Integumentary
Which medication would be prescribed for the client to treat severe nodulocystic acne? A. Imiquimod B. Isotretinoin C. Clindamycin D. Corticosteroids
Isotretinoin 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 may cause flare-ups in clients with acne.
Which description is common to zosteriform-type lesions? A. Wide distribution B. Diffuse distribution C. Bilateral distribution D.Band-like distribution
Band-like diffusion 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.
Which skin color in a client indicates an increased urochrome level? A. Red color B. Blue color C. Reddish-blue color D. Yellow-orange color
yellow-orange A yellow-orange skin color indicates an increased urochrome level. A red color indicates increased blood flow to the skin. A blue color indicates an increase in deoxygenated blood in the body. A reddish-blue color of the distal extremities indicates decreased peripheral circulation.
Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply. One, some, or all responses may be correct. A. Dryness B. Photoaging C. Vascular lesions D. Wrinkling of skin E. Benign neoplasm
Photoaging, wrinkling of skin The skin damages that happen from chronic exposure to ultraviolet rays are photoaging and skin wrinkling. Dryness, vascular lesions, and benign neoplasm are changes related to aging.
Which lesions are considered primary lesions? A. Scales B. Ulcers C. Fissures D. Erosions
Erosions Erosions are considered primary lesions. Scales, ulcers, and fissures are secondary lesions, which are modifications of primary lesions.
Which condition presents as chalk white patches on the skin? A. Vitiligo B. Jaundice C. Cyanosis D. Erythema
Vitiligo Vitiligo is the abnormal condition in which chalky white patches appear on the skin. This is due to a complete absence of melanin. Jaundice is an abnormal condition in which the skin appears yellow or yellow-brownish in color due to increased bilirubin in the blood. Cyanosis is the condition in which the skin is slightly bluish or purple in color due to excessive or reduced hemoglobin in the capillaries. Erythema is the condition in which red-colored patches appear on the skin in variable sizes and shapes.
Which description describes a coalesced type of skin lesion configuration? A. Lesions are well defined with sharp borders. B. Lesions merge together and appear confluent. D. Lesions are ringlike around flat centers of skin. E. Lesions have wavy borders that resemble a snake.
B 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 skin color alteration may be observed in a client diagnosed with methemoglobinemia? A. Red B. Blue c. White D. Yellow-orange
Blue 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 or it may signify a risk of anemia and shock. A yellow-orange skin discoloration may indicate jaundice and is associated with liver disorders.
Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. One, some, or all responses may be correct. A. Burns B. Skin cancer C. Osteomyelitis D. Diabetic ulcers E. Myocardial infarction
Burns, osteomyelitis, diabetic ulcers 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.
Which type of allergic skin condition is associated with immunological irregularity, asthma, and allergic rhinitis? A. Urticaria B. Psoriasis C. Acne vulgaris D. Atopic dermatitis
atopic dermatitis Atopic dermatitis is an allergic skin condition that is a genetically influenced, chronic, relapsing disease. It is associated with immunological 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.
Which information about skin care would the nurse include in the teaching plan for a client who is receiving radiation therapy? A. "Cover the area with a sterile gauze bandage." B. "Put warm compresses on the site once a day." C. "Limit lying on the back and unaffected side when sleeping." D. "Avoid applying lotions and powders over the area."
"Avoid applying locations 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.
Which is a serious side effect of x-rays? A. Vesicles B. Papular C. Desquamation D. Plaque-like lesions
Desquamation X-ray is one of the radiological 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 medication-induced photosensivity.
While palpating the skin of a client, the nurse observes pitting edema on the dorsum of the foot. Which condition could be a possible cause of this? A. Endocrine imbalance B. Excessive collagen production C. Fluid and electrolyte imbalance D. Autonomic nervous system stimulation
Fluid and electrolyte imbalance Fluid and electrolyte imbalance results in pitting edema of the skin. An endocrine imbalance may result in nonpitting edema. Excessive collagen production leads to increased skin thickness. Stimulation of the autonomic nervous system may result in an increase in skin moisture.
Which teaching point would the nurse include when teaching a client about how to care for the skin around a colostomy stoma? A. "Wash with soap and water." B. "Rinse the area with peroxide." C. "Apply a thick coat of an emollient." D. "Rub vigorously to remove hardened feces."
A Soap and water remove fecal debris and microorganisms; this promotes skin integrityand prevents infection. Hydrogen peroxide is too irritating and should be avoided. Applying ointment to this extent is contraindicated because it will interfere with adherence of the appliance. Vigorous rubbing may be irritating and may promote conditions that contribute to infection.
Which clinical manifestation is associated with cellulitis? A. Lymphadenopathy B. Occasional papules C. Vesicles that evolve into pustules D. Isolated erythematous pustules
Lymphadenopathy 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 recommendations would the nurse include in a client's discharge instructions regarding a home skincare program for psoriasis? A. "Shower twice a day with mild soap and warm water." B. "Soak the affected areas in hot water on a daily basis." C. "Apply an alcohol free, moisturizing lotion several times a day." D. "Cover affected areas when in contact with others."
"Apply an alcohol free, moisturizing lotion several times a day." Moisturizing lotions provide an occlusive film on the skin surface so that usual water loss through the skin is limited, thereby allowing the trapped water to hydrate the stratum corneum. Clients should not excessively expose the skin to water, particularly hot water, increases irritation and scaling. Psoriasis is not a communicable disease and affected areas do not need covering when in contact with others.
Which medication can cause chemical burns? A. Anthralin B. Prednisone C. Tazarotene D. Calcipotriene
Anthralin Anthralin is a strong irritant that has an action similar to tar. Therefore this medication 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 sustained minor skin injuries after an accident. Which event occurs close to the time of injury? A. Thinning of the scar tissue B. Formation of granulation tissue C. Migration of leukocytes to the site of injury D. Arrival of fibroblasts to the site of infection
Migration of leukocytes to the site of injury 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 benign condition of the client's skin is associated with the grouping of normal cells derived from melanocytelike precursor cells? A. Nevi B. Psoriasis C. Acne vulgaris D. Plantar warts
Nevi 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 melanocytelike 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.
Which risk would the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn? A. The risk of septicemia and its potential complications from treatment B. The risk of psychosocial adjustments and resuming previous roles C. The risk of oral mucous membrane injury and its associated risks D. The risk of insufficient community resources and emotional support
The risk of septicemia and its potential complications from treatment Skin is the first line of defense against infection. When much of it is destroyed, the client is vulnerable to infection. Complications, such as infection and contractures, still may occur during the acute phase and as the client is healing. Psychosocial adjustments, previous roles, and insufficient community resources are priorities in the rehabilitative phase. Risk of oral mucous membrane injury is in the emergent (resuscitation) stage. Emotional support is provided in all three phases.
Which fungal infection is commonly referred to as athlete's foot? A. Tinea pedis B. Tinea cruris C. Tinea corporis D. Tinea unguium
Tinea pedis Tinea pedis is a fungal infection commonly known as athlete's foot. Tinea cruris is jock itch. Tinea corporis is ringworm. Tinea unguium is onychomycosis.
The 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 asks what to do about itchy, dry skin. Which response by the nurse is appropriate? A. "Wear plenty of warm clothes to keep moisture in the skin." B. "Use a moisturizer on the skin daily to help reduce itching." C. "Take hot tub baths only twice a week to reduce drying of the skin." D. "Expose the skin to the air to help reduce the sensation of itching."
"Use a moisturizer on the skin daily to help reduce itching." Lubricating the skin with a moisturizer effectively relieves dryness and, thus, the pruritus (itching). Wearing warm clothing will not lubricate the skin or relieve pruritus. Warm or cool, not hot, tub baths will reduce itching. Exposing the skin to the air causes further drying and will not relieve pruritus.
Which test is used in the diagnosis of systemic lupus erythematosus? A. Patch test B. Photo patch test C. Direct immunofluorescence test D. 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 intervention would the nurse include in the plan of care for a client admitted with herpes zoster? Select all that apply. One, some, or all responses may be correct. A. Acyclovir B. Silvadene C. Gabapentin D. Wet compresses E. Contact isolation
All A client with herpes zoster would receive antiviral medications such as acyclovir. Silvadene can be applied to open vesicles. Gabapentin can be used to treat the nerve pain associated with herpes zoster. Wet compresses can be applied to the vesicles to relieve discomfort. Herpes zoster is highly contagious, and the client would be placed in contact isolation precautions.
Which integumentary change is associated with delayed wound healing in a client? A. Decreased cell division B. Decreased epidermal thickness C. Decreased immune system cells D. Increased epidermal permeability
Decreased cell division 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.
Which point would the nurse include in a teaching plan to help manage pain during dressing changes if a client has burns over 18% of body surface? A. Deep breathing exercises B. Progressive muscle relaxation C. Active range-of-motion exercises D. Important elements of wound care
Deep breathing exercises 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.
The client reports crumbly, discolored, and thickened toenails. Which reason could be a possible cause for this condition? A. Allergy B. Insect bite C. Fungal infection D. Bacterial infection
Fungal infection Exposure to the pathological fungal varieties may cause infections to the nails along with hair and skin. Dermatological problems associated with allergies and hypersensitivity reactions may include only skin and may not include nails and hair. Insect bites may cause life-threatening allergic reactions due to the venom of the insect. Bacteria may cause scalp infections to hair and skin but do not usually cause nail infections.
Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply. One, some, or all responses may be correct. A. Furuncle B. Cellulitis C. Impetigo D. Folliculitis E .Erysipelas
Impetigo, 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.
Which clinical finding occurs due to thinning of the subcutaneous layer? A. Decreased tone and elasticity B. Decreased sensory perception C. Increased risk for hypothermia D. Increased susceptibility to dry skin
Increased risk for hypothermia 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 type of skin lesion has a wavy border? A. Annular B. Circinate C. Coalesced D. Serpiginous
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.
Which intervention would be included in the plan of care for the prevention of a pressure injury? A. Positioning a client directly on the trochanter B. Keeping the client's skin directly off plastic surfaces C. Keeping the head of the bed elevated above 30 degrees D. Placing a rubber ring or donut under the client's sacral area
Keeping the client's skin directly off plastic surfaces 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.
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? A. Fluid volume B. Skin integrity C. Physical mobility D. Urinary elimination
Skin integrity 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 type of laser is used in the treatment of vascular and other pigmented lesions? A. Argon B. Gold vapors C. Neodymium D. Carbon dioxide
Argon 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.
A dark-skinned client has a gray-colored tongue and lips. Which complication does the nurse suspect? A. Cyanosis B. Jaundice C. Bleeding D. Inflammation
Cyanosis The gray color of the tongue and lips is due to cyanosis. A yellow color to the oral mucous membranes is due to jaundice. If the affected area of the body shows swelling and darkening of the skin when compared with an unaffected area, then it is due to skin bleeding. When the affected area is warm, and the skin color is changed, it is inflammation.
Which term would the nurse use to document a 1 cm elevated solid lesion noted on a client's skin? A. Papule B. Nodule C. Vesicle D. Pustule
Nodule A nodule is an elevated solid lesion greater than 0.5 cm in diameter. A papule is an elevated solid lesion less than 0.5 cm in diameter. A vesicle is a circumscribed, superficial collection of serous fluid. A pustule is an elevated, superficial lesion filled with purulent fluid.
Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? A. Tenting B. Angioma C. Varicosity D. Telangiectasia
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.
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. The nurse would expect to teach the client about which condition? A. Tinea pedis B. Tinea cruris C. Tinea corporis D. Tinea unguium
Tinea pedis 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.
Which secondary skin lesion may include athlete's foot as an example? A. Scar B. Scale C. Ulcer D. Fissure
Fissue 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 after a medication reaction or sunburn. Ulcer-type lesions may include pressure ulcers or chancres.
Which information would the nurse consider when planning care for a client with scabies? A. Scabies is highly contagious. B. It is caused by a fungus. C. Chronic with exacerbations are classic symptoms. D. There is a correlation with other allergies.
Highly contagoius 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.
The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury? A. Hypokalemia and hyponatremia B. Hyperkalemia and hyponatremia C. Hypokalemia and hypernatremia D. Hyperkalemia and hypernatremia
Hyperkalemia and hyponatremia 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.
Which skin lesion in found in clients with acne? A. Wheal B. Plaque C. Vesicle D. Pustule
Pustule Pustules are seen in such conditions as acne. A pustule is an elevated, superficial lesion filled with purulent fluid. A wheal is a firm, edematous, irregularly shaped skin lesion, formed as an inflammatory response to allergens or insect bite. A plaque is a circumscribed, elevated, superficial, solid lesion. A vesicle is a circumscribed, superficial collection of serous fluid.
The nurse observes elevated superficial lesions filled with purulent fluid on a client's skin. Which type of lesion would the nurse document in the health record? A. Wheal B. Plaque C. Pustule D. Vesicle
Pustule Pustules are the primary lesions that cause elevated, superficial lesions filled with purulent fluid on the skin. Acne and impetigo are examples of pustules. A wheal is a firm, edematous, irregularly shaped lesion. Insect bites and urticaria are examples of wheals. Plaque consists of circumscribed, elevated superficial solid lesions less than 0.5 cm in diameter. Psoriasis and seborrheic are examples of plaque. A vesicle is a circumscribed, superficial collection of serous fluid. Varicella and second-degree burns are examples of vesicles.
Which characteristic mental change occurs with delirium and differentiates it from dementia? Select all that apply. One, some, or all responses may be correct. A. Daytime sleepiness B. Rapid-onset confusion C. Lasts over several years D. Progressive deterioration E. Apathetic thought process
Rapid-onset confusion The mental changes associated with delirium have a rapid onset and are usually precipitated by an infection or medication change. Clients with dementia may sleep more during the day, and the duration of the disease lasts several years with a progressive deterioration of body systems. Clients with depression may display apathy, but this mental change is not specific to delirium or dementia.
Which information would the nurse include in a community education session on decreasing the risk for musculoskeletal injuries? Select all that apply. One, some, or all responses may be correct. A. Use of seatbelts B. Obeying speed limits C. Wearing safety equipment C. Avoiding impaired vehicle use D. Refraining from distracted driving
All The nurse can provide several proactive steps for preventing musculoskeletal injuries at home, at work, and in the community. Community members should be advised to wear seatbelts, follow the speed limit, and refrain from distracted or impaired driving. Employees should be instructed to follow workplace safety procedures and practices including wearing safety equipment.
Which disease is caused by the virus that causes chickenpox? A. Athlete's foot B. Herpes zoster C. German measles D. Infectious hepatitis
Herpes zoster Invasion of the posterior (dorsal) root ganglia by the same virus that causes chickenpox can result in herpes zoster, or shingles. This may be caused by reactivation of a previous chickenpox virus that has lain dormant in the body or by recent contact with an individual who has chickenpox. Athlete's foot is caused by a fungus. German measles is caused by a virus, but not the herpes virus. Hepatitis type A is caused by a virus, but not the herpes virus.
Which medication is a newer treatment option for treating metastatic melanoma? A. Lomustine B. Ipilimumab C. Carmustine D. Temozolomide
Ipilimumab Ipilimumab is a type of immunotherapy and is a monoclonal antibody. It is a newer option of medication therapy used in the treatment of metastatic melanoma. Lomustine, carmustine, and temozolomide are established chemotherapy medications in use for many years for the treatment of metastatic melanoma.
Which organism infestation is diagnosed with the help of the mineral oil test? A. Lice B. Ticks C. Mites D. Fungus
Mites 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.
While assessing the skin of a client, the nurse identifies an elevated, solid lesion measuring 4 mm × 4 mm in size. Which type of lesion does the client have? A. Papule B. Vesicle C. Pustule D. Macule
Papule 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.
Which goal is the nurse trying to achieve when placing a client with severe burns on a circulating air bed? A. Increasing mobility B. Preventing contractures C. Limiting orthostatic hypotension D. Preventing pressure on peripheral blood vessels
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 function of the dermis is accurate? A. Provides cells for wound healing B. Assists in retention of body heat C. Acts as mechanical shock absorber D. Inhibits proliferation of microorganisms
Provides cells for wound healing 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 side effects are related to oral psoralen in phototherapy? Select all that apply. One, some, or all responses may be correct. A. Atrophy B. Sunburn C. Mucositis D. Ocular damage E. Persistent pruritus
Sunburn, persisten pruritus Oral psoralen is one form of phototherapy used in the treatment of many dermatological conditions. Sunburn and persistent pruritus are side effects of oral psoralen. Atrophy, mucositis, and ocular damage are the adverse reactions of radiation therapy.
Which gastrointestinal (GI) change may be found in the client with burn injuries? A. Abdominal distention B. Increased peristalsis C. Activation of GI motility D. Increased blood flow to the GI area
Abdominal distention The client with burn injuries may have abdominal distention due to loss of peristalsis. Gastrointestinal motility may be inhibited with burn injuries. Blood flow may be reduced and mucosal damage might have occurred.
Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. A. Monitoring vital signs B. Cutting off the clothing C. Inserting a urinary catheter D. Removing the client's jewelry E. Establishing an intravenous line
All According to the Rule of Nines, the client has full-thickness burns to 22.5% of the body (18% chest and 4.5% right arm). The nurse would monitor vital signs (including oxygen saturation), remove the client's clothing and jewelry, insert a urinary catheter to maintain intake and output, and insert an intravenous line to administer fluids.
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? A. Partial-thickness burns require grafting before they can heal. B. Partial-thickness burns are often painful, reddened, and have blisters. C. Partial-thickness burns cause destruction of both the epidermis and dermis. D. Partial-thickness burns often take months of extensive treatment before healing.
Are often painful, reddened, and have blisters 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 age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? A. Atrophy of the sweat glands B. Decreased subcutaneous fat C. Stiffening of the collagen fibers D. Degeneration of the elastic fibers
Decreased subcutaneous fat In older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers. Atrophy of the sweat glands will cause dry skin and decreased body odor. Stiffening of the collagen fibers and degeneration of the elastic fibers will result in the development of wrinkles.
Which type of biopsy is required for removal of entire lesions on the skin? A. Punch biopsy B. Shave biopsy C. Incisional biopsy D. Excisional biopsy
Excisions 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.
Which disorder is a cause of systemic altered inflammatory response in impaired wound healing? A. Uremia B. Cirrhosis C. Leukemia D. Hypovolemia
Leukemia 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 mechanism of action for wet-to-damp saline-moistened gauze for wound debridement is correct? A. Promoting the dilution of viscous exudate B. Removing the necrotic tissue mechanically C. Causing a breakdown of the denatured protein of the eschar D. Promoting the spontaneous separation of necrotic tissue
Removing the necrotic tissue mechanically Wet-to-damp saline-moistened gauze mechanically removes the necrotic tissue. The dilution of viscous exudates is promoted through the continuous wet-gauze technique. Topical enzyme preparations cause a breakdown of the denatured protein of the eschar. Moisture-retentive dressings promote the spontaneous separation of necrotic tissue through autolysis.
Which assessment finding is associated with chronic eczema? A. Localized edema B. Rough, thick skin C. Decreased skin turgor D. Increased skin temperature
Rough, thick skin Rough and thick skin may indicate chronic eczema. Localized edema is associated with trauma or inflammation. A decrease in skin turgor may indicate severe dehydration. An increase in skin temperature may be a sign of fever.
A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. Which response by the nurse is therapeutic? A. "Why did you sign the consent?" B. "Tell me why you want to refuse the procedure." C. "You are obviously afraid about something concerning the procedure." D. "Although the procedure is very important, I understand why you changed your mind."
"Tell me why you want to refuse the procedure." The response "Tell me why you want to refuse the procedure" is open ended and attempts to explore why the client is refusing the procedure; it promotes communication. The response "Why did you sign the consent?" is accusatory; the client has the right to withdraw consent at any time. The response "You are obviously afraid about something concerning the procedure" is a conclusion without appropriate data; it puts the client on the defensive. The response "Although the procedure is very important, I understand why you changed your mind" is a conclusion without appropriate data; it may raise the client's anxiety level.
When teaching a client self-care measures to prevent dry skin, which client statement indicates misunderstanding of the content? A. "I will decrease intake of caffeine and alcohol." B. "I will use deodorant soap in place of alkaline soap." C. "I will wear splints at night to prevent scratching in a deep sleep." D. " I will adjust my thermostat to remain around 74°F to 78°F (23.3°C-25.5°C)."
B Avoiding caffeine and alcohol will prevent development of dry skin. Wearing splints will prevent damage to dry skin caused by scratching during deep sleep due to pruritus. Higher temperatures lead to increased perspiration and itching. Keeping the client's environment cooler will decrease the itching. Use of deodorant soap will make the skin dry, further, so the nurse needs to follow up to correct this misconception. Clients should avoid deodorant soap when experiencing dry skin.
Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? A. Medication eruption B. Atopic dermatitis C. Contact dermatitis D. Nonspecific eczematous dermatitis
Contact dermatitis In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In medication 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 client conditions does the nurse associate with bluish-colored mucous membranes? Select all that apply. One, some, or all responses may be correct. A. Edema B. Diabetes mellitus C. Hemochromatosis D. Methemoglobinemia E. Cardiopulmonary disease
D, E 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 event occurs in the proliferative phase of wound healing? A. Thinning of scar tissue B. Strengthening of collagen C. Formation of granulation tissue D. Increase in capillary permeability
Formulation of granulation tissue 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.
Which color would the nurse anticipate when assessing a client's skin tears? A. Red B. Gray C. Black D. Yellow
Red A wound 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.
Which variations in nail color would indicate that a client has trauma to the nail beds? A. Red color B. Blue color C. White color D. Yellow-brown color
Red 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 disease, or kidney disease. A yellow-brown color is an indication of jaundice or cardiac failure.
Which interventions can be performed by an unlicensed assistive personnel in skin care? Select all that apply. One, some, or all responses may be correct. A. Assist the client in bathing. B. Apply wet dressings to the skin. C. Report changes in the skin appearance. D. Reinforce teaching as done by the registered nurse. E. Determine whether the client is taking a medication that increases photosensitivity.
assist the client in bathing, apply wet dressings to the skin, report changes in the skin appearance The unlicensed assistive personnel may be responsible for assisting the client in bathing, applying wet dressings to the skin, and reporting changes in the skin appearance. Teaching done by the registered nurse can be reinforced by a licensed practical nurse or a vocational nurse. The registered nurse would be responsible for determining whether the client is taking a medication that increases photosensitivity.
Which factors put a client at risk for bacterial infections? Select all that apply. One, some, or all responses may be correct. A. Dry skin B. Underweight C. Atopic dermatitis D. Diabetes mellitus E. Systemic antibiotics
atopic dermatitis, diabetes mellitus, 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, because 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.
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 mosteffective method for putting out the flames. Which information from the group members indicates successful learning? A. Wrap hand with towel and slap at the flames. B. Instruct the victim to roll on the ground. C. Pour cold liquid over the flames. D. Remove the victim's burning clothes.
Instruct the victim to roll on the ground STOP, DROP, and ROLL is the sequence the victim needs to do to extinguish the flames. Instructing the client, if possible, is priority. Rolling the victim in the grass effectively extinguishes the flames and protects the victim from additional injury. Slapping at the flames will not eliminate the oxygen that supports the fire and will fan the flames. Slapping the flames may also burn the person that is trying to extinguish the fire. Pouring cold liquid over the flames may extinguish the flames, but not as effectively as rolling in the grass. The water may be difficult to pour over all areas, whereas rolling will quickly touch all areas needing to be extinguished. Removing the victim's burning clothes may or may not protect the client from further injury and is dangerous for the rescuer.
While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent which complication? A. Renal calculi B. Disorientation C. Pressure injuries D. Urinary infection
Pressure injuries Clients in advanced stages of muscular dystrophy are immobile. A client who sustained respiratory distress should be frequently repositioned to prevent the development of pneumonia. The client is also at risk of developing pressure injuries, which can be avoided by frequent repositioning of the client. Renal calculi can be prevented in this client by increasing fluid intake and decreasing dietary calcium. Urinary infection can be avoided by fluid intake to flush the renal system and measures to decrease urinary retention. Disorientation is a neurological complication that can be prevented by maintaining a proper sleep-wake schedule in accordance with day-night patterns and reorientation of the client to person, place, time, and control of sensory stimulation.
Which equipment will the nurse prepare for a client whose burn wounds are scheduled to be debrided mechanically? A. Enzymatic agents B. Scissors and forceps C. Autolytic semiocclusive dressing D. Continuous passive-motion device
Scissors and forceps 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.
Which feature is associated with the "maturation phase" of normal wound healing? A. The scar is firm and inelastic on palpation. B. Fibrin strands form a scaffold or framework. C. White blood cells migrate into the wound. D. Epithelial cells are grown over the granulation tissue bed.
The scar is firm and inelastic on palpation 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.
