NCLEX PN Review Questions Integumentary

the nurse is reviewing the health care record of a client with a lesion that has been diagnosed as a malignant melanoma. the nurse should expect which characteristic of this type of lesion to be documented in the client's record? A) an irregularly shaped lesion B) a small papule with a dry, rough scale C) a firm nodular lesion topped with a crust D) a pearly papule with a central crater and a waxy border

A) an irregularly shaped lesion rationale a melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

a client comes to a health care providers 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? A) bull's-eye rash B) patch of oval lesions C) painful rash around a necrotic lesion D) line of papules and vesicles that appear 1 to 3 days after exposure

A) bull's eye rash rationale the classic characteristic of Lyme disease is a small bite with a bull's eye rash, although not all individuals who sustain a bite develop this rash. a painful rash around a necrotic lesion is indicative of a brown recluse spider bite. papules, vesicles and oval lesions are not characteristics of lyme disease.

the nurse is assigned to care for a client with herpes zoster. which characteristics should the nurse expect to note when checking the lesions of this infection? A) clustered skin vesicles B) a generalized body rash C) small blue-white spots with red bases D) a fiery red edematous rash on the cheeks

A) clustered skin vesicles rationale the primary lesion of herpes zoster is a vesicle. the classic presentation is grouped vesicles on an erythematous base along a dematome. because they follow nerve pathways, the lesions do not cross the body's midline. the other options are incorrect descriptions

Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. the nurse is assisting in developing a plan of care for the client and includes which in the plan? A) ensure that the solution is freshly prepared before use B) allow the solution to remain in the wound following irrigation C) soak a sterile dressing with the solution and pack into the wound D) apply the solution to the wound and on normal skin tissue surrounding the wound

A) ensure that the solution is freshly prepared before use rationale Dakin solution is a chloride solution that is used for irrigating and cleaning necrotic or purulent wounds. it can be used for packing necrotic wounds. it cannot be used to pack purulent wounds because the solution is inactivated by copious pus. it should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. solutions are unstable, and the nurse must ensure that the solution has been prepared fresh before use.

the nurse prepares to assist in instructing a client about prevention of Lyme disease. which should the nurse include in the instructions? A) it is caused by a tick carried by deer B) it is caused by contamination from cat feces C) it is contagious by skin contact with an infected individual D) it is caused by the inhalation of spores from bird droppings

A) it is caused by a tick carried by deer rationale lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. persons bitten by the Ixodes ticks are infected with the spirochete borrelia burgdorferi. histoplasmosis is caused by the inhalation of spores from bat or bird droppings. toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

a client with jaundice is complaining of pruritus. which strategy should the nurse institute to help control the problem and prevent injury? A) pat the skin dry after bathing B) maintain a warm environment C) bathe the client with hot water only D) avoid application of emollient creams

A) pat the skin dry after bathing rationale the nurse should pat the client's skin dry after bathing or showering. rubbing should be avoided because it may lead to further skin injury. the client should be bathed with tepid water rather than hot water. a cool environment should be maintained because a warm environment may promote further drying and increased sweating, which should be avoided. emollient creams and lotions can be applied regularly to alleviate dryness.

the nurse reviews a client's chart and notes that the HCP has documented a diagnosis of paronychia. based on this diagnosis, which should the nurse expect to note during data collection? A) red, shiny skin around the nail bed B) white, taut skin in the popliteal area C) white, silvery patches on the elbows D) swelling of the skin near the parotid gland

A) red, shiny skin around the nail bed rationale paronychia or infection around the nail is characterized by red, shiny skin, often associated with painful swelling. these infections frequently result from trauma, picking at the nail, or disorders such as dermatitis. often these become secondarily infected with bacteria or fungus which later involves the nail the other options are incorrect

which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? A) the return of distal pulses B) decreasing edema formation C) brisk bleeding from the injury site D) the formation of granulation tissue

A) the return of distal pulses rationale escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn. escharotomies are performed through avascular eschar to subcutaneous fat. although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. the formation of granulation tissue is not the intent of an escharotomy and escharotomy will not affect the formation of edema.

which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? A) the return of distal pulses B) decreasing edema formation C) brisk bleeding from the injury site D) the formation of granulation tissue

A) the return of distal pulses rationale escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar n a circumferential burn. escharotomies are performed through avascular eschar to subcutaneous fat. although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. the formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema.

the 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 percentage? A) 31.5% B) 36% C)42% D)45%

B) 36% rationale according to the rule of nines, the entire right leg equals 18% and the anterior thorax equals 18%. this totals 36%

which individuals is least likely at risk for the development of psoriasis? A) a client with a systemic illness B) a 32 year old African American C) a woman experiencing menopause D) an individual with emotional distress

B) a 32 year old African American rationale psoriasis occurs among women and men, although the incidence is lower in darker-skinned races. the disorder may begin at any time throughout the life span but most commonly affects persons ages 10 to 40. emotional distress, trauma, systemic illness, seasonal changes, and hormonal changes are linked to exacerbation.

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. how should the nurse interpret this data? A) an allergic reaction to the radiation B) a superficial injury to tissue from the radiation C) an ischemic injury, much like decubitus formation D) a cutaneous reaction to products formed by lysis of the neoplastic cells

B) a superficial injury to tissue from the radiation rationale superficial injury from radiation causes erythema and pain, hyperpigmentation, dry desquamation or moist desquamation the other options are not associated with the description presented in the question.

the nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. the nurse plans to take which action next in the care of this client? A) get out a robe and slippers for the client B) administer an opioid analgesic last taken 6 hours ago C) immediately place the client on NPO status D) gather dressing supplies to send with the client to hydrotherapy

B) administer an opioid analgesic last taken 6 hours ago rationale the client should receive pain medication approximately 30 minutes before a burn dressing change. this will help the client tolerate a painful procedure. the client does not need to be NPO for this procedure. dressing supplies are not sent with the client because they are available in the hydrotherapy area. a robe and slippers are given to the client for transport but are not indicated 30 minutes ahead of time.

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 which associated problem? A) fear B) appearance C) self-esteem D) ability to keep a job

B) appearance rationale the client with a burn injury experiences structural and functional changes of the integumentary system as a result of this injury. the client's statement indicates a problem with appearance. the other options do not relate to the client's statement.

the 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 in which position? A) flat at all times B) elevated and immobilized C) dependent and covered with a blanket D) elevated only when out of bed to the chair

B) elevated and immobilized rationale autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeons preference. this period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation

the nurse is caring for a client after an autograft of a burn wound on the right knee. which position should the nurse anticipate being prescribed for the client? A) placing the affected leg flat B) elevating and immobilizing the affected leg C) placing the affected leg in a dependent position D) immobilizing the client in a dependent position

B) elevating and immobilizing the affected leg rationale autografts placed over joints or on the lower extremities are often elevated and immobilized after surgery for 3 to 7 days. this period of immobilization allows time for the autograft to adhere and attach to the wound bed

the 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 teaching? A) i need to wear sunscreen when participating in outdoor activities B) i need to avoid sun exposure before 10 am and after 4pm C) i need to wear a hat, opaque clothing, and sunglasses when in the sun D) i need to examine my body monthly for any lesions that may be suspicious

B) i need to avoid sun exposure before 10am and after 4pm rationale the client should be instructed to avoid sun exposure between the hours of approximately 10am and 4pm. sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. the client should be instructed to examine the body monthly for the appearance of any possible cancerous or precancerous lesions

the nurse reinforces discharge instructions to a client following patch testing. which statement by the client indicates the need for further teaching? A) i need to keep the test sites dry B) if the patch comes off, i need to reapply it C) i need to avoid activities that will cause me to sweat D) i will return to the clinic in 2 days for the initial reading

B) if the patch comes off, i need to reapply it rationale the nurse instructs the client to keep the test site dry at all times. the nurse also discourages excessive physical activity that will result in sweating. reapplying the patch can interfere with an accurate interpretation of the allergic reactions. the nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. the initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later

the nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. on the fourth day after 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 perform which action? A) recheck the vital signs in 1 hour B) monitor the client for signs of infection C) change the parenteral nutrition solution and IV tubing D) determine when the client was last medicated for pain

B) monitor the client for signs of infection rationale the client is recovering from serious burns. the burn client is prone to several complications such as infection and sepsis. a temperature of 102.8 F is significant. on the fourth hospital day, infection may be the problem. the site of the infection may be the burns, the parenteral nutrition infusion or parenteral nutrition site, or other problems. as an initial action, the nurse needs to check the client for signs of infection and then notify the registered nurse, who will contact the HCP for further prescriptions.

the nurse reinforces home care instructions with a client diagnosed with impetigo. which statement indicates the need for further teaching about the measures that will prevent the spread of infection? A) I need to take the full course of the antibiotics B) My clothes can be laundered with other household members' clothes C) I must wash my hands thoroughly and frequently throughout the day D) I need to wash my dishes and eating utensils separete from other household members

B) my clothes can be laundered with other household members' clothes rationale it is necessary to separate laundry from other household members'. thorough handwashing, separating laundry, and separate washing for the client's dishes are required because the infection is contagious as long as skin lesions are present. antibiotics are administered and should be continued as prescribed

a client has a non-infected pressure ulcer on the left heel. the nurse should use which sterile solutions to cleanse the wound as part of a dressing change procedure? A) warm water B) normal saline C) povidone-iodine D) hydrogen peroxide

B) normal saline rationale normal saline (0.9%) should be used for cleansing ulcers, unless there is a specific prescription for another solution. normal saline is isotonic (unlike water) and does not damage cells that are needed for healing (as povidone-iodine and hydrogen peroxide do)

the nurse inspects the skin of a client who is suspected of having psoriasis. which finding should the nurse note if this disorder is present? A) oily skin B) silvery-white scaly lesions C) patchy hair loss and round, red macules with scales D) the presence of wheal patches scattered about the trunk

B) silvery-white scaly lesions rationale psoriatic patches are covered with silvery white scales. there is no patchy hair loss or round, red macules with scales. the skin is dry and there is no presence of wheal patches scattered about the trunk

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 which stage of pressure ulcer? A) stage 1 pressure ulcer B) stage 2 pressure ulcer C) stage 3 pressure ulcer D) stage 4 pressure ulcer

B) 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.

the 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 should document the ulcer as which category? A) stage I B) stage II C) stage III D) stage IV

B) stage II rationale a stage II ulcer is characterized by nonintact skin. there is partial-thickness skin loss, and the wound may appear as an abrasion, shallow crater, or a blister. a stage I ulcer is a reddened area that doesn't blanch but has intact skin. stages III and IV ulcers are full thickness, or full thickness with necrosis or damage to muscle, bone, or supportive tissue, respectively.

a client asks the nurse about the causes of acne. the nurse should respond by making which statement to the client? A) it is caused by oily skin B) the exact cause of acne is not known C) it is caused as a result of exposure to heat and humidity D) acne is caused by eating chocolate, nuts, and fatty foods

B) the exact cause of acne is not known rationale exacerbations that coincide with the menstrual cycle result from hormonal activity. oily skin alone is not the cause of acne. heat, humidity and excessive perspiration also play a role in exacerbation of acne. there is no evidence that consumption of foods such as chocolate, nuts, or fatty foods affects acne.

a client scheduled for a skin biopsy asks the nurse how painful the procedure is. the nurse should make which response to the client? A) there is no pain associated with this procedure? B) the local anesthetic may cause a burning or stinging sensation C) a preoperative medication will be given so you will be sleeping and will not feel any pain D) there is some pain but the HCP will prescribe an analegsic following the procedure

B) the local anesthetic may cause a burning or stinging sensation rationale depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. the most common source of pain is the initial local anesthetic, such can produce a burning or stinging sensation. the other options are incorrect

a client is newly admitted to the hospital with cellulitis of the lower leg. the nurse checks the HCP's prescriptions sheet to see if which therapy has been prescribed for site care? A) cold compresses B) warm compresses C) intermittent heat lamp treatments D) alternating hot and cold compresses

B) 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

the nurse prepares to care for a client with acute cellulitis of the lower leg. which treatment should the nurse anticipate being prescribed for the client? A) cold compresses to the affected area B) warm compresses to the affected area C) alternating hot and cold compresses continuously D) intermittent heat-lamp treatments four times per day

B) warm compresses to the affected area rationale warm compresses may be used to decrease discomfort, erythema, and edema. after tissue and blood cultures are obtained, antibiotics are initiated. heat lamps can cause more disruption to tissue that is already inflamed. continuous cold and hot compresses are not the best measures.

the nurse reinforces discharge instructions regarding skin care of 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 teaching? A) i need to bathe using a mild soap and to rinse thoroughly B) i need to avoid direct sunlight on the newly healed skin area C) i should never wear warm clothing over the newly healed skin area D) i need to avoid the use of lanolin products to the newly healed skin area

C) I should never wear warm clothing over the newly healed skin area rationale newly healed skin is more sensitive to the cold, and the client should be instructed to wear warm clothing. the client should wash with a mild soap, rinse thoroughly, and pat the skin dry with a clean towel. newly healed skin sunburns easily, and direct sunlight needs to be avoided. products that contain perfume, alcohol, or lanolin should be avoided because they tend to irritate newly healed skin.

the 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 teaching? A) i need to bathe a mild soap and to rinse thoroughly B) i need to avoid direct sunlight on the newly healed skin area C) i should never wear warm clothing over the newly healed skin area D) i need to avoid the use of lanolin products to the newly healed skin area

C) I should never wear warm clothing over the newly healed skin area rationale newly healed skin is more sensitive to the cold, and the client should be instructed to wear warm clothing. the client should wash with a mild soap, rinse thoroughly, and pat the skin dry with a clean towel. newly healed skin sunburns easily, and direct sunlight needs to be avoided. products that contain perfume, alcohol, or lanolin should be avoided because they tend to irritate newly healed skin.

Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. the nurse provides instructions to the client regarding the use of the medication. which statement by the client indicates an accurate understanding of the use of this medication? A) I will apply the ointment once a day and leave it open to the air B) I will apply the ointment twice a day and leave it open to the air C) I will apply the ointment once a day and cover it with a sterile dressing D) I will apply the ointment at bedtime and in the morning and cover it with a sterile dressing

C) I will apply the ointment once a day and cover it with a sterile dressing rationale collagenase is used to promote debridement of dermal lesions and severe burns. it is usually applied once daily and covered with a sterile dressing.

the nurse is checking her clients for skin breakdown. which client should have the lowest priority for concern in the development of skin breakdown? A) a client incontinent of urine and feces B) a client with chronic nutritional deficiencies C) a client with a lowered mental awareness status D) a client who is unable to move about and is confined to bed

C) a client with a lowered mental awareness status rationale bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and a lowered mental awareness can contribute to the development of skin breakdown. the least likely risk as presented in the options is the lowered mental awareness status. the other options identify physiological conditions, which are the highest risk priorities.

the 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? A) obtain blood cultures B) administer antibiotics C) apply cold compresses to the affected area D) administer acetaminophen (Tylenol) for fever

C) apply cold compresses to the affected area rationale warm compresses such as moist heat may be used to decrease discomfort, erythema, and edema. after tissue and blood cultures are obtained, antibiotics are initiated. the nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. cold compresses are not a component of the treatment measures.

a client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. in reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication? A) can cause systemic effects B) has a very agreeable odor C) can stain the skin and hair D) carries no risk of phototoxicity

C) can stain the skin and hair rationale coal tar is used to treat psoriasis and other chronic disorders of the skin. it suppresses DNA synthesis, mitotic activity, and cell proliferation. it frequently can stain the skin and hair, and clients should be taught about this aspect of the medication. it has an unpleasant odor and can cause phototoxicity. it does not carry a risk for systemic effects.

the nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. the nurse interprets this occurrence as which? A) common B) suggests that the client is anemic C) characteristic of a thrush infection D) indicative that oral hygiene needs to be improved

C) characteristic of a thrush infection rationale candidiasis is a fungal infection caused by Candida albicans. when it occurs in the mouth, it is called thrush and appears as white plaques. although it can occur in an immunocompromised client, it is not considered to be common. the other options are not accurate regarding this infection

the HCP suspects a client has herpes zoster. to confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment? A) patch test B) skin biopsy C) culture of the lesion D) wood's light examination

C) culture of the lesion rationale herpes zoster is caused by a reactivation of the varicella zoster virus, which is the cause of chickenpox. a viral culture of the lesion provides the definitive diagnosis. a patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies. a biopsy will determine tissue type. during a wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin

the health care provider suspects a client has herpes zoster. to confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment? A) patch test B) skin biopsy C) culture of the lesion D) Wood's light examination

C) culture of the lesion rationale herpes zoster is caused by a reactivation of the varicella zoster virus, which is the cause of chickenpox. a viral culture of the lesion provides the definitive diagnosis. a patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies. a biopsy will determine tissue type. during a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin

the nurse prepares to assist a health care provider examine the client's skin with a Wood's light. which action should be included in the plan for this procedure? A) prepare a local anesthetic B) obtain an informed consent C) darken the room for the examination D) shave the skin and scrub it with a povidone - iodine solution

C) darken the room for the examination rationale the examination of the skin under a Wood's light is always carried out in a darkened room. this is a noninvasive examination; therefore, informed consent is not required. a hand-held, long-wavelength ultraviolet light or Wood's light is used. the skin does not need to be shaved, and a local anesthetic is not necessary. areas of blue-green or red fluorescence are associated with certain skin infections. the procedure is painless.

the nurse prepares to assist a HCP examine the clients skin with a Woods light. which action should be included in the plan for this procedure A) prepare a local anesthetic B) obtain an informed consent C) darken the room for the examination D) shave the skin and scrub it with a povidone-iodine (Betadine) solution

C) darken the room for the examination rationale the examination of the skin under a Woods light is always carried out in a darkened room this is a noninvasive examination; therefore informed consent is not required. a hand-held, long wave-length ultraviolet light or Woods light is used. the skin does not need to be shaved and a local anesthetic is not necessary areas of blue green or red fluorescence are associated with certain skin infections. the procedure is painless

the nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritius. which client statement indicates the need for further teaching? A) i need to avoid using astringents on my skin B) i should drink 8 to 10 glasses of water a day C) i should use a dehumidifer especially during the winter months D) i should limit myself to one shower per day and apply an emollient to my skin after the shower

C) i should use a dehumidifier especially during the winter months rationale the client should avoid using a dehumidifier because this will further dry the room air instead the client should use a room humidifier during the winter months or whenever the furnace is in use. the client should be taught to maintain a daily fluid intake of 3000 mL unless contraindicated. and to avoid alcohol and caffeine. the client should avoid applying rubbing alcohol, astringents or other drying agents to the skin one bath or shower per day for 15 to 20 minutes with warm water and a mild soap would be immediately followed by the application of an emollient to prevent the evaporation of water from the hydrated epidermis.

the nurse is reinforcing discharge instructions to a client who had a skin biopsy. which statement by the client indicates the need for further teaching? A) i will use antibiotic ointment as prescribed B) i will return in 7 days to have the sutures removed C) i will remove the dressing when i get home and wash the site with tap water D) i will call the HCP if i see any drainage from the wound

C) i will remove the dressing when i get home and wash the site with tap water rationale after a skin biopsy the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. after the dressing is removed, the site is cleansed once a day with tap water or saline to remove any dry blood or crusts. the HCP may prescribe an antibiotic ointment to minimize local bacterial colonization. the nurse instructs the client to report any redness or excessive drainage at the site. sutures are usually removed 7 to 10 days after biopsy.

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 describes a characteristic of this type of lesion? A) metastasis is rare B) it is encapsulated C) it is highly metastatic D) it is characterized by local invasion

C) it is highly metastatic rationale melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. this skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. basal cell carcinomas arise in the basal cell layer of the epidermis. early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. squamous cell carcinomas are malignant neoplasms of the epidermis. they are characterized by local invasion and the potential for metastasis.

a client with AIDS is diagnosed with cutaneous Kaposi's sarcoma. based on this diagnosis the nurse understands that this has been determined by which? A) swelling in the genital area B) swelling in the lower extremities C) punch biopsy of the cutaneous lesions D) appearance of reddish-blue lesions on the skin

C) punch biopsy of the cutaneous lesions rationale Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. these large plaques ulcerate or open and drain. the lesions spread by metastasis through the upper body and then to the face and oral mucosa. they also can spread to the lymphatic system, lungs and gastrointestinal tract. late disease results in swelling and pain in the lower extremities, penis, scrotum or face. diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions

the nurse is discussing skin biopsy with a client scheduled for the procedure. the nurse tells the client to expect which amount of discomfort during the procedure? A) none because it is painless B) none because it is done under general anesthesia C) slight because the local anesthetic may burn or sting D) somewhat painful but easily managed with opioids afterward

C) slight because the local anesthetic may burn or sting rationale the most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation. a biopsy is usually quick and may be almost painless, depending on the size and location of the lesion

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? A) come to the emergency department B) apply calamine lotion immediately to the exposed skin areas C) take a shower immediately and later and rinse several times D) it is not necessary to do anything if you cannot see anything on your skin

C) take a shower immediately and lather and rinse several times rationale when an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the skin. the client should be instructed to shower immediately, to lather the skin several times, and to rinse each time in running water. calamine lotion is a treatment that is used when dermatitis develops. it is not necessary for the client to be seen in the emergency department at this time

a client had a radical neck dissection with a musculocutaneous flap. 24 hours following the procedure, the nurse observes that the flap has a slightly blue hue. the nurse draws which conclusion? A) this is a normal expectation B) heat should be applied to the area C) venous circulation is being impaired D) the client is exhibiting generalized hypoxia

C) venous circulation is being impaired rationale the blue color is a sign of venous impairment resulting from venous stasis, which increases local tissue hypoxia and can lead to necrosis of the area affected. this is not a normal expectation. heat application would cause more damage to the tissue. there is no evidence to support the last option.

a client, admitted to the emergency department, is suspected of having frostbite of the hands. which finding should the nurse note in this condition? A) a pink edematous hand B) red skin with edema in the nail beds C) white skin that is insensitive to touch D) black fingertips surrounded by an erythematous rash

C) white skin that is insensitive to touch rationale findings in frostbite include white or blue skin that is hard, cold, and insensitive to touch. as thawing occurs, flushing of the skin, blisters or blebs, or tissue edema appears. gangrene develops in 9 to 15 days

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 should determine that this injury constitutes which body percentage? A) 27% B) 36% C) 45% D) 54%

D) 54% rationale according to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. the right leg is equal to 18% and the left leg is equal to 18%. the anterior thorax is equal to 18% and the posterior thorax is equal to 18%. the head is equal to 9% and the perineum is equal to 9%. if the anterior thorax, the right leg, and the right and left arms were burned the area of injury would equal 54% according to the rule of nines.

the nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition? A) rapid and continual rewarming of the toes when flushing occurs B) rapid and continual rewarming of the toes in cold water for 45 minutes C) rapid and continual rewarming of the toes in hot water for 15 to 20 minutes D) rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

D) Rapid and continual rewarming of the toes in a warm water bath until flushing of the skin occurs rationale frostbite is ideally treated with rapid and continual rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Hot or cold water is not used in the treatment of frostbite.

a client arrives at the emergency department and has experienced frostbite to the right hand. which should the nurse expect to find when inspecting the client's hand? A) a pink, edematous hand B) fiery red skin with edema in the nail beds C) black fingertips surrounded by an erythematous rash D) a white color of the skin, which is insensitive to touch

D) a white color of the skin, which is insensitive to touch rationale the findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. as thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. gangrene can develop in 9 to 15 days

after 7 days of wound care, a client who has a well-granulated pressure ulcer reports to the nurse, i'm feeling better overall. which nursing intervention most likely contributed to the client's feelings? A) pain management program B) frequent comfort measure C) dressing change twice daily D) ambulation three times daily

D) 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, metabolic, integumentary, neuromuscular, and conditioning benefits. thus, the wide-ranging benefits of exercise are more likely o 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.

which individual is least likely at risk for the development of Kaposi's sarcoma? A) a renal transplant client B) a male with a history of same-sex partners C) a client receiving antineoplastic medications D) an individual working in an environment in which exposure to asbestos is possible

D) an individual working in an environment in which exposure to asbestos is possible rationale Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder. it is a common AIDs indicator. Malignancy is seen most frequently in men with a history of same sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. the renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppresion. exposure to asbestos is not related to the development of Kaposi's sarcoma.

the nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder A) an adolescent B) an active elderly client C) a physical education teacher D) an outdoor construction worker

D) an outdoor construction worker rationale prolonged exposure to the sun, unusual cold or other conditions can damage the skin. an older client may be at higher risk than a younger individual because immobility and lack of nutrition may increase the older person's risk an adolescent may be prone to the development of acne, but this does not occur in all adolescents the physical education teacher is at low risk of developing an integumentary problem

the nurse is preparing a client for skin grafting and identifies 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 which source? A) a skin bank B) a cadaver C) the burned client D) another species

D) another species rationale biological dressings are obtained from living or deceased humans (homograft or allograft) or animals (heterograft or xenograft). heterograft is skin from another species. the most commonly used type of heterograft is pigskin because of its relative compatibility with human skin. homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank.

the nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. the nurse should include on the poster instructions to avoid which activities? A) using sunscreen when spending time outdoors B) wearing a hat, opaque clothing, and sunglasses when in the sun C) examining the skin monthly for any lesions that might be cancerous D) being in the sun for prolonged periods between 10 am and 3pm

D) being in the sun for prolonged periods between 10 am and 3 pm rationale the client should be instructed to avoid sun exposure between the hours of 10 am and 3 pm. sunscreen, a hat, opaque clothing, and sunglasses should be worm when spending time outdoors. the client should examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

the nurse is caring for a client with a diagnosis of pemphigus vulgaris. the nurse understands that which is a characteristic of this condition? A) dry skin B) hard skin C) leathery skin D) blistering skin

D) blistering skin rationale pemphigus vulgaris is a rare, chronic, blistering disease caused by an autoimmune disorder that occurs most often during middle and old age. the lesions occur on normal-appearing skin or mucous membrane surfaces as fragile, flaccid bullae. breaking the bullae leaves partial-thickness wounds that bleed, weep, and eventually form crusts. the skin is not dry, hard or leathery

the nurse is caring for a client with a diagnosis of pemphigus vulgaris. the nurse understands that which is a characteristic of this condition? A) dry skin B) hard skin C) leathery skin D) blistering skin

D) blistering skin rationale pemphigus vulgaris is a rare, chronic, blistering disease caused by an autoimmune disorder that occurs most often during middle and old age. the lesions occur on normal-appearing skin or mucous membrane surfaces as fragile, flaccid bullae. breaking the bullae leaves partial-thickness wounds that bleed, weep, and eventually form crusts. the skin is not dry, hard or leathery

an older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. which combination of dietary items should the nurse encourage the client to eat to promote wound healing? A) salad, watermelon, tea B) spaghetti, bread, cola C) baked potatoes, jell-o, water D) chicken breast, broccoli, strawberries, milk

D) chicken breast, broccoli, strawberries, milk rationale protein and vitamin C are necessary for wound healing. poultry and milk are good sources of protein. broccoli and strawberries are good sources of vitamin C. the other options do not provide protein or vitamin C.

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? A) rubbing the application into the skin B) placing the area under a heat lamp for 20 minutes C) applying a dry sterile dressing over the affected area D) covering the application with a warm, moist dressing and an occlusive outer wrap

D) covering the application with a warm, moist dressing and an occlusive outer wrap rationale the nurse can enhance penetration of topical corticosteroid therapy to the client with psoriasis by applying warm moist heat and an occlusive outer wrap. the wrap may consist of a plastic film, glove, bootie, or a similar item. if large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic side effects. the remaining options are not measures that will enhance the effectiveness of therapy.

a client has sustained partial-thickness burns on the posterior thorax and legs. the nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury? A) decreased heart rate B) increased urinary output C) decreased blood pressure D) elevated hematocrit levels

D) 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.

the nurse is caring for a client with circumferential burns of both legs. which leg position is appropriate for this type of a burn? A) a dependent position B) elevation of the knees C) flat, without elevation D) elevation about the level of the heart

D) elevation about the level of the heart rationale circumferential burns of the extremities may compromise circulation. elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation. the other options are incorrect

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 reinforces instructions to the client regarding preparation for the test. which statement by the client indicates an understanding regarding the preparation for this procedure? A) i need to have clear fluids only on the morning of the test B) i need to take my prednisone on the morning of the test C) i need to shower on the morning of the test using povidone - iodine (Betadine) D) i need to stop taking my antihistamine 2 days before i come to the clinic for the test

D) i need to stop taking my antihistamine 2 days before i come to the clinic for the test rationale client preparation for a patch test includes informing the client to discontinue the administration of systemic corticosteriods or antihistamines for at least 48 hours before the test. topical corticosteriod therapy may be continued as long as the agent is not applied on the area to be tested. to prevent suppression of the inflammatory response to an allergen, these medications must be discontinued. there are no dietary restrictions, and the client is not instructed to shower on the morning of the test using povidone-iodine, which is very irritating to already irritated skin

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? A) tell the client that a blood test is needed immediately B) inform the client that there is no test available for Lyme disease C) tell the client that testing is not necessary unless arthralgia develops D) 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

D) 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 rationale there is a blood test available to detect Lyme disease; however, it is not reliable if performed before 4 to 6 weeks following the tick bite. the other options are incorrect

a client arrives at the health care clinic and tells the nurse that the was just bitten by a tick and would like to be tested for Lyme disease. which nursing action is appropriate? A) tell the client that a blood test is needed immediately B) inform the client that there is no test available for Lyme disease C) tell the client that testing is not necessary unless arthralgia develops D) 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

D) inform the client that he will need to return in 4 to 6 weeks to be tested before this time is not reliable rationale there is a blood test available to detect Lyme disease; however, it is not reliable if performed before 4 to 6 weeks following the tick bite. the other options are incorrect

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. which response should the nurse give to the client's question? A) it is just a superficial infection B) it is an inflammation of the lymphatic system C) it is due to an infection caused by Staphylococcus D) it is a skin infection that involves the deeper skin layers and subcutaneous fat

D) it is a skin infection that involves the deeper skin layers and subcutaneous fat rationale cellulitis is a skin infection into the deeper dermis and the subcutaneous fat, usually caused by Streptococcus pyogenes; it results in deep red erythema without sharp borders, and it spreads widely through tissue spaces. the skin is erythematous, edematous, tender, and sometimes nodular. erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and the lymphatics.

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. which response should the nurse give to the client's question? A) it is just a superficial infection B) it is an inflammation of the lymphatic system C) it is due to an infection caused by staphylococcus D) it is a skin infection that involves the deeper skin layers and subcutaneous fat

D) it is a skin infection that involves the deepr skin layers and subcutaneous fat rationale cellulitis is a skin infection into the deeper dermis and the subcutaneous fat, usually caused by streptococcus pyogenes; it results in deep red erythema without sharp borders, and it spreads widely through tissue spaces. the skin is erythematous, edematous, tender, and sometimes nodular. Erusipeias is an acute, superfical, rapidly spreading inflammation of the dermis and the lymphatics.

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. what is the most appropriate response to the client? A) it is skin from a cadaver B) it is skin from a skin bank C) it is skin from the burned client D) it is skin from another species

D) it is skin from another species rationale biological dressings are obtained from living or decreased humans (homograft or allograft) or animals (heterograft or xenograft) a heterograft is skin from another species. the most commonly used type of heterograft is pigskin because of its relative compatibility with human skin. a homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank.

following diagnostic evaluation, it has been determined that the client has Lyme disease, stage 2. the nurse understands that which is most indicative of this stage? A) arthralgias B) joint enlargement C) erythematous rash D) neurological deficits

D) neurological deficits rationale stage 2 of Lyme disease develops within 1 to 6 months in most untreated individuals. the most serious problems include cardiac conduction defects and neurological disorders such as Bells palsy and paralysis. these problems are not usually permanent arthralgias and joint enlargement are noted in stage 3. a rash appears in stage 1.

the nurse is assigned to assist in caring for a client with frostbite of the toes. which should the nurse anticipate to be prescribe for this condition? A) rapid and continual rewarming of the toes when flushing occurs B) rapid and continual rewarming of the toes in cold water for 45 minutes C) rapid and continual rewarming of the toes in hot water for 15 to 20 minutes D) rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs

D) rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs rationale frostbite is ideally treated with rapid and continual rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. hot or cold water is not used in the treatment of frostbite

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 be the nurse's first action? A) use tweezers to remove the insect stinger B) apply an occlusive dressing over the stinger C) apply a warm compress to relieve the discomfort D) use the edge of a sterile surgical tool to scrape out the stinger

D) use the edge of a sterile surgical tool to scrape out the stinger rationale using the edge of a sterile surgical tool to scrape out the stinger will not likely squeeze any bee venom into the tissue. tweezers likely would squeeze additional venom into the tissues. apply warm compresses likely would cause additional absorption because of vasodilation. an occlusive dressing would not prevent tissue absorption and would not assist in removal of the stinger.

the nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. the nurse understands that moist desquamation is best described as which? A) a rash B) dermatitis C) reddened skin D) weeping of the skin

D) weeping of the skin rationale moist desquamation occurs when the basal cells of the skin are destroyed. the dermal level is exposed, which results in the leakage of serum. Reddened skin, a rash, and dermatitis may occur with external radiation but are not described as moist desquamation.

which clients are at risk for developing skin breakdown? select all that apply a client who is underweight a client diagnosed with sinusitis a client diagnosed with heart failure a client diagnosed with spinal cord injury a client diagnosed with benign prostatic hypertrophy

a client who is underweight // a client diagnosed with heart failure // a client diagnosed with spinal cord injury rationale the client who is underweight does not have any cushioning to protect bony prominences. a client with a spinal cord injury has decreased mobility, which can cause skin breakdown to develop. many clients with heart failure have edema, which can also lead to the development of skin breakdown. sinusitis and benign prostatic hypertrophy do put the client at risk for skin breakdown

the nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure ulcer in the sacral area. which nursing actions will encourage healing of a stage 2 pressure ulcer? select all that apply utilize a rubber ring clean with mild soap and water encourage adequate nutritional intake massage the area around the affected area apply a dressing that allows oxygen to pass through

clean with mild soap and water // encourage adequate nutritional intake // apply a dressing that allows oxygen to pass through rationale in general, stages I and II pressure ulcers should be cleaned with mild soap and water or normal saline. adequate nutrients are essential to maintain or restore skin integrity. all wound covers should allow oxygen to pass through. any kind of massage around or on a reddened area of skin can damage fragile capillaries. in addition, rubber rings should not be used to elevate heels or sacral areas. rings cause a concentrated area of pressure that places the client at a higher risk for developing pressure ulcers.

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 percentage? A) 22.5% B) 31.5% C) 36% D)40.5%

A) 22.5% rationale according to the rule of nines, the posterior side of the head equals 4.5%, the upper half of the posterior trunk equals 9% and the back of both arms equals 9%, totaling 22.5%.

the nurse is checking for the presence of cyanosis in a dark-skinned client. which body area should provide the best information? A) sacrum B) earlobes C) back of the hands D) palms of the hands

D) palms of the hands rationale in a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae and palms and soles at regular intervals for subtle color changes. in a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae and nail beds have a bluish tinge

the 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 should the nurse expect to find when checking the client's sacral area? A) intact skin B) the presence of tunneling C) a deep, crater-like appearance D) partial-thickness skin loss of the epidermis

D) partial-thickness skin loss of the epidermis rationale with a stage 2 pressure ulcer, the skin is not intact. there is partial-thickness skin loss of the epidermis or dermis. the ulcer is superficial, and it may look like an abrasion, blister, or shallow crater. the skin is intact with a stage 1 pressure ulcer. a deep, crater-like appearance occurs during stage 3 and tunneling develops during stage 4.

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% rationale according to the rule of nines, with the initial burn, the anterior half of the head equals 4.5% the upper half of the anterior torso equals 9% and the lower halves of both arms equal 9% the subsequent burn included the posterior half of the head, which equals 4.5% and the upper half of the posterior torso which equals 9%. this totals 36%

an older client is complaining of chronic dry skin and occasional pruritus. the nurse reinforces instructions for the client to avoid which skin care regimen that will aggravate the condition? A) using astringents to clean the skin B) drinking 8 to 10 glasses of water a day C) applying emollient to the skin after a shower D) using a humidifier, especially during the winter months

A) 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 15-20 minute warm bath or one shower per day. the client should then apply an emollient to prevent eater 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.

the nurse is working on a surgical unit. which surgical clients are most at risk for wound infection? select all that apply wound from repair of a perforated appendix surgical wound after an open cholecystectomy gunshot wound that punctured the small intestine sterile wound resulting from a total radical mastectomy traumatic wound to the abdomen and intentionally left open for several days wound related to debridement of a chronic pressure ulcer resulting in a cavity-like defect

wound from repair of a perforated appendix // gunshot wound that punctured the small intestine // traumatic wound to the abdomen and intentionally left open for several days // wound related to debridement of a chronic pressure ulcer resulting in a cavity-like defect rationale surgical incisions that enter a nonsterile body cavity or traumatic wounds that occur under unclean conditions place the client at risk for wound infection. a perforated appendix, puncture of the intestine, an open wound, and a wound requiring debridement increase the risk for wound infection. a simple surgical wound and a sterile wound are at less risk for becoming infected