of the eccrine gland may not be associated with decreased vitamin D synthesis.
Which conditions in a client are associated with a bluish color of the mucous membranes? Select all that apply.
1 Edema Incorrect2 Diabetes mellitus 3 Hemochromatosis Correct4 Methemoglobinemia Correct5 Cardiopulmonary disease A bluish color of the mucous membranes may indicate methemoglobinemia (the presence of methemoglobin in the blood, which is an oxidized form of hemoglobin) and cardiopulmonary disease in the client. The presence of a white color of the mucous membranes may indicate edema in the client. Diabetes mellitus is associated with a yellow-orange color of the palms and soles. The presence of a brown color of the distal lower extremities may indicate hemochromatosis (deposition of iron salts in the tissues).
Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply.
1 Furuncle Incorrect2 Cellulitis Correct3 Impetigo 4 Folliculitis Correct5 Erysipelas Impetigo is caused by group A β-hemolytic streptococci, staphylococci, or a combination of both. Erysipelas is caused by group A β-hemolytic streptococci. Furuncle is a deep infection with staphylococci. Staphylococcus aureus and streptococci are the usual causative agents of cellulitis. Usually staphylococci are responsible for folliculitis.
A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia (CREST syndrome). Which clinical indicators should the nurse expect to identify upon assessment? Select all that apply.
1 Joint pain 2 Masklike facies Correct3 Esophageal dysmotility Correct4 Spiderlike hemangiomas Correct5 Episodic blanching of the fingers Esophageal dysmotility is associated with CREST syndrome; it results in dysphagia and esophageal reflux. Spiderlike hemangiomas (telangiectasia) is associated with CREST syndrome. Episodic blanching of the fingers (Raynaud phenomenon), caused by vasospasms of the arterioles, is a sign associated with CREST syndrome. Joint pain, caused by inflammation, is a symptom associated with scleroderma, not CREST syndrome. Masklike facies is a sign associated with scleroderma, not CREST syndrome; it is caused by fibrotic tissue changes.
Which functions does the nurse associate with the epidermis? Select all that apply.
1 Serves as an energy reserve Incorrect2 Provides cells for wound healing Incorrect3 Serves as a mechanical shock absorber Correct4 Inhibits proliferation of microorganisms Correct5 Allows the photoconversion of 7-dehydrocholesterol to vitamin D The epidermis inhibits the proliferation of microorganisms because of its dry external surface. It also allows the photoconversion of 7-dehydrocholesterol to vitamin D. The subcutaneous tissue serves as an energy reserve. The dermis helps in providing cells for wound healing. Subcutaneous tissue acts as a mechanical shock absorber.
Drainage in an open drain
occurs passively by gravity and capillary action, which is the movement of a liquid at the point of contact with a solid, which in this case is the gauze dressing
A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report?
A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? 1 20 2 25 3 30 Correct4 36 Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% total for both arms) and 18% for the anterior trunk; thus the total body surface area burned is 36%. The choices 20%, 25%, and 30% are too low.
A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan?
A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan? 1 "Rinse the mouth three times a day with lemon juice and water." 2 "Brush the teeth once daily and use dental floss after each meal." Correct3 "Clean the mouth with a soft toothbrush or a gentle spray." 4 "Gently clean the mouth with commercial mouthwash." Chemotherapy destroys the rapidly dividing cells of the oral mucosa; frequent gentle oral hygiene limits additional trauma. Although it is recommended to rinse the mouth every 2 hours, the client does not need to brush teeth and clean the mouth as often. Lemon juice is too caustic to the compromised mucosa. Flossing can disrupt and traumatize the gum surfaces; oral hygiene is needed more than once a day. Commercial mouthwashes contain alcohol, which is irritating to the mucosa.
A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as which of the following?
A laceration is a wound with ragged edges with torn tissue.
Debridement is the act
of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration. (less)
Which interventions might a nurse be expected to perform when providing competent care for a patient with a draining wound
Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary. • Change the dressing midway between meals. • Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound.
Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity?
Allergic contact dermatitis Rationale: Allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens.
purulent drainage is made up
of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
. A bandage is a strip
or roll of cloth wrapped around a body part to help support the area around the wound.
Intentional wounds with minimal tissue loss,
such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.
Which complications does the nurse anticipate in the client who has blue-colored nail beds?
Cardiopulmonary disease
The nurse is examining the nails of four different clients. Which client does the nurse suspect as having an iron deficiency?
Client B has iron deficiency. Rationale: The shape of the nail is koilonychias, characterized by flattening of the nail plate with an increased smoothness of the nail surface.
A nurse is assessing four clients for risk factors for developing a pressure ulcer. List in order of priority the client with the greatest risk for developing a pressure ulcer to the client with the smallest risk.
Correct 1. 70-year-old man, admitted with metastatic bone cancer, weighing 80 lbs (36.36 kg), dehydrated, and bed bound Correct 2. 62-year-old woman, admitted because of a cerebrovascular accident (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift Incorrect 3. 78-year-old woman, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory Incorrect 4. 25-year-old man, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory Risk factors for pressure ulcers include inadequate nutrition, dehydration, pain, decreased subcutaneous fat, and confinement to bed, making the 70-year-old man at greatest risk. An inability to sense or move the left side will inhibit changing positions without assistance, making the 62-year-old woman who had the CVA next at risk. Urine and fecal incontinence may result in skin breakdown in the perineal and sacral areas. The 25-year-old male client is at some risk by not being able to communicate verbally and having urinary incontinence. The 78-year-old female client's nutritional status is acceptable, and she is able to move. This client has minimal risk factors. Because she is scheduled for a knee replacement, which is an elective procedure, it can be assumed that her general health is within acceptable limits. Also, she is continent and ambulatory.
Which type of laser is used in the treatment of vascular and other pigmented lesions?
Correct1 Argon 2 Gold vapors Incorrect3 Neodymium 4 Carbon dioxide An argon laser is used in the treatment of vascular and other pigmented lesions. Gold vapors and neodymium are type of lasers used in the treatment of skin disorders. A carbon dioxide laser is also a type of laser used in the treatment of skin disorders; it has numerous applications as a vaporizing and cutting tool for most tissues.
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
Notify the physician and prepare for surgery. Explanation: Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required
A nurse is preparing to change a client's dressing. Which information should the nurse recall for using surgical asepsis?
Correct1 Keep the area free of microorganisms. 2 Protect self from microorganisms in the wound. 3 Confine the microorganisms to the surgical incision site. 4 Limit the number of opportunistic microorganisms to a minimum. Surgical asepsis means that the defined area will contain no microorganisms. The purpose of personal protective equipment is to protect self from microorganisms in the wound. Confining the microorganisms to the surgical incision site and keeping the number of opportunistic microorganisms to a minimum apply to medical, not surgical, asepsis.
Which component of skin maintains optimal barrier function?
Correct1 Keratin 2 Melanin 3 Collagen 4 Adipose tissue Keratin is a protein produced by keratinocytes that helps to maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.
Which clinical manifestation is associated with cellulitis?
Correct1 Lymphadenopathy Incorrect2 Occasional papules 3 Vesicles that evolve into pustules 4 Isolated erythematous pustules Cellulitis is accompanied by lymphadenopathy. Occasional papules are present in folliculitis. Herpes simplex viral infections evolve the vesicles into pustules. Isolated erythematous pustules occur in folliculitis bacterial infections.
Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells?
Correct1 Nevi 2 Psoriasis 3 Acne vulgaris 4 Plantar warts Nevi (moles) are hyperpigmented areas that vary in form and size. Nevi are a common benign condition of the skin that is associated with the grouping of normal cells derived from melanocyte-like precursor cells. Psoriasis is an autoimmune chronic dermatitis that involves excessively rapid turnover of epidermal cells. Acne vulgaris is an inflammatory disorder of sebaceous glands. Plantar warts are formed due to a viral infection. Plantar warts appear on the bottom surface of the feet and grow inward because of pressure.
The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings?
Correct1 Azotemia 2 Hypokalemia Incorrect3 Metabolic alkalosis 4 Respiratory alkalosis The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.
What is an example of third spacing in a burn injury?
Correct1 Blister formation 2 Edema formation 3 Fluid mobilization 4 Fluid accumulation Blister formation is an example of third spacing in burn injuries. Edema formation and fluid mobilization generally happen in every burn injury. Fluid accumulation is formed in second spacing in a burn injury.
Which integumentary change is associated with delayed wound healing in a client?
Correct1 Decreased cell division 2 Decreased epidermal thickness 3 Decreased immune system cells Incorrect4 Increased epidermal permeability Delayed wound healing is associated with decreased cell division. Decreased thickness of the epidermis may cause skin transparency and fragility. Decreased cells of the immune system are the reason for a decreased skin inflammatory response. Increased epidermal permeability increases the risk for irritation.
While assessing the skin of a client, the nurse notices an elevated, solid lesion measuring 4 mm × 4 mm in size. Which type of lesion is observed in the client?
Correct1 Papule 2 Vesicle 3 Pustule 4 Macule A papule is an elevated, solid skin lesion of less than 0.5 to 1 cm in diameter. A macule is a circumscribed, flat area with a change in skin color. The vesicle is a circumscribed, superficial collection of serous fluid. A pustule is an elevated, superficial lesion filled with purulent fluid.
A client has bright-red erythematosus macules and papules on the skin. What could be the diagnosis?
Correct1 Drug eruption 2 Atopic dermatitis Incorrect3 Contact dermatitis 4 Nonspecific eczematous dermatitis Drug eruptions are characterized by bright-red erythematosus macules and papules on the skin, which occur because of an adverse reaction to a drug. Atopic dermatitis is characterized by scaling and excoriation, which occurs due to food allergies, chemicals, or stress. Contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens. Nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques.
nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client?
Correct1 Highly contagious 2 Caused by a fungus 3 Chronic with exacerbations 4 Associated with other allergies Scabies is caused by the itch mite (Sarcoptes scabiei), the female of which burrows under the skin to deposit eggs. It is intensely pruritic and is transmitted by direct contact or in a limited way by soiled sheets or undergarments. It is not caused by a fungus. Scabies is an acute infestation; there are no remissions and exacerbations. It is a disease unrelated to allergies.
Which statement by the nurse is true regarding dandruff?
Correct1 "It is a problem of excessive oil production." 2 "It can occur as a side effect of drug therapy." 3 "It is associated with tenderness of the scalp." 4 "It is a manifestation of hormonal imbalance." Dandruff is associated with excessive oil production. Hirsutism may occur as a side effect of a drug therapy. Tenderness of the scalp is associated with lice and nits. Hirsutism is a manifestation of a hormonal imbalance.
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. What is the nurse's best response?
Correct1 "It is a temporary graft; it is expected to fall off." 2 "You must have pulled it loose; I'll notify your primary healthcare provider." 3 "An infection may be starting; I anticipate that antibiotics will be prescribed." 4 "It is a permanent graft; it is likely that it will need to be replaced." An allograft is a temporary measure; it is expected to come off, and the primary healthcare provider should be notified that it is happening at this time. The response "you must have pulled it loose" is an unwarranted accusation that places guilt on the client; allografts are temporary. The response "an infection may be starting" is inaccurate information that may frighten the client. An allograft is a temporary, not permanent, measure and is expected to fall off.
What is the function of the dermis?
Correct1 Provides cells for wound healing 2 Assists in retention of body heat 3 Acts as mechanical shock absorber Incorrect4 Inhibits proliferation of microorganisms The dermis is present between the epidermis and subcutaneous layers and has such functions as giving the skin its flexibility and strength and providing cells for wound healing. Subcutaneous tissue is the innermost layer of the skin that helps in retention of body heat and acts as a mechanical shock absorber. Epidermis is the outermost layer of skin that inhibits the proliferation of microorganisms.
Which dermatologic problem is treated by using intralesional corticosteroids?
Correct1 Psoriasis 2 Cellulitis 3 Erysipelas 4 Carbuncles Psoriasis is a dermatologic problem treated by using intralesional corticosteroids. Cellulitis, erysipelas, and carbuncles are treated by using systemic antibiotics such as synthetic sulfur.
What is the color of a client's wound caused by skin tears?
Correct1 Red 2 Gray 3 Black 4 Yellow A wound that is caused by skin tears is red in color. A wound caused by a full-thickness or third-degree burn is gray or black in color. Wounds with nonviable necrotic tissue that create an ideal situation for bacterial growth are yellow in color.
After assessing the color of a client's nail beds, the primary healthcare provider concludes that the client has trauma to the nail beds. Which variations in nail color might the client have?
Correct1 Red color 2 Blue color Incorrect3 White color 4 Yellow-brown color A red color is an indication of trauma to the nail bed. A blue color is an indication of respiratory failure. A white color is an indication of anemia, chronic liver, or kidney disease. A yellow-brown color is an indication of jaundice or cardiac failure.
The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing?
Correct1 The scar is firm and inelastic on palpation. 2 Fibrin strands form a scaffold or framework. 3 White blood cells migrate into the wound. Incorrect4 Epithelial cells are grown over the granulation tissue bed. The maturation phase of normal wound healing involves a mature scar that is firm and inelastic when palpated. In the proliferative phase, the fibrin strands form a scaffold or framework. White blood cells migrate into the wound during the inflammatory phase. In the proliferative phase, the epithelial cells are grown over the granulation tissue bed.
A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. What could be the possible condition in the client?
Correct1 Tinea pedis 2 Tinea cruris Incorrect3 Tinea corporis 4 Tinea unguium Tinea pedis is a fungal infection with an itching sensation associated with pain. It is clinically manifested as interdigital scaling and maceration and a scaly plantar surface, sometimes with erythema and blistering. Tinea cruris is a fungal infection that is clinically manifested with well-defined scaly plaque in the groin area. Tinea corporis is clinically manifested as an erythematous, annular, ring-like scaly appearance with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.
A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care?
Correct1 Use a consistent approach to care and encourage participation. Incorrect2 Prepare equipment while doing the procedure and explain the treatment to the client. 3 Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature. 4 Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done. Client participation provides for a sense of control, and a consistent approach provides a routine with no surprises; these approaches may limit pain and promote adherence to the regimen. Preparation of the equipment and explanation of the procedure should be performed before the procedure; when performed during the procedure, it wastes time, which can prolong pain and increase anxiety. Water temperature of 105° F (40.6° C) is too hot; the rinse water should be room temperature. Changing staff disrupts the client's routine and sense of trust.
The registered nurse is teaching a community event about health promotion activities appropriate for good skin health. Which instructions given by the nurse would be beneficial? Select all that apply.
Correct1 "Eat foods rich in vitamin B." Correct2 "Sleep for longer periods of time." 3 "Use alkaline soaps for better hygiene." Incorrect4 "Use sunscreen of sun protection factor (SPF) 30 daily." Correct5 "Avoid exposure to sun after administering ketoconazole." Deficiency of vitamin B4 (niacin) and B6 (pyridoxine) are manifested as erythema, bullae, and seborrhea-like lesions. Deficiency of biotin, a B-complex vitamin, may cause rashes and alopecia. Adequate rest increases tolerance to itching, thereby decreasing skin damage from scratching in pruritic skin diseases. Some medications potentiate the effect of the sun causing sunburns. Acidic activity of the skin protects against bacterial overgrowth. Alkaline soaps neutralize the skin thereby decreasing the protection. Sunscreen of SPF 15 should be used daily by everybody. People with history of skin cancer or problems with photosensitivity may use sunscreen with SPF of at least 30.
Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply.
Correct1 Burns Incorrect2 Skin cancer Correct3 Osteomyelitis Correct4 Diabetic ulcers 5 Myocardial infarction Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue's oxygen concentration. Burns, osteomyelitis, and diabetic ulcers are treated by hyperbaric oxygen therapy. Skin cancer and myocardial infarctions are not treated using hyperbaric oxygen therapy.
What are the functions of a client's subcutaneous layer of skin? Select all that apply.
Correct1 It provides insulation. Correct2 It acts as an energy reservoir. Incorrect3 It prevents systemic dehydration. 4 It provides cells for wound healing. Correct5 It acts as a mechanical shock absorber. The subcutaneous layer provides insulation and acts as an energy reservoir and mechanical shock absorber. The epidermal layer prevents systemic dehydration. The dermal layer provides cells for wound healing.
A client sustains full-thickness and deep partial-thickness burns. The client asks, "What is the difference between my full-thickness and deep partial-thickness burns?" Which information will the nurse share with the client?
Correct4 Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis. The response that full-thickness burns extend into the subcutaneous tissue and deep partial-thickness burns extend through the epidermis and involve only part of the dermis correctly describes the difference between full-thickness and deep partial-thickness burns. Whereas full-thickness burns extend into the subcutaneous tissue, deep partial-thickness burns affect both the epidermis and dermis. Deep partial-thickness burns not only extend through the epidermis but also involve part of the dermis; superficial partial-thickness, not full-thickness, burns affect the superficial layers of the epidermis.
A nurse uses an open drain to drain the blood and drainage from a client's wound. The nurse knows that an open drain functions in which of the following ways?
Drainage occurs passively by gravity and capillary action
A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?
Inadequate gas exchange caused by smoke inhalation
A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan?
Incorrect1 "Cover the area with a sterile gauze bandage." 2 "Put warm compresses on the site once a day." 3 "Limit lying on the back and unaffected side when sleeping." Correct4 "Avoid applying lotions and powders over the area." Lotions and powders can cause a skin reaction on irradiated areas and should be avoided. Gauze and tape may irritate the skin further and should be avoided. Warm compresses are contraindicated because they may precipitate skin breakdown. The client can assume a position of comfort.
nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client says, "What should I do about my dry skin? It is so itchy." What is the best response by the nurse?
Incorrect1 "Wear warm clothes to keep moisture in the skin." Correct2 "Use a moisturizer on the skin daily to help reduce itching." 3 "Take hot tub baths only twice a week to reduce drying of the skin." 4 "Expose the skin to the air to help reduce the sensation of itching." Lubricating the skin with a moisturizer effectively relieves dryness and thus the pruritus. Wearing warm clothing will do nothing to lubricate the skin or relieve the pruritus. Warm or cool, not hot, tub baths will decrease itching. Exposing the skin to the air causes further drying and will not relieve pruritus.
Which description is associated with fissures?
Incorrect1 Deep erosions that extend beneath the epidermis 2 Thinning of the skin surface with a loss of skin markings Correct3 Linear cracks in the epidermis that extend into the dermis 4 Thickened areas of epidermis with accentuated skin markings Fissures are linear cracks in the epidermis that extend into the dermis. Ulcers may be described as deep erosions extending beneath the epidermis. Atrophy is the thinning of the surface of the skin with a loss of skin markings. Lichenifications are characterized by thick areas of epidermis with accentuated skin markings.
The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?
Incorrect1 Fluid volume Correct2 Skin integrity 3 Physical mobility 4 Urinary elimination Necrotizing fasciitis destroys subcutaneous tissue and fascia and predisposes the client to infection and sepsis. Although fluid volume and physical mobility are important, they are not the primary concern at this time. Necrotizing fasciitis is a problem of the integumentary, not the urinary, system.
Which organism infestation is diagnosed with the help of the mineral oil test?
Incorrect1 Lice 2 Ticks Correct3 Mites 4 Fungus Mites are the causative organism of scabies. Examination using mineral oil is a diagnostic measure for the scabies infection. To check for infestations, scrapings are placed on a slide with mineral oil and viewed microscopically. Lice leave excrement and eggs on skin and hair, live in seams of clothing (if body lice), and in hair as nits. A diagnosis of Lyme disease caused by ticks is often based on clinical manifestations, in particular the erythema migrans lesion, and a history of exposure in an endemic area. If the enzyme immunoassays is positive or inconclusive, a Western blot test is done to confirm the infection. The microscopic examination of skin lesions in 10% to 20% potassium hydroxide is a diagnostic measure to determine the presence of a fungus.
A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation?
Incorrect1 Neurologic 2 Wound Correct3 Pain 4 Skin Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. A neurologic check is not necessary unless the client's neurologic status has worsened since the stroke. Both skin and wound checks can be assessed once client comfort has been determined and handled.
Which client has a primary lesion?
Incorrect1 One with scales 2 One with ulcers 3 One with fissures Correct4 One with erosions Erosions are considered primary lesions. Scales, ulcers, and fissures are secondary lesions, which are modifications of primary lesions.
A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey-colored crust and surrounded by erythema. Which infection is suspected by the primary healthcare provider?
Incorrect1 Shingles Correct2 Impetigo 3 Folliculitis 4 Verruca vulgaris Impetigo is a primary bacterial infection most common on the face. This is clinically manifested as vesiculopustular lesions that develop as thick, honey-colored crust surrounded by erythema. Shingles or herpes zoster is a viral infection that usually occurs unilaterally on the trunk, face, and lumbosacral areas. Folliculitis is a bacterial infection seen most commonly on the scalp, beard, and extremities in men. Verruca vulgaris is a viral infection that is clinically manifested as circumscribed, hypertrophic, flesh-colored papule limited to the epidermis.
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 lymphadenopathy. What could be the possible diagnosis?
Incorrect1 Shingles 2 Cellulitis Correct3 Furuncle 4 Folliculitis A furuncle is a skin infection seen in the axilla. It is characterized by a small erythematous lesion filled with pus and is tender on percussion. Lymphadenopathy in the axilla is called regional lymphadenopathy. This is also associated with a furuncle. Shingles do not have small, red, pus-filled lesions. Cellulitis is a local inflammatory reaction associated with skin trauma and does not have small, red, pus-filled lesions. Folliculitis presents with hair in the center of the lesion.
A nurse is assessing a newly admitted client with the pressure ulcer indicated in the picture. Which pressure ulcer stage should the nurse document on the admission history and physical?
Incorrect1 Stage I Correct2 Stage II 3 Stage III 4 Stage IV A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater; has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum-filled blister. A stage I ulcer has tissue injury with intact skin with nonblanchable redness of a localized area; the ulcer may appear with persistent red, blue, or purple hues. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present. It presents as a deep crater with or without undermining, and bone, tendon, and muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.
Which description is associated with a hematoma?
Incorrect1 The occurrence of redness in patches of variable size and shape 2 The thickening of the skin with accentuated normal skin markings Correct3 The visible swelling due to extravasation of blood of sufficient size 4 The pinpoint, discrete deposits of blood in the extravascular tissues A hematoma may cause visible swelling due to the extravasation of a sufficient amount of blood. The occurrence of red patches of variable sizes and shapes indicates erythema. The thickening of the skin with accentuated normal skin markings indicates lichenifications. Petechiae are the pinpoint, discrete deposits of blood in the extravascular tissues.
he nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice?
Incorrect1 Thinning subcutaneous layer 2 Degeneration of elastic fibers Correct3 Decreased dermal blood flow 4 Benign proliferation of capillaries With decreased dermal blood flow the client is susceptible to dry skin; the nurse should advise the client to apply moisturizer when the skin is moist. If a client is found to have a thinning subcutaneous layer, the nurse should teach the client to dress warmly in cold weather. If a client presents with degenerated elastic fibers, the nurse should check the skin turgor on the forehead or chest of the client. If a client has benign proliferation of the capillaries, this indicates cherry hemangiomas; the nurse should teach the client that these are benign.
What are the side effects of oral psoralen in phototherapy? Select all that apply.
Incorrect1 Atrophy Correct2 Sunburn Incorrect3 Mucositis 4 Occular damage Correct5 Persistent pruritus Oral psoralen is one form of phototherapy used in the treatment of many dermatologic conditions. Sunburn and persistent pruritus are side effects of oral psoralen. Atrophy, mucositis, and ocular damage are the adverse reactions of radiation therapy.
Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply.
Incorrect1 Dryness Correct2 Photoaging 3 Vascular lesions Correct4 Wrinkling of skin Incorrect5 Benign neoplasm The skin damage that happens from chronic exposure to ultraviolet rays are photoaging and skin wrinkling. Dryness, vascular lesions, and benign neoplasm are changes related to aging.
() A nurse assessing the skin of patients knows that the following are health states that may predispose patients to skin alterations. Select all that apply
Obesity • Excessive perspiration • Low BMI
Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply.
Photoaging Wrinkling of the skin
Which teaching points would the nurse use to explain the development of pressure ulcers to patients and how to prevent them
Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." • "The skin can tolerate considerable pressure without cell death, but for short periods only." • "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation.
What is the function of the dermis?
Provides cells for wound healing
Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor?
Pseudomonas
Sutures are
Sutures are knotted ties that hold an incision together. Sutures generally are constructed from silk or synthetic materials such as nylon.
Which topical immunomodulator is used to treat a client with atopic dermatitis?
Tacrolimus Rationale: Tacrolimus is used to treat atopic dermatitis. Mupirocin is used to treat impetigo. Clindamycin and erythromycin are used to treat acne vulgaris.
A student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as unstageable. Which of the following wound descriptions should the student nurse expect to assess
The wound is 3 cm x 5 cm with yellow tissue covering the entire wound. Explanation: The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound is unable to be determined because it is covered entirely with slough.
Which fungal infection in a client is commonly referred to as athlete's foot?
Tinea pedis
A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema should the nurse initially assess?
Tissue ischemia Rationale: Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia, and should be assessed first.
What are the roles of an unlicensed assistive personnel in skin care?
To assist the client in bathing To apply wet dressings to the skin To report changes in the skin appearance
A nurse is caring for a 78 year old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which of the following actions should the nurse perform to prevent a pressure ulcer?
Using pillows to maintain a side lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every two hours and as needed to decrease moisture and irritation to the skin.
After emptying a portable wound suction device, place the following in the order in which the nurse would perform them
Wipe the drainage spout with an antiseptic Re-establish suction Reinsert the drainage plug Remove gloves Perform hand hyigene Return the client to a comfortable position
) Which nursing interventions reflect the accurate use of heat or cold during wound care? (Select all that apply.)
You selected: • The nurse makes more frequent checks of the skin of an older adult using a heating pad. • The nurse fills an ice bag with small pieces of ice to about two-thirds full. • The nurse covers a cold pack with a cotton sleeve to keep it in a cold pack with a cotton sleeve to keep it in place on an arm.
NPWT is not considered for use in the presence of
active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin
Penrose drains are commonly used
after a surgical procedure or for drainage of an abscess.
With dehiscence, there is
an accidental separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together
Vincristine suppresses
antibody production.
Wounds healing by secondary intention
are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue.
Transparent film dressings
are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms.
Stage II is defined
as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed
Transparent dressing allows the nurse to
assess a wound without removing the dressing; transparent dressings are especially used for peripheral and IV insertion sites.
A nurse is caring for a client who has recently undergone hernial surgery. The nurse knows that which of the following are possible causes of complications with regard to surgical wounds? Select all that apply.
insufficient protein and vitamin C intake • Weak tissue and muscular support due to obesity • Distension of the abdomen from accumulated intestinal gas
Stage I is defined as
intact skin with a localized area of nonblanchable redness, usually over a bony prominence.
A Hemovac drain is placed
into a vascular cavity where blood drainage is expected after surgery.
Mechanical debridement
involves physically removing the necrotic tissue, such as surgical debridemen
the client's position should be
changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every two hours and as needed to decrease moisture and irritation to the skin.
A nurse is performing wound care on the chronic pressure ulcer on a client's coccyx. Which of the following should be used during this procedure?
clean technique, It is appropriate for chronic wounds and pressure ulcers to be treated using clean technique rather than sterile or aseptic technique.
Saline solution is the
common solution of choice when performing an irrigation. When the solution from the wound turns clear, the irrigation should be discontinued. If bleeding is noted that was not previously there, the nurse should stop the irrigation and notify the physician
Serous drainage is
composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery.
sanguineous drainage
consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged. (l
Hemostasis involves
constriction of blood vessels and the beginning of blood clotting immediately after the initial injury.
Collagen synthesis and accumulation s.
continue, peaking in five to seven days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care consideration
Gauze dressing is ideal for
covering fresh wounds because of its highly absorbent nature. Gauze is applied to fresh wounds that are likely to bleed or wounds that exude drainage.
. Gauze dressing is ideal for
covering fresh wounds that are likely to bleed, or wounds that exude drainage.
negative pressure wound therapy
is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns.
Clients who are taking corticosteroid medications are at high risk for
delayed healing and wound complications such as infections, because corticosteroids decrease the inflammatory process that may in turn delay healing
Hemovacs, and negative pressure
dressings all utilize a suction device or collection reservoir and are considered to be closed systems. (l
A Penrose drain typically
exits a patient's skin through a stab wound created by the surgeon, Antimicrobial dressings are appropriate for chronic wounds at risk for infection.
. Open drains are
flat, flexible tubes that provide a pathway for drainage toward the dressing.
Biosurgical debridement uses
fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases.
A foot board prevents
foot drop in clients but does not decrease the risk for pressure ulcers
The nurse uses a hydrocolloid dressing when caring
for a client with superficial burn wounds as hydrocolloid dressings are self-adhesive, opaque, air- and water-occlusive wound coverings that keep wounds moist.
Clients who are taking corticosteroid medications are at high risk
for delayed healing and wound complications such as infections, because corticosteroids decrease the inflammatory process that may in turn delay healing.
Wounds healing by primary intention
form a clean, straight line with little loss of tissue.
. Stage III is defined as
full-thickness loss without exposed bone, tendon, or muscle.
Stage IV is defined as
full-thickness tissue loss with exposed bone, tendon, and muscle
The client reports crumbly, discolored, and thickened toenails. What could be the possible reason for this condition?
fungal infection
A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client?
his limits muscle contractions that may force causative organisms into the bloodstream.
Leukocytosis means the
increased production of white blood cells
. Chemotherapeutic agents, such as 5-fluorouracil,
inhibit fibroblast replication and collagen synthesis.
A hydrocolloid dressing help
keep the wounds moist
The epidermis is the
outer layer that protects the body with a waterproof layer of cells.
A suspected deep tissue injury
presents as a maroon or purple lesion or a blood filled blister.
A skin preparation applied to the periwound
protects intact skin and assists transparent film dressing to adhere to skin for better vacuum sea
77-year-old man has experienced an ischemic stroke and is now dependent for all his activities of daily living. What intervention should his nurse prioritize in order to minimize the patient's chance of skin breakdown?
reposition, For patients who are immobilized, it is imperative to regularly turn and reposition the patient in order to prevent ischemia and consequent skin breakdown. Hydration is also necessary to maintain skin integrity, but dehydration is less of a risk factor than prolonged immobility. It is unnecessary to keep the patient upright in order to protect his skin. Massage may promote circulation, but it is less important than turning the patient on a scheduled basis
source of energy for malnourished patients
rhe subcutaneous tissue is the skin layer that is responsible for storing fat for energy.
The nurse should never use
ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible.
A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which of the following stages should the nurse assign to this client's wound?
stage 3
A bandage is a
strip or roll of cloth wrapped around a body part.
Immunosuppressive agents,
such as corticosteroids, suppress protein synthesis.
A nurse bandages the knee of a client who has recently undergone a knee surgery. Which of the following is the major purpose of the bandage?
supports the area around the wound Explanation: Bandages and binders support the area around the wound or injury to reduce pain. The other purposes of bandages and binders are to hold dressings in place, especially when tape cannot be used or the dressing is extremely large, and to limit the movement of the wounded area to promote healing.
Closed drains are more efficient
than open drains because they pull fluid by creating a vacuum or negative pressure. This is done by opening the vent on the receptacle, squeezing the drainage collection chamber, and then capping the vent.
A Penrose drain is an open system
that lacks a collection device. Jackson-Pratt drains,
flat, flexible tubes
that provide a pathway for drainage toward the dressing.
Autolytic debridement involves using
the client's own body to break down the necrotic tissue.
. The maturation phase is
the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms
When measuring the depth of a wound, what should a nurse do
the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler
Using pillows to maintain a side lying position allows
the nursing staff to change position to alleviate and alternate pressure on client's bony prominences.
Enzymatic debridement involves
the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed.
The nurse should understand that the integrity of the skin and damaged tissues is restored how
through resolution or the process by which damaged cells recover and re-establish their normal function
All foam pieces must be touching
to assure effective negative pressure.
Chemotherapy and radiation
treatments retard wound repair
Open drains are
tubes that provide pathways for drainage toward the dressing.
Jackson-Pratt drains are
typically used with breast and abdominal surgery.
iv dressing type
use a transparent dressing to cover the IV insertion site because such dressings allow the nurse to assess a wound without removing the dressing.
Clean technique can be
used on a closed wound.
Wound pouching is
used on wounds that have excessive drainage
Cyanoacrylate glue can be
used to close acute wounds in certain situations.
Ace wraps are elastic bandages
used to provide light support to an area or to secure dressings. Ace strips do not help to approximate wound edges, facilitate closure of acute wounds, or prevent abscess formation.
A shearing force results
when one layer of tissue slides over another layer. Patients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces
Black foam touching periwound skin
will cause erythema to intact skin. The black foam dressing must touch all the wound edges to allow for healing from deepest part of the wound first (healing from inside to the outside).
Steristrips are applied to wounds to approximate
wound edges and promote healing.
An abrasion is a
wound involving friction of the skin.
A puncture is a
wound that occurs from penetration of the skin and underlying tissue
A bandage is a strip or roll of cloth
wrapped around a body part to help support the area around the wound. (less)
A nurse is developing a plan of care for a client who is at high risk for developing pressure ulcers. Which of the following interventions should the nurse include in the plan to prevent the development of pressure ulcers?
• Provide incontinent care every 2 hours and as needed • Turn client every 2 hours while client in bed • Encourage client to take fluids every 2 hours
Which of the following processes are responsible for restoring integrity of the skin and damaged tissues when caring for a client with an open wound?
• Resolution • Regeneration • Scar formation