integumentary unit T (ch.41,42,38)

The student nurse is preparing to document a suspicious area over a bony prominence. Which description would be most appropriate?

Nonblanching area over left trochanter 0.8 cm 1.2 cm

a nurse is collecting data on a client who has a surgical would healing by secondary intention. which of the following should the nurse report to the charge nurse

the would has a halo of erythema on the surrounding skin

open inspection of a client skin a nurse identifies a stage 3 pressure ulcer on sacrum which of the following statement by the nurse describes stage 3 ulcer?

there is full thickness skin loss with a crater

A nurse is checking a school age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?

Firmly attached white particles on the hair

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Large incisions will be made in the burned tissue to improve circulation

A newly admitted 86-year-old patient has scratch marks in the groin and axilla and on her limbs. There are small, punctate red lesions that the patient says itch "like crazy." Which is the most likely cause and the best nursing action?

Scabies, and employs Standard Precautions

The nurse changing a wet-to-damp normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be:

add normal saline to loosed it

when is the best time for the nurse to apply prescribed ointment to a patient with inflamed skin?

after the patient bathes

ABCD of melanoma

asymmetry, border, color, diameter

the nurse is educating a patient with acne rosacea that has facial erythema and telangiectasis. which information should the nurse include in the teaching plan?

avoid direct sunlight

Psoriasis

chronic, recurrent dermatosis marked by itchy, scaly, red plaques covered by silvery gray scales

The nurse teaches the patient the "ABCD" technique for evaluating melanomas. In this memory prompt, the "D" stands for:

diameter

erythema

diffuse redness of the skin

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

drawing the wound edges together by a negative pressure

plaque

elevated superficial solid lesion >1cm diameter

wheal:

firm, edematous, irregular shaped area

macule

flat area with a change in skin color <1 cm diameter

a nurse is collecting data on a Clients wound. the nurse observes the would surface is covered with soft, red tissue that bleeds daily. the nurse should record this is a manifestation of which of the following?

granulation tissue

A patient has a pooling of blood under unbroken skin of the hip after a fall. The nurse should document that this patient has a(n):

hematoma

a 84 year old patient has a low grade fever for 2 days. this morning the patient complains of burning. tingling hip pain that shoots down the leg. the nurse obtains small group of vesicles on the leg. these findings are consistent with which disease?

herpes zoster

The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

in a circular motion around the wound cleaning to the outside

the nurse clarifies that the first stage of would healing is

inflammation

Turgor

measure of skin elastic and hydration

the student nurse is preparing to document a suspicious area over a bony prominence. which description would be most appropriate?

non blanching area over left trochanter 0.8 cm by 1.2 cm

a nurse is bathing a patient with poison ivy. which action is most appropriate?

pat skin dry.

The action of the CNA that the nurse observes that would be harmful to a patient's skin is:

pulling the draw sheet out from under the patient.

debridement

removal of foreign material and dead or damaged tissue from a wound

The nurse best describes a "shave biopsy" of a skin lesion as:

removal of the top of the lesion that stands above the skin line

petechiae

small, purplish, hemorrhagic spots on the skin

The nurse warns the patient that one of the patient's habits has caused the reduction of functional hemoglobin, which limits the hemoglobin's oxygen-carrying ability. To improve this situation, the nurse suggests that the patient quit:

smoking cigarettes.

the nurse explains that the primary purpose of the whirlpool bath given to the patient with a stage 111 pressure ulcer is to:

stimulate granulation tissue growth

pustule

superficial lesion filled with purulent fluid

a skin biopsy has been scheduled on a patient to run out the presence of a malignancy. which instruction is most important for the nurse to include patient teaching?

suture placed at the site of the biopsy will be removed in approximately 10 days.

a skin biopsy has been scheduled on a patient to rule out the presence of a malignancy. which instruction is most important for the nurse to include a patient teaching?

sutures placed at the site of the biopsy will be removed in approximately 10 days.

the nurse is caring for a patina tight an order for an "open dressing" which action indicates that the nurse accurately understands the order?

the nurse changes wet compresses frequently enough to keep them wet.

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place. As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

uses one alcohol wipe to clean both the spout and the plug

the nurse recommends the the person who suffers with psoriasis can increase comfort by :

using a humidifier to keep psoriasis plaques moist

which term should the nurse use to document a raised, fluid filled lesion 1 centimeter?

vesicle

When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

vessels have dilated and allowed plasma to leak into the wound site.

a nurse is caring for a client who has a large surgical would healing by secondary intention. the nurse should recommend a diet high protein and which of the following nutrients?

vitamin C

When applying lotion to the skin, the nurse should:

wash off residue before applying fresh lotion

what should you do for acne vulgaris

wash your face gently with mild soap.

while bathing a patient, the nurse assess a red, unbalanceable area on the. the best dressing for this lesion is a ----- dressing

wet-to-dry

the nurse recognizes that of the drugs a patient is currently taking. several contribute to delayed healing such as:

1. steroids 2. antineoplastic drugs 3. heparin

which age related changes in the integumentary system

1.elastic fibers adipose tissue diminish 2.skin thins and become transparent 3. skin becomes dry 4.thinned skin leads to cold intolerene

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)

A. Capillary refill 2 secondsD. Thick skin on the soles of the feet E. Numerous light brown macules on the face

The nurse admitting a patient with significant burns to the emergency department notes the presence of symptoms consistent with an inhalation burn. Which finding is the nurse most likely noting?

Persistent coughing

a nurse is Caring for a client following the application of an aquatheria pad the following manifestations should the nurse identify as an indication that they have a superficial burn?

blistering

Ecchymosis

blue-black bruise, chasing to greenish brown or yellow with time.