Integumentary System

a. b. c. d.

Rationale:

Which of the following individuals is least likely to be at risk of developing psoriasis? a. A 32 year old African American b. A woman experiencing menopause c. A client with a family history of the disorder d. An individual who has experienced a significant amount of emotional distress

a. A 32 year old African American Rationale: The incidence is lower in darker skinned races and ethnic groups.

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following? a. An irregularly shaped lesion b. A small papule with a dry, rough scale c. A firm, nodular lesion topped with crust d. A pearly papule with a central crater and a waxy border

a. An irregularly shaped lesion Rationale: Melanoma is an irregularly shaped pigmented papule with a red, white, or blue-toned color. Squamous cell carcinoma (firm, nodular lesion topped with crust or central area of ulceration). Basil cell carcinoma (a pearly papule with a central crater and rolled waxy border)

The nurse is implementing a teaching plan to a group of adolescents regarding the cause of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder? a. Acne is caused by oily skin b. The actual cause is unknown c. Acne is caused by eating chocolate d. Acne is caused as a result of exposure to heat and humidity

b. The actual cause is unknown Rationale: Oily skin and eating chocolate does NOT cause acne. Exacerbations may happen during menstrual due to hormonal activity.

The nurse prepares to treat a client with frostbite of the toes. Which of the following do the nurse anticipate to be prescribed for this condition? a. Rapid and continuous rewarming of the toes after flushing returns b. Rapid and continuous rewarming of the toes in cold water for 45 minutes c. Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes d. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs

d. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs Rationale: Cold and hot water are NOT used.

The clinic nurse assesses the skin of a white client diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder? a. Clear, thin nail beds b. Red-purplish scaly lesions c. Oily skin and no episodes of pruritus d. Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions

d. Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions Rationale: Psoriatic patches are covered with silvery-white scales. Affected areas include the scalp, elbows, knees, shins, trunk, and sacral area

The nurse is assigned to care for a client with herpes zoster (shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection? a. Clustered skin vesicles b. A general body rash c. Small blue-white spots with a red base d. A fiery red, edematous rash on the cheeks

a. Clustered skin vesicles Rationale: Classic presentation is group vesicles on an erythematous base along a dermatome. The lesions do not cross the midline of the body because the follow the nerve pathways

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which statement by a client indicate a need for further instructions? a. I will avoid sun exposure after 3PM b. I will use sunscreen when participating in outdoor activities c. I will wear a hat, opaque clothing, and sunscreen when in the sun d. I will examine my body monthly for any lesions that may be suspicious

a. I will avoid sun exposure after 3PM Rationale: Sun exposure should be avoided between the hour of 11AM and 3PM

The client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. The nurse base the response on the understanding that the characteristic of cellulitis include: a. an inflammation of the epidermis only. b. A skin infection into the dermis and subcutaneous tissue c. An acute superficial infection of the dermis and lymphatics d. An epidermal and lymphatic infection caused by Staphylococcus

b. A skin infection into the dermis and subcutaneous tissue Rationale: It is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red, erythema w/o sharp borders and spreads widely throughout tissue spaces. Skin is red swollen, tender, and sometimes nodular.

Ultraviolet light therapy is prescribed as a component of the treatment plan for a client with psoriasis and the nurse provide instructions to the client regarding the treatment. Which statement by the client indicate a need for further instructions? a. Treatments are limited to two or three times a week b. The ultraviolet light treatments are given on consecutive days c. Eye goggles need to be worn to prevent exposure to ultraviolet light d. Just the area requiring treatment should be exposed to the ultraviolet light

b. The ultraviolet light treatments are given on consecutive days Rationale: Treatments are limited to two or three times a week and ultraviolet light treatments are NOT given on consecutive days. Safety precautions are required during therapy

The nurse begins to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which of the following will be prescribed for the client? a. Cold compresses to the affected area b. Warm compresses to the affected area c. Intermittent heat lamp treatments four times daily d. Alternating hot and cold compress continuously

b. Warm compresses to the affected area Rationale: Warm compresses can be used to decrease the discomfort, reddness, and edema.

The clinic nurse notes that the physician has documented a diagnosis of of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made following which diagnostic test? a. Patch test b. Skin biopsy c. Culture of the lesion d. Wood's light examination

c. Culture of the lesion Rationale: A viral cultural of the lesion provides the definitive diagnosis. Patch test(allergies), Biopsy (tissue), and Wood's light (identify superficial infection of the skin)

A client returns to the client for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of lesion? a. Metastasis is rare b. Melanoma is encapsulated c. Melanoma is highly metastatic d. Melanoma is characterized by local invasion

c. Melanoma is highly metastatic Rationale: This skin cancer is highly metastatic and survival rate depends on early diagnosis and treatment

A male client calls the emergency room and tells the nurse that he had been cleaning a wooded area in the backyard and came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. Which of the following is the appropriate nursing response? a. Come to the emergency room b. Apply calamine lotion immediately to the exposed skin areas. c. Take a shower immediately, lathering and rinsing several times. d. It is not necessary to do anything if you cannot see anything on your skin.

c. Take a shower immediately, lathering and rinsing several times. Rationale: Because the ivy plant forms an invisible film on the human skin so client needs to shower immediately lathering and rinsing the skin several times.

The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes zoster? a. The nurse who never had roseola b. The nurse who never had mumps c. The nurse who never had chickenpox d. The nurse who never had German measles

c. The nurse who never had chickenpox Rationale: Caused by a reativation of the varicella-zoster virus. It is very contagious to those who has not has the virus(responsible for chickenpox)

The client arrives at the emergency room and has experience frostbite to the right hand. Which of the following would the nurse note on assessment of the client's hand? a. A pink, edematous hand b. A fiery red skin with edema in the nail beds c. Black fingertips surrounded by an erythematous rash d. A white color to the sin, which is insensitive to touch

d. A white color to the sin, which is sensitive to touch Rationale: Frostbite includes white or blue color, skin will be hard, cold, and insensitive to touch

The nurse prepares discharge instructions for a client following cryosurgery for the treatment of a malignant skin lesion . Which of the following should the nurse include in the instructions? a. Avoid showering for 7 to 10 days b. Apply ice to the site to prevent discomfort c. Apply alcohol-soaked dressings twice a day d. Clean the site with hydrogen peroxide to prevent infection

d. Clean the site with hydrogen peroxide to prevent infection Rationale: Done to prevents secondary infection

The evening nurse reviews the clients documentation in the chart and notes that the day nurse has documented that the client has stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? a. Intact skin b. Full thickness skin loss c. Expose bone, tendons, or muscle d. Partial-thickness skin loss of the dermis

d. Partial-thickness skin loss of the dermis Rationale: Stage I(skin intact), stage III (full-thickness skin loss occurs), and Stage IV (expose bone, tendons, or muscle)