NCLEX - Integumentary Questions

Which of the following individuals is least likely at risk for the development of psoriasis? 1. A 32-year-old African American 2. A client with a systemic illness 3. An individual who has experienced a significant amount of emotional distress 4. A woman experiencing menopause

1. A 32-year-old African American

A client with a burn injury is scheduled for a heterograft. The nurse is preparing the client for the skin grafting, and the client asks the nurse what "heterograft" means. The appropriate response to the client is: 1. "It is skin from another species." 2. "It is skin from a cadaver." 3. "It is skin from the burned client." 4. "It is skin from a skin bank."

1. "It is skin from another species."

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which of the following? 1. 22.5% 2. 31.5% 3. 36% 4. 40.5%

1. 22.5%

A nurse is reviewing the health care record of a client with a lesion that has been diagnosed as malignant melanoma. The nurse would expect which characteristic of this type of lesion to be documented in the client's record? 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm nodular lesion topped with a crust 4. A pearly papule with a central crater and a waxy border

1. An irregularly shaped lesion

A nurse is preparing a client for skin grafting and notes that the health care provider has documented that the client is scheduled for a heterograft. The nurse understands that a heterograft used for the burn client is skin from: 1. Another species 2. A cadaver 3. The burned client 4. A skin bank

1. Another species

A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing a problem with which of the following? 1. Appearance 2. Fear 3. Self-Esteem 4. Ability to keep a job

1. Appearance

An older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. Which combination of dietary items would the nurse encourage the client to eat to promote wound healing? 1. Chicken breast, broccoli, strawberries, milk 2. Salad, watermelon, tea 3. Baked potatoes, Jell-O, water 4. Spaghetti, bread, cola

1. Chicken breast, broccoli, strawberries, milk

A nurse is assigned to care for a client with herpes zoster. Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection? 1. Clustered skin vesicles 2. A generalized body rash 3. Small blue-white spots with red bases 4. A fiery red edematous rash on the cheeks

1. Clustered skin vesicles

A nurse in a health care provider's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse would tell the client to do which of the following before the procedure? 1. Discontinue the prescribed antihistamine 2 days before the test. 2. Refrain from eating solid food on the day of the test. 3. Do not eat or drink anything on the morning of the test. 4. Shower using povidone-iodine on the morning of the test.

1. Discontinue the prescribed antihistamine 2 days before the test.

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client would monitor for which of the following during the first 24 hours after the burn injury? 1. Elevated hematocrit levels 2. Increased urinary output 3. Decreased heart rate 4. Decreased blood pressure

1. Elevated hematocrit levels Rationale: The emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the emergent phase, the hematocrit rises above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury but generally return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, reducing renal perfusion and glomerular filtration. This leads to a decreased urine output. Pulse rates are typically higher than normal; the blood pressure is normal or slightly elevated unless hypovolemia is severe.

A nurse prepares to assist in instructing a client about prevention of Lyme disease. Which of the following would the nurse include in the instructions? 1. It is caused by a tick carried by deer. 2. It is caused by contamination from cat feces. 3. It is contagious by skin contact with an infected individual. 4. It is caused by the inhalation of spores from bird droppings.

1. It is caused by a tick carried by deer.

A client with jaundice is complaining of pruritus. Which of the following strategies should the nurse institute to help control the problem and prevent injury? 1. Pat the skin dry after bathing. 2. Maintain a warm environment. 3. Bathe the client with hot water only. 4. Avoid application of emollient creams.

1. Pat the skin dry after bathing.

A nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during data collection? 1. Red, shiny skin around the nail bed 2. White, taut skin in the popliteal area 3. White, silvery patches on the elbows 4. Swelling of the skin near the parotid gland

1. Red, shiny skin around the nail bed

A nurse is discussing skin biopsy with a client scheduled for the procedure. The nurse tells the client to expect how much discomfort during the procedure? 1. Slight because the local anesthetic may burn or sting 2. None because it is done under general anesthesia 3. None because it is painless 4. Somewhat painful but easily managed with opioids afterward

1. Slight because the local anesthetic may burn or sting

Which of the following would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? 1. The return of distal pulses 2. Decreasing edema formation 3. Brisk bleeding from the injury site 4. The formation of granulation tissue

1. The return of distal pulses

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

1. Use sunscreen when participating in outdoor activities. 2. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Examine your body monthly for any lesions that may be suspicious.

Using the rule of nines, calculate the burn percentage for the client. Refer to the figure; the burned area is the darkly shaded area. (figure shows entire torso, chest and genital area)

19

A nurse reinforces instructions to a client diagnosed with impetigo. Which statement by the client indicates a need for further instructions? 1. "I need to continue with the antibiotics as prescribed." 2. "I can wash my laundry with other household members' items." 3. "I need to wash my hands thoroughly and frequently throughout the day." 4. "I need to separate my dishes and wash them separately from the dishes of other household members."

2. "I can wash my laundry with other household members' items."

A nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further instruction? 1. "I need to wear sunscreen when participating in outdoor activities." 2. "I need to avoid sun exposure before 10:00 ᴀᴍ and after 4:00 ᴘᴍ." 3. "I need to wear a hat, opaque clothing, and sunglasses when in the sun." 4. "I need to examine my body monthly for any lesions that may be suspicious."

2. "I need to avoid sun exposure before 10:00 ᴀᴍ and after 4:00 ᴘᴍ."

A nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further instruction? 1. "I need to keep the test sites dry." 2. "If the patch comes off, I need to reapply it." 3. "I need to avoid activities that will cause me to sweat." 4. "I will return to the clinic in 2 days for the initial reading."

2. "If the patch comes off, I need to reapply it."

The nurse reviews home care instructions with a client diagnosed with impetigo. Which statement indicates that the client does not understand the measures that will prevent the spread of infection? 1. "I need to take the full course of the antibiotics." 2. "My clothes can be laundered with other household members' clothes." 3. "I must wash my hands thoroughly and frequently throughout the day." 4. "I need to wash my dishes and eating utensils separate from other household members."

2. "My clothes can be laundered with other household members' clothes."

A client asks the nurse about the causes of acne. The nurse most appropriately responds by telling the client: 1. "It is caused by oily skin." 2. "The exact cause of acne is not known." 3. "It is caused as a result of exposure to heat and humidity." 4. "Acne is caused by eating chocolate, nuts, and fatty foods."

2. "The exact cause of acne is not known."

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse makes which response to the client? 1. "There is no pain associated with this procedure." 2. "The local anesthetic may cause a burning or stinging sensation." 3. "There is some pain, but the health care provider will prescribe an analgesic following the procedure." 4. "A preoperative medication will be given so you will be sleeping and will not feel any pain."

2. "The local anesthetic may cause a burning or stinging sensation."

A client sustains a burn injury to the anterior right and left legs and perineal area. According to the rule of nines, the nurse would determine that this injury constitutes which of the following body percentages? 1. 10% 2. 19% 3. 23% 4. 37%

2. 19%

A nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which of the following? 1. 31.5% 2. 36% 3. 42% 4. 45%

2. 36%

A client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes that the chest and neck are red, and the client is complaining of pain at the radiation site. The nurse interprets this data as: 1. An allergic reaction to the radiation 2. A superficial injury to tissue from the radiation 3. An ischemic injury, much like decubitus formation 4. A cutaneous reaction to products formed by lysis of the neoplastic cells

2. A superficial injury to tissue from the radiation

A nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to do which of the following next in the care of this client? 1. Get out a robe and slippers for the client. 2. Administer an opioid analgesic last taken 6 hours ago. 3. Immediately place the client on nothing-by-mouth (NPO) status. 4. Gather dressing supplies to send with the client to hydrotherapy.

2. Administer an opioid analgesic last taken 6 hours ago.

A nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse would include on the poster instructions to avoid which of the following activities? 1. Wearing a hat, opaque clothing, and sunglasses when in the sun 2. Being in the sun for prolonged periods between 10:00 ᴀᴍ and 3:00 ᴘᴍ 3. Using sunscreen when spending time outdoors 4. Examining the skin monthly for any lesions that might be cancerous

2. Being in the sun for prolonged periods between 10:00 ᴀᴍ and 3:00 ᴘᴍ Rationale: The client should be instructed to avoid sun exposure between the hours of 10:00 ᴀᴍ and 3:00 ᴘᴍ. Sunscreen, a hat, opaque clothing, and sunglasses should be worn when spending time outdoors. The client should examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

A client comes to a health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick? 1. Painful rash around a necrotic lesion 2. Bullseye rash 3. Line of papules and vesicles that appear 1 to 3 days after exposure 4. Patch of oval lesions

2. Bullseye rash

A nurse is assisting in caring for a client with a severe burn who has just received an autograft to the knee area of the right leg. The nurse plans to keep the right leg positioned in which manner? 1. Elevated only when out of bed to the chair 2. Elevated and immobilized 3. Flat at all times 4. Dependent and covered with a blanket

2. Elevated and immobilized

A nurse is caring for a client after an autograft and grafting of a burn wound on the right knee. Which of the following would the nurse anticipate being prescribed for the client? 1. Placing the affected leg flat 2. Elevating and immobilizing the affected leg 3. Placing the affected leg in a dependent position 4. Immobilizing the client in a dependent position

2. Elevating and immobilizing the affected leg

A client with a major burn is admitted to the emergency department. The nurse anticipates that which of the following medication routes will be prescribed for analgesics for this client? 1. Oral 2. Intravenous 3. Intramuscular 4. Subcutaneous

2. Intravenous

A nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day post-injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially: 1. Recheck the vital signs in 1 hour. 2. Monitor the client for signs of infection. 3. Change the parenteral nutrition solution and IV tubing. 4. Determine when the client was last medicated for pain.

2. Monitor the client for signs of infection.

A nurse is checking the skin on a client who is immobile and notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents this finding as a pressure ulcer of which stage? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2. Stage 2

A nurse notes the presence of a partial-thickness skin loss of the upper layer of the skin in the sacral area of a client on bedrest. The nurse documents these findings as a: 1. Stage 1 pressure ulcer 2. Stage 2 pressure ulcer 3. Stage 3 pressure ulcer 4. Stage 4 pressure ulcer

2. Stage 2 pressure ulcer

During the inspection of a client's skin, the nurse notes redness and an abrasion type wound on the sacrum area. The nurse determines that this finding is indicative of a: 1. Stage 1 pressure ulcer 2. Stage 2 pressure ulcer 3. Stage 3 pressure ulcer 4. Stage 4 pressure ulcer

2. Stage 2 pressure ulcer Rationale: In a stage 1 pressure ulcer, the skin is intact; the area is red and does not blanch with external pressure. In a stage 2 pressure ulcer, the skin is not intact; the ulcer is superficial and may characterize as an abrasion, blister, or shallow crater. In stage 3, skin loss is full thickness and the skin has a deep crater-like appearance. In stage 4, skin loss is full thickness with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

A nurse inspects a pressure ulcer on a client's sacrum and notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse categorizes the ulcer as: 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

2. Stage II

A nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which of the following would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

2. Urine output

An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. On data collection of the client, which of the following would indicate that the client sustained a respiratory injury as a result of the burn? 1. Clear breath sounds 2. Use of accessory muscles for breathing 3. Fear and anxiety 4. Complaints of pain

2. Use of accessory muscles for breathing

A nurse is caring for a client with a skin infection who is receiving amoxicillin (Amoxil) 500 mg every 8 hours. Which of the following indicates to the nurse that the client is experiencing a frequent side effect related to the medication? 1. Severe abdominal cramps 2. Vaginal drainage 3. Fever 4. Severe watery diarrhea

2. Vaginal drainage

A nurse prepares to care for a client with acute cellulitis of the lower leg. Which of the following would the nurse anticipate being prescribed for the client? 1. Cold compresses to the affected area 2. Warm compresses to the affected area 3. Alternating hot and cold compresses continuously 4. Intermittent heat-lamp treatments four times per day

2. Warm compresses to the affected area

A nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further instructions? 1. "I need to bathe using a mild soap and to rinse thoroughly." 2. "I need to avoid direct sunlight on the newly healed skin area." 3. "I should never wear warm clothing over the newly healed skin area." 4. "I need to avoid the use of lanolin products to the newly healed skin area."

3. "I should never wear warm clothing over the newly healed skin area."

A nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which of the following client statements indicates the need for further instructions? 1. "I should drink eight to ten glasses of water a day." 2. "I need to avoid using astringents on my skin." 3. "I should use a dehumidifier, especially during the winter months." 4. "I should limit myself to one shower per day and apply an emollient to my skin after the shower."

3. "I should use a dehumidifier, especially during the winter months."

A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he 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. The nurse makes which statement to the client? 1. "Come to the emergency department." 2. "Apply calamine lotion immediately to the exposed skin areas." 3. "Take a shower immediately, and lather and rinse several times." 4. "It is not necessary to do anything if you cannot see anything on your skin."

3. "Take a shower immediately, and lather and rinse several times."

A client is brought to the emergency department immediately following a smoke inhalation injury. The initial nursing action is to prepare the client to receive: 1. Pain medication 2. Oxygen via nasal cannula 3. 100% humidified oxygen by face mask 4. Endotracheal intubation

3. 100% humidified oxygen by face mask

The nurse is assessing her clients for skin breakdown. Which of the following clients would have the lowest priority for concern in the development of skin breakdown? 1. A client incontinent of urine and feces 2. A client with chronic nutritional deficiencies 3. A client with a lowered mental awareness status 4. A client who is unable to move about and is confined to bed

3. A client with a lowered mental awareness status

A nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription? 1. Obtain blood cultures. 2. Administer antibiotics. 3. Apply cold compresses to the affected area. 4. Administer acetaminophen (Tylenol) for fever.

3. Apply cold compresses to the affected area.

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy? 1. Rubbing the application into the skin 2. Applying a dry sterile dressing over the affected area 3. Covering the application with a warm, moist dressing and an occlusive outer wrap 4. Placing the area under a heat lamp for 20 minutes

3. Covering the application with a warm, moist dressing and an occlusive outer wrap

A nurse notes that the health care provider has documented a diagnosis of herpes zoster in the client's chart. On the basis of an understanding of the cause of this disorder, the nurse would determine that this diagnosis was made after the use of which diagnostic test? 1. Patch test 2. Skin biopsy 3. Culture of the lesion 4. Wood's light examination

3. Culture of the lesion

A nurse prepares to help a health care provider examine the client's skin with a Wood's light. Which of the following would be included in the plan for this procedure? 1. Prepare a local anesthetic. 2. Obtain an informed consent. 3. Darken the room for the examination. 4. Shave the skin and scrub it with a povidone-iodine (Betadine) solution.

3. Darken the room for the examination.

A client who sustained an inhalation injury arrives in the emergency department. On data collection of the client the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing: 1. Anxiety 2. Fear 3. Hypoxia 4. Pain

3. Hypoxia

During the emergent phase after a major burn injury, which of the following abnormalities would the nurse expect to note? 1. Increased albumin and decreased hematocrit 2. Decreased hemoglobin and increased sodium 3. Increased hematocrit and increased potassium 4. Decreased hemoglobin and decreased potassium

3. Increased hematocrit and increased potassium Rationale: During the emergent phase of a burn injury, the client's hemoglobin and hematocrit will be elevated because of fluid loss. Sodium will be decreased because of trapping in edema fluid and loss through plasma leakage. Potassium will be increased because of disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis; and albumin will be low because of loss through the wound and increased capillary permeability.

A nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse determines that this occurrence: 1. Is common 2. Suggests that the client is anemic 3. Is characteristic of a thrush infection 4. Is indicative that oral hygiene needs to be improved

3. Is characteristic of a thrush infection

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was 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 a lesion? 1. Metastasis is rare. 2. It is encapsulated. 3. It is highly metastatic. 4. It is characterized by local invasion.

3. It is highly metastatic.

A nurse inspects the skin of a client who is suspected of having scabies. Which of the following findings would the nurse note if this disorder was present? 1. Patchy hair loss and round, red macules with scales 2. The presence of wheal patches scattered about the trunk 3. Multiple straight or wavy threadlike lines beneath the skin 4. The appearance of vesicles or pustules with a thick, honey-colored crust

3. Multiple straight or wavy threadlike lines beneath the skin

A nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should immediately: 1. Increase the intravenous (IV) flow rate. 2. Cover the client with a warm blanket. 3. Notify the registered nurse. 4. Check the client in 30 minutes.

3. Notify the registered nurse.

A nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which first? 1. Heart rate 2. Temperature 3. Peripheral pulses 4. Blood pressure (BP)

3. Peripheral pulses

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which of the following? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions on the skin

3. Punch biopsy of the cutaneous lesions

A nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse would anticipate which of the following signs in the client? 1. Flushing 2. Dizziness 3. Tachycardia 4. Coma

3. Tachycardia

A nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough and that the client is expectorating sputum with black flecks. The client's eyelashes and eyebrows are singed, and the eyelids are swollen. The client suddenly becomes restless, and his color becomes dusky. The nurse interprets this data as indicating which of the following? 1. The client is hypotensive. 2. Pain is present from the burn injury. 3. The burn has probably caused laryngeal edema, which has occluded the airway. 4. The client is afraid and is having a panic attack as a result of the unfamiliar surroundings.

3. The burn has probably caused laryngeal edema, which has occluded the airway.

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should the nurse's first action be? 1. Use tweezers to remove the insect stinger. 2. Apply a warm compress to relieve the discomfort. 3. Use the edge of a sterile surgical tool to scrape out the stinger. 4. Apply an occlusive dressing over the stinger.

3. Use the edge of a sterile surgical tool to scrape out the stinger.

A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse notes that the flap has a slightly blue hue. The nurse concludes: 1. This is a normal expectation. 2. Heat should be applied to the area. 3. Venous circulation is being impaired. 4. The client is exhibiting generalized hypoxia.

3. Venous circulation is being impaired.

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet to see if which of the following therapies has been prescribed for site care? 1. Intermittent heat lamp treatments 2. Alternating hot and cold compresses 3. Warm compresses 4. Cold compresses

3. Warm compresses Rationale: Warm compresses may be used to decrease the discomfort, erythema, and edema that accompany cellulitis. Definitive treatment includes antibiotic therapy after appropriate cultures have been done. Other supportive measures also are used to manage symptoms such as fatigue, fever, chills, headache, or myalgia. Heat lamps are not used because of the risk of burns and because moist heat is most useful in treating this disorder.

A nurse is told that an assigned client is suspected of having scabies. Which of the following precautions will the nurse institute during the care of the client? 1. Wear gloves only. 2. Wear a mask and gloves. 3. Wear a gown and gloves. 4. Avoid touching the client's clothes.

3. Wear a gown and gloves.

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition? 1. A pink edematous hand 2. Red skin with edema in the nail beds 3. White skin that is insensitive to touch 4. Black fingertips surrounded by an erythematous rash

3. White skin that is insensitive to touch

An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client's upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, what would be the percent of the burn injury? Refer to the figure.

31.5%

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury?

36 %

A nurse reinforces instructions to a client who is to return to the health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client? 1. "Remain nothing per mouth (NPO) prior to the test." 2. "Consume fluids only on the day of the test." 3. "Shower using an antibacterial soap on the morning of the test." 4. "Discontinue the prescribed antihistamine 2 days before the test."

4. "Discontinue the prescribed antihistamine 2 days before the test."

A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse provides instructions to the client regarding preparation of the test. Which statement by the client indicates an understanding regarding the preparation for this procedure? 1. "I need to have clear fluids only on the morning of the test." 2. "I need to take my prednisone on the morning of the test." 3. "I need to shower on the morning of the test using povidone-iodine (Betadine)." 4. "I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

4. "I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

A nurse has reinforced discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further instruction? 1. "I will use the antibiotic ointment, as prescribed." 2. "I will return in 7 days to have the sutures removed." 3. "I will call the health care provider (HCP) if I see any drainage from the wound." 4. "I will remove the dressing when I get home and wash the site with tap water."

4. "I will remove the dressing when I get home and wash the site with tap water."

The client arrives at the emergency department after a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which of the following should the nurse anticipate as being prescribed for the client? 1. Oxygen via nasal cannula at 10 L 2. Oxygen via nasal cannula at 15 L 3. 100% oxygen via an aerosol mask 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4. 100% oxygen via a tight-fitting, nonrebreather face mask

A client sustains a burn injury to the entire right and left arms, right leg, and anterior thorax. According to the rule of nines, the nurse would determine that this injury constitutes which of the following body percentages? 1. 27% 2. 36% 3. 45% 4. 54%

4. 54%

A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. The nurse bases the response on the understanding that the characteristics of cellulitis include: 1. An acute superficial infection 2. An inflammation of the lymphatics 3. A superficial infection caused by Staphylococcus 4. A skin infection into the deep dermis and subcutaneous fat

4. A skin infection into the deep dermis and subcutaneous fat

A client arrives at the emergency department and has experienced frostbite to the right hand. Which of the following would the nurse note when performing data collection regarding the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color of the skin, which is insensitive to touch

4. A white color of the skin, which is insensitive to touch

After 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, "Feeling better overall." Which nursing intervention most likely contributed to the client's feelings? 1. Pain management program 2. Frequent comfort measures 3. Dressing change twice daily 4. Ambulation three times daily

4. Ambulation three times daily Rationale: The effects of exercise include client reports of feeling better generally, because the benefits of exercise are wide ranging. Ambulation can enhance tissue oxygenation and other cardiovascular, pulmonary, metabolic, integumentary, neuromuscular, and conditioning benefits. Thus the wide-ranging benefits of exercise are more likely to promote an overall sense of feeling better versus benefiting from pain control, less discomfort, or a well-granulated wound. The benefits of pain management, comfort measures, and dressing changes are more limited (options 1, 2, and 3).

Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma? 1. A renal transplant client 2. A male with a history of same-sex partners 3. A client receiving antineoplastic medications 4. An individual working in an environment in which exposure to asbestos is possible

4. An individual working in an environment in which exposure to asbestos is possible

Which of the following individuals would be at the greatest risk for development of an integumentary disorder? 1. An adolescent 2. An older female 3. A physical education teacher 4. An outdoor construction worker

4. An outdoor construction worker

A nurse is caring for a client with a diagnosis of pemphigus vulgaris. The nurse understands that a characteristic of this condition is: 1. Dry skin 2. Hard skin 3. Leathery skin 4. Blistering skin

4. Blistering skin

A client has sustained full-thickness circumferential burns of the trunk. Which of the following should be the priority concern of the nurse? 1. Urine output of 30 to 50 mL/hr 2. Client's increased risk for infection 3. Adequate management of burn pain 4. Client's ability to adequately ventilate

4. Client's ability to adequately ventilate

A nurse is caring for a client with circumferential burns of both legs. Which of the following leg positions is appropriate for this type of a burn? 1. A dependent position 2. Elevation of the knees 3. Flat, without elevation 4. Elevation above the level of the heart

4. Elevation above the level of the heart

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate? 1. Tell the client that a blood test is needed immediately. 2. Inform the client that there is no test available for Lyme disease. 3. Tell the client that testing is not necessary unless arthralgia develops. 4. Inform the client that he will need to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

4. Inform the client that he will need to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which action is contraindicated as the nurse delivers care to this client? 1. Suctioning the airway on an as-needed basis 2. Encouraging regular use of an incentive spirometer 3. Repositioning side to side every 2 hours 4. Keeping the client in a supine position

4. Keeping the client in a supine position

Following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. The nurse understands that which of the following is most indicative of this stage? 1. Arthralgias 2. Joint enlargement 3. Erythematous rash 4. Neurological deficits

4. Neurological deficits

A client has a non-infected pressure ulcer on the left heel. The nurse should use which of the following sterile solutions to cleanse the wound as part of a dressing change procedure? 1. Hydrogen peroxide 2. Povidone-iodine 3. Warm water 4. Normal saline

4. Normal saline

A nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area would provide the best information? 1. Sacrum 2. Earlobes 3. Back of the hands 4. Palms of the hands

4. Palms of the hands

An evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which of the following would the nurse expect to note when checking the client's sacral area? 1. Intact skin 2. The presence of tunneling 3. A deep, crater-like appearance 4. Partial-thickness skin loss of the epidermis

4. Partial-thickness skin loss of the epidermis

A nurse is assigned to assist in caring for a client with frostbite of the toes. Which of the following would the nurse anticipate to be prescribed for this condition? 1. Rapid and continual rewarming of the toes when flushing occurs 2. Rapid and continual rewarming of the toes in cold water for 45 minutes 3. Rapid and continual rewarming of the toes in hot water for 15 to 20 minutes 4. Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

4. Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

An older client is complaining of chronic dry skin and occasional pruritus. The nurse tells the client to avoid which of the following that will aggravate the condition? 1. Applying emollient to the skin after a shower 2. Using a humidifier, especially during the winter months 3. Drinking 8 to 10 glasses of water a day 4. Using astringents to clean the skin

4. Using astringents to clean the skin Rationale: The client should avoid the use of rubbing alcohol, astringents, or other drying agents on the skin. The client should take one 15- to 20-minute warm bath or one shower per day. The client should then apply an emollient to prevent water evaporation from the hydrated epidermis. A room humidifier is useful during the winter months or whenever a furnace is in use. The client should maintain a daily fluid intake of 3000 mL, unless contraindicated, and should avoid ingestion of alcohol and caffeine.