NCLEX Integumentary

An adult client was burned and explosion. The burning initially affected the clients entire face and the upper half of the anterior torso and there were circumferential burns to the lower half of both arms. The clients close caught on fire and the client ran causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines what would be the extent of the burn injury?

36%

The nurse is caring for a client who sustains superficial partial thickness burns on the anterior lower leg and anterior thorax. Which finding is the nurse expect to note during the resuscitation/emergent phase of the burn injury?

Increased Hematocrit levels

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 a pulse rate of 110 and a urine output of 20 mL over the past hour. The nurse reports the finding to the HCP and anticipates which prescription?

Increasing the amount of IV lactated ringer's solution administered per hour

Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. The nurse should take which most appropriate action? 1. Discontinue the medication. 2. Notify the health care provider. 3. Inform the client that this is expected. 4. Apply a thinner film than prescribed to the burn site.

Inform the client that this is expected.

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed one week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that the melanoma has which characteristic?

It is highly metastatic

The nurse is conducting session about the principles of first aid and is discussing the interventions for a snake bite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action?

Move the victim to a safe area away from the snake and encourage the victim to rest

The evening nurse reviews the nursing documentation in a clients chart and notes that the day nurse has documented that the client has a stage two pressure ulcer in the sacral area. Which finding with the nurse expect to note on assessment of the clients sacral area?

Partial thickness skin loss of the dermis

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy ?

Return of distal pulses

herpes zoster (shingles)

an acute viral infection of the nerve structure caused by varicella-zoster. Contagious to individuals who never had chickenpox and have not been vaccinated against the disease.

pressure ulcer

area of tissue damage that occurs as a result of skin and underlying soft tissue compression from pressure between a surface and a bony prominence.

Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication will permanently stain my skin." 4. "The medication should be applied directly to the wound."

"The medication will permanently stain my skin."

A client arrives at the ER phone in the burn injury that occurred in the basement at home and in inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?

100% oxygen via a tightfitting nonrebreather face mask

A client is being a minute to the hospital for treatment of acute cellulitis of the lower left leg and asked the admitting nurse to explain what cellulitis means. The nurse base is the response on the understanding that cellulitis has which characteristics?

A skin infection of the dermis and underlying hypodermis

A client arriving at the ER as experienced frostbite to the right hand. Which finding would the nurse note on assessment of the clients hand?

A white color to the skin which is insensitive to touch

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid (Azelex). Because of the medication prescription, the nurse would suspect that the client is being treated for which condition? 1. Acne 2. Eczema 3. Hair loss 4. Herpes simplex

Acne

When assessing a lesion diagnosed as a malignant melanoma the nurse most likely expects to note which finding?

And irregularly shaped lesion

A client is brought to the ER with partial thickness burns to his face neck arms and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client?

Assess for airway patency Administer oxygen as prescribed Elevate extremities if no fractures are present

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? 1. Immediately before swimming 2. 5 minutes before exposure to the sun3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun

At least 30 minutes before exposure to the sun

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication were being applied to which body area? 1. Back 2. Axilla 3. Soles of the feet 4. Palms of the hands

Axilla

The clinic nurse notes that the healthcare provider has documented a diagnosis of herpes Soster in the clients chart. Based on an understanding of the calls of this disorder the nurse determines that this definitive diagnosis was made by which diagnostic test?

Culture of the lesion

The nurse is caring for a client who suffered and inhalation injury from a wood stove. The carbon monoxide blood report reveals the level of 12%. Based on this level the nurse wouldn't dissipate noting which sign in the client?

Flushing

A burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? 1. Hyperventilation 2. Local rash at the burn site 3. Elevated blood pressure 4. Local pain at the burn site

Hyperventilation

The nurse is caring for a client following an autograft and grafting to a burn on the right knee. What would the nurse anticipate to be prescribed for the client?

Immobilization of the affected leg

The client nurse assesses the skin of a client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with the skin disorder?

Silvery white scaly patches

A client called the ER and tells the nurse that he came directly into contact with poison ivy. The client tells the nurse that he cannot see anything on the skin and asked the nurse what to do. The nurse should make which response?

Take a shower immediately lathering and rinsing several times

The nurse manager is planning the clinical assessments for the day. Which staff members can be assigned to care for the client with herpes zoster?

The nurse who had never had roseola The nurse who had never had mumps The nurse who had never had German measles

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations

Tinnitus

Isotretinoin (Amnesteem or Claravis) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1. Platelet count 2. Triglyceride level 3. Complete blood count 4. White blood cell count

Triglyceride level

The nurse is in administering fluids intravenously as prescribed to the client to sustain superficial partial thickness burn injuries on the back and legs. In evaluating the adequacy of fluid resuscitation the nurse understands that which assessment with provide the most reliable indicator for the determining the adequacy?

Urine output

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Avoid sun exposure in the late afternoon and early evening hours. 5. Examine your body monthly for any lesions that may be suspicious

Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun. Examine your body monthly for any lesions that may be suspicious.

A client with severe acne is seen in the clinic and the health care provider (HCP) prescribes isotretinoin (Amnesteem or Claravis). The nurse reviews the client's medication record and would contact the HCP if the client is taking which medication? 1. Vitamin A 2. Digoxin (Lanoxin) 3. Furosemide (Lasix) 4. Phenytoin (Dilantin)

Vitamin A

The nurse manager is observing a new nursing graduate caring for a burn client and protective isolation. The nurse manager intervenes if the nursing graduate plan to implement which unsafe component of protective isolation technique?

Wearing gloves and again only one giving direct care to the client

skin cancer

a malignant lesion of the skin that may or may not metastasize

carbon monoxide poisoning

carbon monoxide is a colorless, odorless, and tasteless gas that has an affinity for hemoglobin 200 times greater than oxygen. Occurs from the inhalation of gas. O2 molecules are displaced and carbon monoxide reversibly binds to hemoglobin to form carboxyhemoglobin. Tissue hypoxia results.

burn

cell destruction of the layers of the skin caused by heat, friction, electricity, radiation, or chemicals

deep full-thickness burn

injury extends beyond the skin into underlying fascia and tissues, and muscle, bone, and tendons are damaged

deep partial-thickness burn

injury extends deep into the dermis

full-thickness burn

involves injury and destruction of the epidermis and the dermis

superficial partial-thickness burn

involves injury that extends into the dermis

superficial-thickness burn

involves injury to the epidermis

smoke inhalation injury

respiratory injury that occurs due to inhalation of products of combustion during a fire

shingles

same as the herpes zoster infection. An acute viral infection of the nerve structure caused by varicella-zoster, contagious to individuals who never had chickenpox and have not been vaccinated against the disease.