NU272 Week 2 EAQ Evolve Elsevier: HESI Prep Med-Surg Integumentary System
A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. Which is the best response by the nurse? 1) "May I take a look at it?" 2) "It's time for another graft." 3) "Is there any sign of redness?" 4) "It is supposed to curl up at the edges."
1) "May I take a look at it?" An autograft is a permanent graft that should not be rejected; the nurse would assess the site immediately. An autograft should not need to be replaced, and the edges should not curl. The nurse needs to assess the site; the responsibility of assessment should not be left to the client.
Which benign condition shows silver scaly plaques on the skin? 1) Nevi 2) Psoriasis 3) Urticaria 4) Acne vulgaris
2) Psoriasis A silver, scaly plaque on the skin is due to psoriasis and is most commonly seen on the elbows and scalp. Hyperpigmented areas that vary in form and color are due to nevi. Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to urticaria. Noninflammatory lesions, including open comedones and closed comedones, are due to acne vulgaris.
Which topical immunomodulator is used to treat a client with atopic dermatitis? 1) Mupirocin 2) Tacrolimus 3)Clindamycin 4) Erythromycin
2) Tacrolimus Tacrolimus is used to treat atopic dermatitis. Mupirocin is used to treat impetigo. Clindamycin and erythromycin are used to treat acne vulgaris.
The nurse is caring for two clients with a below-the-knee amputation. The first client was in a motor vehicle collision. The second client has a history of chronically decreased arterial perfusion. Which information would cause the nurse to conclude that the postoperative courses of these two clients may differ? 1) The first client probably will adjust more quickly. 2) The second client's incision will take longer to heal. 3) These clients are likely to have very different occupations. 4) The first client is more likely to have phantom limb sensations.
2) The second client's incision will take longer to heal. Decreased arterial circulation in the second client will delay healing. The first client received an amputation without preoperative preparation for the loss of the limb and will most likely have greater difficulty adapting. Clients with chronic limb pain before surgery (e.g., the second client with chronically decreased arterial perfusion) are more likely to have phantom limb sensations. Both clients' responses may be influenced by their occupations, but there is no data to support this conclusion.
Scald injuries could be caused by contact with which item? 1) Grease 2) Hot liquids or steam 3) Alkali in oven cleaners 4) Open flame in house fires
2) Hot liquids or steam
Which benign tumor forms on the surface of the client's epithelium? 1) Fibroma 2) Adenoma 3) Papilloma 4) Chondroma
3) Papilloma A papilloma is a benign tumor that forms on the surface of the epithelium. A fibroma forms on the fibrous tissue. An adenoma forms on the glandular epithelium. A chondroma forms on the cartilage.
The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? 1) Decreased rate of glomerular filtration 2) Excessive blood loss through the burned tissues 3) Plasma proteins moving out of the intravascular compartment 4) Sodium retention occurring as a result of the aldosterone mechanism
3) Plasma proteins moving out of the intravascular compartment The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.
Which type of laser is used in the treatment of vascular and other pigmented lesions? 1) Argon 2) Gold vapors 3) Neodymium 4) Carbon dioxide
1) Argon An argon laser is used in the treatment of vascular and other pigmented lesions. Gold vapors and neodymium are type of lasers used in the treatment of skin disorders. A carbon dioxide laser is also a type of laser used in the treatment of skin disorders; it has numerous applications as a vaporizing and cutting tool for most tissues.
The nurse observes elevated superficial lesions filled with purulent fluid on a client's skin. Which type of lesion would the nurse document in the health record? 1) Wheal 2) Plaque 3) Pustule 4) Vesicle
3) Pustule Pustules are the primary lesions that cause elevated, superficial lesions filled with purulent fluid on the skin. Acne and impetigo are examples of pustules. A wheal is a firm, edematous, irregularly shaped lesion. Insect bites and urticaria are examples of wheals. Plaque consists of circumscribed, elevated superficial solid lesions less than 0.5 cm in diameter. Psoriasis and seborrheic are examples of plaque. A vesicle is a circumscribed, superficial collection of serous fluid. Varicella and second-degree burns are examples of vesicles.
A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching? 1) Placing the old dressing in a plastic bag 2) Changing the dressing without wearing a mask 3) Donning nonsterile gloves for removing the old dressing 4) Using a back-and-forth motion with the same gauze while cleaning the wound
4) Using a back-and-forth motion with the same gauze while cleaning the wound After each swipe, sterile gauze should be discarded, and a new sterile gauze should be used for the next swipe. The other options are correct. Placing the old dressing in a plastic bag confines the soiled dressing to a leak-proof bag and prevents contamination of the environment or others. A mask is not necessary. Nonsterile gloves are acceptable for dressing removal because the dressing is contaminated; sterile gloves may be required for dressing application.
Which client actions may worsen the symptoms of decreased eccrine and apocrine gland function? Select all that apply. One, some, or all responses may be correct. 1) Dressing in warm clothing 2) Frequent bathing with hot water 3) Using soap with high fat content 4) Applying moisturizer before bathing 5) Lowering the water heater temperature
2) Frequent bathing with hot water 4) Applying moisturizer before bathing The decreased function of the eccrine and apocrine glands may increase the susceptibility to dry skin. Frequent bathing with hot water may result in persistence of the symptoms. Moisturizers should be applied on the body after bathing, when the skin is moist. Warm dressings are used to prevent hypothermia in a client with thinning of the subcutaneous layer. A high-fat content bathing soap is appropriate for a client with decreased eccrine and apocrine function. Lowering the water heater temperature prevents scalds in clients with reduced sensory perception.
The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow? 1) High caloric intake, liberal potassium intake, and 3 g protein/kg per day 2) High caloric intake, restricted potassium intake, and 1 g protein/kg per day 3) Moderate caloric intake, liberal potassium intake, and 3 g protein/kg per day 4) Moderate caloric intake, restricted potassium intake, and 1 g protein/kg per day
1) High caloric intake, liberal potassium intake, and 3 g protein/kg per day A high-calorie diet is needed for the increased metabolic rate associated with burns; the administration of potassium prevents hypokalemia, which can occur after the first 48 to 72 hours when potassium moves from the extracellular compartment into the intracellular compartment; protein promotes tissue repair. High caloric intake, restricted potassium intake, and 1 g protein/kg per day do not meet the body's needs for tissue repair; the protein and potassium are too limited. Moderate caloric intake, liberal potassium intake, and 3 g protein/kg per day do not meet the body's needs for tissue repair; the calories are too limited. Moderate caloric intake, restricted potassium intake, and 1 g protein/kg per day do not meet the body's needs for tissue repair; the calories, potassium, and protein are too limited.
The nurse is teaching a client about self-management to prevent dry skin. Which statement made by the client indicates the need for further teaching? 1) "I should use nonalkaline soap for a bath." 2) "I should put on moisturizer and then take a warm bath." 3) "I should avoid clothing that continuously rubs the skin." 4) "I should use a room humidifier during the winter months."
2) "I should put on moisturizer and then take a warm bath."
A client reports fever, redness, skin breakdown, and inflammation on the leg. Upon assessment, the nurse finds the area to be tender and edematous with diffused borders. The nurse would anticipate teaching the client about which condition? 1) Shingles 2) Cellulitis 3) Folliculitis 4) Onychomycosis
2) Cellulitis Fever and redness due to inflammation are followed by skin breakdown in cellulitis. This condition is clinically manifested by redness, warmth, and tenderness around the edematous area. Shingles is characterized by linear distribution along a dermatome of grouped vesicles and pustules on an erythematous or red base resembling chickenpox. Shingles may not be associated with edema. Folliculitis is manifested by minimum erythema and small pustules at the hair follicle opening. Onychomycosis is a fungal infection manifested by brittle, thickened, broken, or crumbling nails with yellowish discoloration.
While assessing the skin of a light-skinned client, the nurse concludes that the client has ecchymosis. Which skin color variation would confirm this diagnosis? 1) Gray color 2) Dark red color 3) Deep brown color 4) White color
2) Dark red color Dark red skin coloring is identified as ecchymosis. A grayish skin color is due to cyanosis. A deep brown skin coloring is caused by erythema in dark-skinned clients. A white or ashen skin color is found in clients with pallor.
While providing care for an obese client who underwent an open cholecystectomy, the nurse identifies a separation in the surgical incision. Which complication is the client experiencing? 1) Adhesions 2) Dehiscence 3) Evisceration 4) Contractions
2) Dehiscence
Which recommendations would the nurse include in a client's discharge instructions regarding a home skincare program for psoriasis? 1) "Shower twice a day with mild soap and warm water." 2) "Soak the affected areas in hot water on a daily basis." 3) "Apply an alcohol free, moisturizing lotion several times a day." 4) "Cover affected areas when in contact with others."
3) "Apply an alcohol free, moisturizing lotion several times a day." Moisturizing lotions provide an occlusive film on the skin surface so that usual water loss through the skin is limited, thereby allowing the trapped water to hydrate the stratum corneum. Clients should not excessively expose the skin to water, particularly hot water, increases irritation and scaling. Psoriasis is not a communicable disease and affected areas do not need covering when in contact with others.
A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information would the nurse include in the teaching plan? 1) "Rinse the mouth 3 times a day with lemon juice and water." 2) "Brush the teeth once daily and use dental floss after each meal." 3) "Clean the mouth with a soft toothbrush or a gentle spray." 4) "Gently clean the mouth with commercial mouthwash."
3) "Clean the mouth with a soft toothbrush or a gentle spray." Chemotherapy destroys the rapidly dividing cells of the oral mucosa; frequent gentle oral hygiene limits additional trauma. Although it is recommended to rinse the mouth every 2 hours, the client does not need to brush teeth and clean the mouth as often. Lemon juice is too caustic to the compromised mucosa. Flossing can disrupt and traumatize the gum surfaces; oral hygiene is needed more than once a day. Commercial mouthwashes contain alcohol, which is irritating to the mucosa.
The nurse is assessing a client with the diagnosis of scleroderma for signs of CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia). Which clinical indicators would the nurse expect to identify upon assessment? Select all that apply. One, some, or all responses may be correct. 1) Joint pain 2) Masklike facies 3) Esophageal dysmotility 4) Spiderlike hemangiomas 5) Episodic blanching of the fingers
3) Esophageal dysmotility 4) Spiderlike hemangiomas 5) Episodic blanching of the fingers Esophageal dysmotility is associated with CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia); it results in dysphagia and esophageal reflux. Spiderlike hemangiomas (telangiectasia) is associated with CREST syndrome. Episodic blanching of the fingers (Raynaud phenomenon), caused by vasospasms of the arterioles, is a sign associated with CREST syndrome. Joint pain, caused by inflammation, is a symptom associated with scleroderma, not CREST syndrome. Masklike facies is a sign associated with scleroderma, not CREST syndrome; it is caused by fibrotic tissue changes.
The nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. Which action would the nurse take in response to the client's comment? 1) Tell the client to take a friend along for safety. 2) Encourage participation in this activity, because it provides excellent range-of-motion exercise. 3) Explain that the incision should not be immersed in water until it has healed. 4) Let the client know that swimming can substitute for the prescribed physical therapy
3) Explain that the incision should not be immersed in water until it has healed. Because of the risk for infection, the client should avoid tub baths, hot tubs, pools, and immersion in other bodies of water until after the wound has healed and these activities are approved by the primary health care provider. Immersion in water for a prolonged period interferes with wound healing, because water may macerate tissue. Having a friend along does not change the fact that immersion in water for a prolonged period will interfere with wound healing. The client needs to continue physical therapy after discharge whether or not the client goes swimming.
Which event occurs in the proliferative phase of wound healing? 1) Thinning of scar tissue 2) Strengthening of collagen 3) Formation of granulation tissue 4) Increase in capillary permeability
3) Formation of granulation tissue Granulation tissue is formed in the proliferative tissue. Thinning of scar tissue and strengthening of collagen fibers is seen in the maturation phase of wound healing. The increase in capillary permeability occurs in the inflammatory phase of wound healing.
The client reports crumbly, discolored, and thickened toenails. Which reason could be a possible cause for this condition? 1) Allergy 2) Insect bite 3) Fungal infection 4) Bacterial infection
3) Fungal infection Exposure to the pathological fungal varieties may cause infections to the nails along with hair and skin. Dermatological problems associated with allergies and hypersensitivity reactions may include only skin and may not include nails and hair. Insect bites may cause life-threatening allergic reactions due to the venom of the insect. Bacteria may cause scalp infections to hair and skin but do not usually cause nail infections.
A client sustained minor skin injuries after an accident. Which event occurs close to the time of injury? 1) Thinning of the scar tissue 2) Formation of granulation tissue 3) Migration of leukocytes to the site of injury 4) Arrival of fibroblasts to the site of infection
3) Migration of leukocytes to the site of injury Beginning at the time of injury and lasting 3 to 5 days is the inflammatory phase in which migration of leucocytes takes place. Scar tissue is formed in the maturation phase. Formation of granulation tissue and migration of fibroblasts occurs in the proliferative phase.
An adolescent girl who has sustained superficial partial-thickness burns of the face because of excessive exposure to the sun exclaims, "Prom night is only 4 weeks away. I'll never be healed!" Which is the nurse's best response? 1) "The eschar will be healed in 2 weeks." 2) "Liquid makeup base can cover the area." 3) "The edema is expected for several weeks." 4) "Recovery will take about 3 weeks."
4) "Recovery will take about 3 weeks." the expected recovery time for an uncomplicated superficial partial-thickness burn is 10 to 21 days. Eschar occurs with full-thickness, not superficial partial-thickness, burns. The response "Liquid makeup base can cover the area" may raise anxiety by implying that facial lesions still will be present in 4 weeks. Edema is not present for several weeks.
