NURS 3107 - Exam 4 - Saunders: Integumentary

A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe? 1. White color 2. Pink or red color 3. Weeping blisters 4. Insensitivity to pain and cold

2 Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold.

The nurse is providing home care instructions to the client who just had surgery for squamous cell carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which characteristics of this type of skin carcinoma? 1. Irregularly shaped, pigmented papules or plaques 2. Pearly papule with a central crater and rolled, waxy borders 3. Small macules or papules with dry, rough, adherent yellow or brown scale 4. Firm, nodular lesion topped with a crust or with a central area of ulceration

4 Squamous cell carcinoma presents with a firm, nodular lesion topped with a crust or with a central area of ulceration. Option 1 describes melanoma. Option 2 describes actinic keratosis. Option 3 describes basal cell carcinoma.

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased heart rate 2. Increased urinary output 3. Increased blood pressure 4. Elevated hematocrit levels

4. The resuscitation/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 resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

The nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The nurse should make which response to the client? 1. "The procedure is painless." 2. "A preoperative medication will put you to sleep." 3. "An analgesic will be prescribed after the procedure." 4. "The local anesthetic may cause a stinging sensation."

4 A skin biopsy is not painless. The most common source of pain during a skin biopsy is the initial local anesthetic, which can produce a burning or stinging sensation. A preoperative medication that puts the client to sleep is not a component of this procedure. Analgesics may be prescribed after the procedure, but this option does not address the issue related to the amount or type of pain associated with the procedure itself.

An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. 1. Heels 2. Ankles 3. Elbows 4. Sacrum 5. Back of the head 6. Greater trochanter

1,3,4,5 When the client is lying supine, the heels, sacrum, and back of the head are all at risk, as are the elbows and scapulae. The greater trochanter and ankles are at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position.

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 1. Superficial 2. Full-thickness 3. Deep partial-thickness 4. Partial-thickness superficial

2 Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.

The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply. 1. Wash feet with hot water daily. 2. Use a mild soap when washing the feet. 3. Use lanolin on the feet to prevent dryness. 4. Wear open-toed shoes to allow air flow to the feet. 5. Exercise the feet daily by walking and flexing at the ankle.

2,3,5 The client with a diabetic ulcer needs to take strict precautions and implement very specific measures to allow for wound healing. Interventions include washing the feet with warm (not hot) water daily with a mild soap, using lanolin to prevent drying and cracking, wearing closed-toed shoes that are well fitting and avoiding high-heel and open-toed shoes, and exercising the feet daily by walking and flexing at the ankle to promote circulation.

In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? 1. Fatigue 2. Constipation 3. Impaired safety 4. Altered body image

4 Psoriasis is an autoimmune dermatitis that is expressed as silvery scales on reddish-colored skin on areas such as scalp, elbows, hands, and knees. Onset of the disease generally occurs before age 40, with symptoms varying in intensity from mild to severe. Skin disorders, particularly when experienced by young persons and particularly when visible on exposed body parts, can cause significant psychosocial distress. Altered body image is a priority client problem that should be considered when planning care for a client with psoriasis. The remaining options are not priority client problems associated with psoriasis.

The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful? 1. "My nails may become clubbed." 2. "My nails may have multiple small pits." 3. "I may develop flattening of the nail plate." 4. "I may develop horizontal depressions on my nails."

1 A client with COPD will have clubbing of the nails, described as an angle between the nail plate and the proximal nail fold exceeding 180 degrees. Psoriasis is represented by multiple small pits in the nail bed. Flattening of the nail plate is caused by several conditions, such as iron deficiency anemia and poorly controlled diabetes for greater than 15 years. Horizontal depression across the nail beds is caused by medical problems, such as acute, severe illness and isolated periods of severe malnutrition.

The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client? 1. Keep the test sites dry. 2. All activities can be continued. 3. Reapply the patch if it comes off. 4. Return to the clinic in 2 weeks for the initial reading.

1 The nurse instructs the client to keep the test sites dry at all times. The nurse also discourages excessive physical activity that will result in sweating. If the client reapplies patches that come loose, this 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 preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply. 1. Red, raised papules 2. Large plaques covered by silvery scales 3. Tiny red vesicles that weep serous material 4. Erythema noted mostly under the breast area 5. Pink to dark red, patchy eruptions on the skin

1,2 Psoriasis lesions appear as red, raised papules that may coalesce into large plaques covered by silvery scales. Eczema can manifest as tiny red vesicles that weep serous or purulent material. Erythema noted mostly under the breast area is characteristic of seborrheic dermatitis. Pink to dark red, patchy eruptions on the skin may be indicative of exfoliative dermatitis.

The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply. 1. The exact cause of acne is unknown. 2. Acne requires active treatment for control until it resolves. 3. Oily skin and a genetic predisposition may be contributing factors for acne. 4. Acne is an acute skin disorder that usually begins in puberty and is more common in females. 5. The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules.

1,2,3,5 Acne is a chronic skin disorder that usually begins in puberty and is more common in males. Lesions develop on the face, neck, chest, shoulders, and back. Acne requires active treatment for control until it resolves. The types of lesions include comedones (open and closed), pustules, papules, and nodules. The exact cause is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes (and the enzymes that reduce lipids to irritating fatty acids). Exacerbations coincide with the menstrual cycle because of hormonal activity. Oily skin and a genetic predisposition may be contributing factors.

The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply. 1. Reposition every 2 hours. 2. Use a bed cradle as indicated. 3. Apply protective pads to heels and elbows. 4. Add a small amount of alcohol to the daily bath water. 5. Provide perineal care every 8 hours and after incontinence.

1,2,3,5 Unconscious clients are completely immobile, having lost the protective reflexes to shift body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours. Use of a bed cradle can protect the client's toes from breakdown due to weight from linens. Protective pads can be applied to the heels and elbows to reduce friction and shear. Appropriate perineal care is essential to keep waste products from excoriating the skin. The nurse can reduce skin dryness and irritation by adding a superfatty solution (such as baby oil or castile soap) to the daily bath water. Drying agents such as alcohol are avoided because dry skin can crack and break down.

The nurse in the ambulatory care clinic is reviewing a plan of care for a client who will be returning from the postanesthesia care unit after a blepharoplasty. Which nursing interventions should be a component of the postoperative care plan for this client? Select all that apply. 1. Monitoring for swelling 2. Elevating the head of the bed 3. Applying warm gauze pads to the eyes 4. Instructing the client to avoid Valsalva maneuvers 5. Assessing the function of the extraocular eye muscles

1,2,4,5 Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Postoperatively, the client is assessed for swelling, bruising, bleeding, and eye pain. The head of the bed should be elevated, and cool eye compresses are applied to the area to reduce swelling. The client is instructed to avoid the Valsalva maneuver, which increases intracranial pressure and also pressure in the head and eye, thereby increasing the risk of hemorrhage. The function of extraocular eye muscles also is assessed. Gauze pads are not used because cotton is thick and pulls the skin when it is removed; in addition, warm compresses will increase the swelling.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreasing edema formation 4. Formation of granulation tissue

1. Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. 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. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is expected from the chemotherapeutic agent. Which statement made by the client indicates a need for further teaching? 1. "Excessive hair brushing should be avoided." 2. "I can't believe my hair loss will be permanent." 3. "I guess I'll have to stop using my electric hair dryer and curling rod." 4. "I will have my hair stylist cut my hair short just before I start my treatments."

2 Alopecia refers to loss of hair and is a temporary side effect of many chemotherapeutic agents. Excessive brushing and use of electric appliances on the hair may hasten hair loss once chemotherapy is started. Cutting the hair short before starting the chemotherapy helps the client to gradually adapt to the loss.

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

2 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 administration of the initial local anesthetic, which can produce a burning or stinging sensation. Preoperative medication is not necessary with this procedure. Opioid analgesics are not necessary following the procedure.

Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction? 1. "Treatments are limited to 2 or 3 times a week." 2. "The UV light treatments are given on consecutive days." 3. "Eye goggles need to be worn to prevent exposure to UV light." 4. "Just the area requiring treatment should be exposed to the UV light."

2 UV light treatments are limited to 2 or 3 times a week and are not given on consecutive days. Safety precautions are required during UV light therapy. It is best to expose only those areas requiring treatment to the UV light. Protective wraparound goggles prevent exposure of the eyes to UV light. The face should be shielded with a loosely applied pillowcase if it is unaffected. Direct contact with the lightbulbs of the treatment unit should be avoided to prevent burning of the skin.

Which individuals are most likely to be at risk for development of psoriasis? Select all that apply. 1. A 32-year-old African American 2. A woman experiencing menopause 3. A client with a family history of the disorder 4. An individual who has experienced a significant amount of emotional distress 5. A female client with a thin body frame who adheres to a regular exercise program

2,3,4 Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. Various forms exist, with psoriasis vulgaris being the most common type. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a cause. The disorder also may be exacerbated by the use of certain medications. Psoriasis occurs equally among women and men, although the incidence is lower in darker-skinned races and ethnic groups.

The nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client makes which statements? Select all that apply. 1. "I need to avoid baths or showers for 7 to 10 days." 2. "I need to clean the site as prescribed to prevent infection." 3. "I need to apply ice to the site continuously to prevent swelling." 4. "I need to expect some swelling and tenderness in the affected area." 5. "I need to apply alcohol-soaked dressings twice a day for 30 minutes each time."

2,4 Cryosurgery involves the local application of liquid nitrogen to isolated lesions, causing cell death and tissue destruction. The nurse teaches the client to expect swelling and increased tenderness of the treated area when the skin thaws. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister formation. The nurse instructs the client to clean the treatment site as prescribed to prevent secondary infection. A topical antibiotic also may be prescribed. Intermittent application of a warm, damp washcloth to the site will provide relief from any discomfort. Alcohol-soaked dressings will cause irritation. It is not necessary to avoid bathing or showering. Because cryosurgery involves tissue freezing, the application of ice is avoided following the procedure.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

2. Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? 1. Run a dehumidifier in the home. 2. Apply astringents to the skin twice daily. 3. Apply emollients to the skin after bathing. 4. Take baths twice daily using a dilute solution of alcohol and water.

3 One bath or one shower per day for 15 to 20 minutes with warm water and a mild soap should be followed immediately by the application of an emollient to prevent evaporation of water from the hydrated epidermis. The client should avoid using a dehumidifier because this will further dry room air. The client should be instructed to avoid applying rubbing alcohol, astringents, or other drying agents to the skin. A bath using a dilute alcohol solution will cause further drying of the skin.

An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions? 1. Purpura 2. Venous star 3. Spider angioma 4. Cherry angioma

3 Spider angiomas have a bright red center with legs that radiate outward. Spider angiomas are commonly seen in liver disease and vitamin B deficiency, although they occasionally can occur without underlying pathology. Purpura results from hemorrhage into the skin. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Cherry angioma occurs with increasing age and has no clinical significance. It appears as a small, round, bright red lesion on the trunk or extremities.

The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure? 1. Avoid the use of sunscreen on the skin for at least 2 years. 2. Apply an emollient lotion to the skin to enhance softening. 3. Scrub the skin vigorously with soap and water to remove the dead skin. 4. Soak the skin for 1 hour 6 times daily to assist in removing any dry scales.

3 The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days; however, soaking for 1 hour 6 times daily is excessive and could lead to skin breakdown. The skin should not be scrubbed vigorously because this action also could lead to skin breakdown. The skin should be patted dry, and a lubricating lotion should be applied. The client should avoid overexposing the skin to the sunlight.

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%

3. 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 half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.

The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? 1. "Apply ice to the site to prevent swelling." 2. "Clean the site with alcohol 3 times daily." 3. "Apply a warm, damp washcloth if discomfort occurs." 4. "Avoid showering or taking baths until seen by the health care provider in 1 week."

3. Cryotherapy involves the local application of liquid nitrogen to the lesion; this causes cell death and tissue destruction. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister formation; therefore, ice is not applied to the site. The application of a warm, damp washcloth intermittently to the site will provide relief of any discomfort. The nurse instructs the client to clean the site with the prescribed solution to prevent secondary infection. A topical antibiotic also may be prescribed. Alcohol would cause irritation to the skin. There is no reason for the client to avoid showering or bathing.

A client calls the emergency department and tells the nurse that he came directly into 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 should make which response? 1. "Come to the emergency department." 2. "Apply calamine lotion immediately to the exposed skin areas." 3. "Take a shower immediately, lathering and rinsing several times." 4. "It is not necessary to do anything if you cannot see anything on your skin."

3. When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.

The nurse prepares to assist the health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care? 1. Shave the skin site. 2. Prepare a local anesthetic. 3. Obtain an informed consent. 4. Tell the client that the procedure is painless.

4 A Wood's light examination is a painless procedure. The skin does not need to be shaved, and a local anesthetic is not necessary. Examination of the skin under a Wood's lamp is always carried out in a darkened room. This is a noninvasive examination; therefore, an informed consent is not required. A hand-held long-wavelength ultraviolet light source or Wood's lamp is used. Areas of blue-green or red fluorescence are associated with certain skin infections.

A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What should the nurse include in client teaching to maximize the effects of the treatment? 1. Rub the application into the skin. 2. Place the area under a heat lamp for 20 minutes. 3. Apply a dry sterile dressing over the affected area. 4. Cover the application with a warm, moist dressing and an occlusive outer wrap.

4 Penetration of topical corticosteroid therapy can be enhanced by applying warm, moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or 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 adverse effects. The medication is applied but not rubbed into the skin. Dry sterile dressings are not used. A heat lamp can cause a burn injury.

The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder? 1. An adolescent 2. An older woman 3. A physical education teacher 4. An outdoor construction worker

4 Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. The outdoor construction worker would fit into a high-risk category for the development of an integumentary disorder. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. Immobility and lack of nutrition would increase the older client's risk, but the older client is not at as high a risk as the outdoor construction worker. The physical education teacher is at low or no risk of developing an integumentary problem.

The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions? 1. "I need to assess my skin for ring-shaped lesions." 2. "I have to monitor for the presence of linear skin lesions." 3. "I have to monitor for the presence of arc-shaped skin lesions." 4. "I need to assess my skin for lesions that appear net-like."

4 Reticular skin lesions resemble a net in appearance. Linear lesions appear in a straight line, whereas annular lesions are ring shaped. Arciform lesions are shaped like an arc.

The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? 1. "Each treatment will last at least 30 minutes." 2. "Your entire body will be exposed to the light treatment." 3. "You will need to wear cotton clothes during the treatment." 4. "You will need to wear dark eye goggles during the treatment."

4 Safety precautions are required during UV light therapy. Protective dark eye goggles are required to prevent exposure of the eyes to the UV light; it may be necessary to wear the goggles for the remainder of the day following treatment. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Most UV light therapies require the client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UV light. Direct contact with the lightbulbs used for the treatment should be avoided to prevent burning of the skin.

A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound? 1. Dry sterile dressing 2. Wet to dry dressing 3. Gelfoam sponge dressing 4. Semipermeable film dressing

4 Semipermeable film dressings are used on superficial wounds, on ulcers, and occasionally on some deep, draining, or necrotic ulcers. These dressings have the advantage of staying in place for several days, allowing tissues to heal underneath. Dry sterile dressings would stick to the wound and are inappropriate. Wet to dry dressings are unnecessary because the tissue does not need debridement. Gelfoam sponge dressings are a type of enzyme dressing used in the treatment of necrotic tissue.

A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse should tell the client to take which measure? 1. Maintain room humidity at less than 40%. 2. Use very hot or very cold water for bathing. 3. Apply emollients once the skin is thoroughly dry. 4. Avoid bathing in the shower or tub more than once daily.

4 Several things may be done to promote hydration of the skin. The client should limit tub or shower bathing to once daily or every other day and should sponge bathe on the other days. Room humidity should be maintained at greater than 40%. Bath water should be between 95°F and 100°F (35°C to 37.8°C) (tepid) and not very hot or very cold. Harsh soaps should be avoided, and emollients should be applied generously to skin while it is still damp.

The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction? 1. "I will keep the dressing dry." 2. "I will watch for any drainage from the wound." 3. "I will use the antibiotic ointment as prescribed." 4. "I will return tomorrow to have the sutures removed."

4 Sutures usually are removed 7 to 10 days after a skin biopsy, depending on health care provider (HCP) preference. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours as prescribed. After the dressing is removed, the site is cleaned 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. The site may be closed with sutures or may be allowed to heal without suturing.

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 1. 1200 mL of 5% dextrose in water solution 2. 2400 mL of 0.45% normal saline solution 3. 4800 mL of 0.9% normal saline solution 4. 9600 mL of lactated Ringer's solution

4 The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.

The nurse provides home care instructions to a client diagnosed with impetigo. Which statement by the client indicates the need for further instruction? 1. "I need to continue with the antibiotics as prescribed." 2. "I need to wash my hands thoroughly and frequently throughout the day." 3. "I should wash my dishes separately from those of other household members." 4. "It is not necessary to separate my linens and towels from those of other household members."

4 The client needs to separate his or her linens and towels from those of other household members. Thorough hand washing, separating linens and towels, and separate washing of the client's dishes are required because the infection is contagious so long as skin lesions are present. Antibiotics are administered and should be continued as prescribed.

The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction? 1. "I should use tepid water for bathing." 2. "I need to keep my skin lubricated and cool." 3. "After bathing, I should pat my skin dry rather than rubbing it." 4. "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."

4 The client should be instructed that a lubricant is applied immediately after the bath, while the skin is still damp, to help increase hydration of the stratum corneum. Options 1, 2, and 3 are appropriate home care measures to control the symptoms associated with pruritus.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? 1. Allow the client to have full liquids. 2. Give the client small glasses of clear liquids. 3. Order the client a full meal tray with extra liquids. 4. Keep the client on NPO (nothing by mouth) status.

4 The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border 5. Location in the bald spot atop the head that is exposed to outdoor sunlight

4,5 Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. 1. Presence of striae 2. Palpable radial pulses 3. Absence of any ecchymosis on the extremities 4. Thinner and decrease in number of reddish papules 5. Scarce amount of silvery-white scaly patches on the arms

4,5 Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.

The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity? 1. Pallor 2. Cyanosis 3. Erythema 4. Jaundice

3 Cellulitis presents with erythema (redness), which is localized inflammation. Options 1, 2, and 4 are not signs or symptoms of cellulitis.

A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? 1. Biobrane 2. Autograft 3. Homograft 4. Xenograft

2 A full-thickness burn will require terminal coverage with an autograft-the client's own skin. Biobrane is porcine collagen bonded to a silicone membrane, which is temporary and lasts anywhere from 10 to 21 days. Homografts (cadaveric skin) and xenografts (pigskin) provide temporary coverage of the wound by acting as a dressing for up to 3 weeks before rejecting.

An adult client trapped in a burning house has 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, what percentage does the nurse determine the extent of the burn injury to be?

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

The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching? 1. "I will inspect my skin daily." 2. "I can sit in my favorite chair all day." 3. "I need to drink at least 2 liters of fluid daily." 4. "I will make sure that my skin is clean and well moisturized."

2 Sitting in one position all day can be a risk factor for pressure ulcer development. Options 1, 3, and 4 are preventative measures for pressure ulcer development.

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? 1. Eschar 2. Intact blisters 3. Liquefaction necrosis 4. Cherry-red, firm tissue

3 Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury.

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.

54% 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 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%.

The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"? 1. Monitor temperature every 4 hours. 2. Leave the dressing intact for 3 to 5 days. 3. Maintain the right lower extremity in a dependent position. 4. Apply an ice pack to the site to decrease edema formation.

2 After surgery, graft sites are immobilized with bulky cotton pressure dressing for 3 to 5 days to allow vascularization, or "take," of the newly grafted skin. Dressings should not be disturbed. Elevation and complete rest of the grafted area is required to allow blood vessels to connect the graft with the wound bed. Any activity that might cause movement of the dressing against the body and separation of the graft from the wound is prohibited, such as application of an ice pack. Additionally, cold promotes vasoconstriction.

The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? 1. Sclera 2. Oral mucosa 3. Soles of the foot 4. Palms of the hand

2 In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa and in areas of lighter melanization such as the abdomen and buttocks. Jaundice would best be noted in the sclera of the eye. Cyanosis is best noted on the palms of the hands and soles of the feet.

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? 1. Clustered skin vesicles 2. A generalized body rash 3. Small blue-white spots with a red base 4. A fiery-red edematous rash on the cheeks

1 The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Options 2, 3, and 4 are incorrect descriptions.

A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply. 1. Fever 2. Vasodilation 3. Inflammation 4. Deoxygenated hemoglobin 5. Excessively high environmental temperature

1,2,4,5 Erythema (or redness) of the skin can be caused by vasodilation from high environmental temperatures, fever, or inflammation. The presence of deoxygenated hemoglobin is responsible for cyanosis of the skin.

The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate that teaching was successful? Select all that apply. 1. "I have to avoid excessive exposure to sunlight." 2. "My dark skin color predisposes me to skin cancer." 3. "I am at higher risk for skin cancer because my mother had one." 4. "I am at higher risk for skin cancer because I am 20 years old." 5. "I am immune to skin cancer because I work as a pest control exterminator."

1,3 Options 1 and 3 describe risk factors for skin cancer. Additional risk factors for skin cancer include age greater than 60 years, light-colored skin, and occupation exposure to arsenic, which is commonly used in pest control. Cognitive Ability: Evaluating

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? 1. Purpura 2. Petechiae 3. Erythema 4. Ecchymosis

4 Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.

The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition? 1. Acne 2. Freckles 3. Psoriasis 4. Sebaceous cysts

1 Acne is characterized by vesicles filled with cloudy or purulent fluid. Freckles are flat lesions less than 1 centimeter. Psoriasis is presented by elevated, plateaulike patches more than 1 centimeter. Sebaceous cysts are nodules filled with either liquid or semisolid material that can be expressed.

The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? 1. Applying warm compresses to the affected area 2. Placing iced compresses to the affected area every 4 hours 3. Alternating the application of hot and iced compresses every 2 hours 4. Placing antibiotic ointment on the affected site followed by continuous heat lamp application

1 Warm compresses may be prescribed to decrease the discomfort, erythema, and edema associated with a skin infection that is characteristic of cellulitis. The nurse should also provide supportive care as prescribed to manage associated symptoms such as fever or chills. After tissue and blood are obtained for culture, antibiotics are initiated. Heat lamps can cause more disruption to already inflamed tissue. Iced compresses are not prescribed because they can damage tissue.

The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first? 1. Nails 2. Hair follicles 3. Pilosebaceous glands 4. Epithelial layer of skin

1 Paronychia is a fungal infection that most often is caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The affected area generally is tender to touch and has purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. A variety of disorders may involve the epithelial skin layer.

The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply. 1. Lips 2. Tongue 3. Earlobes 4. Conjunctiva 5. Mucous membranes

1,4,5 Changes in skin color can be difficult to assess in the dark-skinned client. Color changes are most easily seen in areas of the body where the epidermis is thin and in areas where pigmentation is not influenced by exposure to sunlight. The nurse should assess the lips, conjunctiva, and oral mucous membranes for signs of anemia in the dark-skinned client. Signs of anemia are less easily observed in the tongue and earlobes.

The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for? 1. Lichenification with scaling and excoriation 2. Lesions with well-defined geometric margins 3. Bright red erythematous macules and papules 4. Evolution of lesions from vesicles to weeping papules and plaques

2 Contact dermatitis findings include skin lesions with well-defined geometric margins. Option 1 describes a medication eruption. Option 3 describes nonspecific eczematous dermatitis. Option 4 describes atopic dermatitis.

A client is seen in the health care clinic 2 weeks after rhinoplasty. The client tells the nurse that the upper lip is numb. Which nursing response would be appropriate? 1. "The numbness is normal and is likely to be permanent." 2. "In many cases the nose and upper lip are numb for up to 6 months." 3. "Numbness usually indicates nerve damage that occurred during the procedure." 4. "You will need to see the health care provider because this may indicate a complication of the procedure."

2 The nurse should instruct the client that after this procedure ecchymosis will last approximately 2 weeks, and the nose and upper lip may be numb for approximately 6 months. Options 1, 3, and 4 are inappropriate and inaccurate nursing responses.

The nurse has provided home care instructions to a client after dermabrasion. Which statement by the client indicates a need for further instruction? 1. "I need to apply wet soaks to my skin." 2. "I need to apply an emollient to my skin." 3. "I need to keep my skin dry to allow it to heal." 4. "I need to use sunscreen if I plan to be outdoors."

3 After dermabrasion, the client is instructed to implement measures that will prevent dry skin. The client will be instructed to use wet soaks and to use emollients when the wet soaks are not being used. The client should avoid exposure to the sun. If the client plans to be outdoors, a sunscreen needs to be applied, and protective clothing and items such as a hat should be worn.

The nurse prepares to assist a health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include 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 with povidone-iodine solution.

3 Examination of the skin under a Wood's light is always carried out in a darkened room. The procedure is painless. This is a noninvasive examination; therefore, an 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 nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? 1. Venous stars noted on trunk and thighs 2. Spider angiomas observed on trunk and thighs 3. Appears to have purpura on trunk and thighs 4. Appears to have cherry angiomas on trunk and thighs

4 A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby-colored round lesions on the trunk and/or extremities. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology. Purpura results from hemorrhage into the skin.

A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder? 1. Hyperthyroidism 2. Pernicious anemia 3. Cardiopulmonary disorders 4. Systemic lupus erythematosus (SLE)

4 An early sign of SLE is the appearance of a butterfly rash across the nose. Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia is exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of the fingers.

An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? 1. Heels 2. Sacrum 3. Back of the head 4. Greater trochanter

4 The greater trochanter is at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position. When the client is lying supine, the heels, sacrum, and back of the head all are at risk, as are the elbows and scapulae.

The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Venous insufficiency 4. Arterial insufficiency

2 When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. Options 1, 3, and 4 are not complications.

The presence of which finding leads the home health nurse to suspect infestation of a client with scabies? 1. Patchy hair loss and round red macules with scales 2. The presence of white 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 Scabies can be identified by the presence of multiple straight or wavy, threadlike lines beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the skin and lays its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 4 are not characteristics of scabies.

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? 1. Pallor of all extremities 2. Pulse oximetry reading of 93% 3. Peripheral pulses are diminished 4. High pressure alarm keeps sounding on the ventilator

4 A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction.

A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1. Gastric pH of 3 2. Absence of abdominal discomfort 3. GI drainage that is guaiac negative 4. Presence of hypoactive bowel sounds

1 The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.

The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. 1. Antibiotic therapy 2. Cold compresses to the affected area 3. Warm compresses to the affected area 4. Intermittent heat lamp treatments 4 times daily 5. Alternating hot and cold compresses continuously

1,3 Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

A client has undergone laser surgery to remove 2 nevi. The nurse determines that the client has understood discharge instructions if the client makes which statement? 1. "I can expect significant discomfort after the procedure." 2. "I need to cleanse the operated areas daily using scrubbing motions." 3. "I need to protect the operated areas from direct sunlight for at least 3 months." 4. "I need to report any signs of swelling or redness immediately to the health care provider."

2 After laser surgery to remove any type of skin lesion, the skin should be protected from direct sunlight for a minimum of 3 months. There should be minimal or no discomfort after the procedure, and, if present, the discomfort should be relieved easily with acetaminophen. The operated area should be cleansed gently with half-strength hydrogen peroxide twice a day after the dressing is removed (24 hours after the procedure). Redness and swelling are expected after this procedure.

The nurse has been working with the client diagnosed with candidiasis (thrush). What should the nurse assess for in this client? 1. The presence of blisters 2. The presence of white patches 3. The presence of purple patches 4. The presence of numerous small, red, pinpoint lesions

2 Assessment of the client with candidiasis (thrush) will reveal white patches on the tongue, palate, and buccal mucosa. The lesions adhere firmly to the tissues and are difficult to remove. The lesions often are referred to as "milk curds" because of their appearance. Clients often describe the lesions as dry and hot. Options 1, 3, and 4 are not characteristics of thrush.

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client? 1. Pillow 2. Foam pad 3. Folded blankets 4. Plastic-lined absorbent pad

2 The client who cannot shift weight unassisted should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for this purpose are those that have a tendency to equalize the client's weight on the pad. These include foam, water, gel, and alternating air products. A pillow provides cushion but does not distribute weight equally. A plastic-lined pad and folded blankets provide no pressure relief.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? 1. An inflammation of the epidermis only 2. A skin infection of the dermis and underlying hypodermis 3. An acute superficial infection of the dermis and lymphatics 4. An epidermal and lymphatic infection caused by Staphylococcus

2. Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis.

The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition? 1. Rapid and continuous rewarming of the toes after flushing returns 2. Rapid and continuous rewarming of the toes in cold water for 45 minutes 3. Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes 4. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs

4 Acute frostbite is treated ideally with rapid and continuous rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because they can contribute to increased cellular damage. Cold or hot water is not used. Thawing can cause considerable pain, and the nurse administers analgesics as prescribed.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? 1. "It is an acute superficial infection." 2. "It is an inflammation of the epidermis." 3. "Staphylococcus is the cause of this epidermal infection." 4. "This skin infection involves the deep dermis and subcutaneous fat."

4 Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red erythema without sharp borders and spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Options 1, 2, and 3 are incorrect descriptions.

A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem? 1. Skin that is uniformly dark 2. Very pale skin with little pigmentation 3. Patches of skin with loss of pigmentation 4. Blotchy brown macules across the cheeks and forehead

4 Chloasma is a condition caused by hormonal influences on melanin production and is characterized by blotchy brown macules across the cheeks and forehead. Options 1 and 2 refer to normal variations in skin color. Option 3 describes vitiligo.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss of the dermis

4. In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure? 1. Ensure that the consent form has been signed. 2. Ensure that a Foley catheter has been inserted. 3. Provide chlorhexidine wipes to be used before the procedure. 4. Verify the blood bank has 1 unit of packed red blood cells available if needed.

1 A punch biopsy involves use of a punch instrument that punctures the skin and is rotated to obtain some of the dermis and fat. It is used for diagnostic purposes. A signed consent form is required for this procedure. A Foley catheter is not indicated and should be avoided if possible for any condition or procedure due to the risk for catheter-associated urinary tract infection. Chlorhexidine wipes are not specifically indicated for this procedure; usually an antibacterial such as povidone-iodine is used. There is not typically a lot of bleeding with this procedure; therefore, units of blood are not typically made available for the client undergoing punch biopsy.

A client with severe psoriasis has a problem of chronic low self-esteem. The nurse should incorporate which nursing action when working with this client? 1. Listening attentively 2. Keeping communications brief 3. Approaching the client in a formal manner 4. Avoiding looking at the affected skin areas

1 Clients with chronic skin disorders may experience chronic low self-esteem because of the disorder itself and possible rejection by others. The nurse demonstrates acceptance of the client by using a quiet, unhurried manner and by using appropriate visual contact, facial expression, and therapeutic touch. Communications that seem brief and formal may reinforce the feelings of rejection, as may avoidance of looking at the affected skin areas.

The nurse in the postanesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring? 1. Frequent swallowing 2. Client complaints of discomfort 3. Ecchymosis around the client's eyes 4. Blood on the external nasal dressing

1 The client should be assessed for frequent swallowing, which may be the only sign of bleeding. Bleeding may not always be externally visible after rhinoplasty because blood may run down the back of the client's throat. The surgical procedure and the packing may be uncomfortable, so discomfort is expected and analgesics would be prescribed. The area around the client's eyes is expected to be edematous and ecchymotic, and ice compresses are applied. Some blood on the external nasal dressing is expected.

A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply. 1. Hepatitis 2. Infection 3. Hypertension 4. Muscle cramping 5. Post-treatment blood clots

1,2 Complications directly related to the access site for hemodialysis include hepatitis or infection as a result of poor infection control practices, as well as post-treatment blood loss from certain dialysis procedure practices and the removal of needles following the procedure. In addition, heparin is often given to prevent clotting of the access site; this can potentiate postdialysis bleeding. Hypotension from rapid removal of vascular volume can occur, as can muscle cramps from fluid shifting; however, these complications are not directly related to the access site.

The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy of a client's skin lesion. Which interventions should be included in the preprocedure plan of care? Select all that apply. 1. Obtain an informed consent. 2. Clean the area of the lesion with water. 3. Prepare to apply direct pressure to the biopsy site after the procedure. 4. Tell the client that a small piece of tissue will be removed for examination. 5. Teach the client about the need to cleanse the site post procedure with hydrogen peroxide and a topical corticosteroid every 4 hours.

1,3,4 The nurse would obtain an informed consent from the client because the procedure is invasive. The nurse would cleanse the biopsy site with an antibacterial solution (not water) before the biopsy. The client is informed that a small piece of tissue will be removed for examination. Direct pressure is applied to the area to stop bleeding after the procedure. In the postprocedure period, the client is usually directed to keep the site clean and dry; antibiotic ointment may be prescribed, but normally a topical corticosteroid is not necessary.

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. 1. Lesion is painful to touch. 2. Lesion is highly metastatic. 3. Lesion is a nevus that has changes in color. 4. Skin under the lesion is reddened and warm to touch. 5. Lesion occurs in body area exposed to outdoor sunlight.

2,3 Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions are most commonly found on the upper back and legs and on the soles and palms of persons with dark skin.

The nurse is providing home care instructions to a client after rhinoplasty. Which statement by the client indicates a need for further instruction? 1. "I should sleep on 2 pillows to elevate my head." 2. "I should avoid any activities such as bending over." 3. "I should be sure to run a dehumidifier in my home." 4. "I need to sneeze through the mouth and not blow through the nose."

3 After rhinoplasty, the client is taught to sleep on at least 2 pillows; this elevates the head and reduces edema. The client also is told to avoid any activities, such as bending over, that would increase intracranial pressure and cause nasal bleeding. A humidifier (not a dehumidifier) decreases the dry throat associated with mouth breathing. The client should be instructed to sneeze through the mouth and not blow through the nose.

A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint? 1. Anemia 2. Hypothyroidism 3. Diabetes mellitus 4. Chronic kidney disease

4 Clients with chronic kidney disease often have pruritus, or itchy skin. This is because of impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with diabetes mellitus are at risk for skin infections and skin breakdown.

Which information should the nurse include while providing education for a client scheduled for a rhinoplasty? 1. General anesthesia is always administered. 2. Packing will need to be removed in 1 week. 3. Incisions are made around the outside of the nose. 4. The nasal bone is fractured, and the cartilage and bone are remolded into the desired shape.

4 In a rhinoplasty procedure, the nasal bone is fractured, excess tissue is removed, and cartilage and bone are remolded into the desired shape. The client usually receives a local anesthetic in combination with intravenous sedation or general anesthesia. The packing is removed on the day after the surgery, and the splint remains in place for 1 week. Incisions are made inside the nose, so scars are not visible.

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of 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 to the skin, which is insensitive to touch

4. Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.

The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease? 1. It is caused by a tick bite. 2. It can be contagious by skin contact with an infected person. 3. It can be caused by the inhalation of spores from bird droppings. 4. It is caused by contamination from cat feces or the consumption of rare or raw meat.

1 Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from 1 person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused from the inhalation of cysts from contaminated cat feces or the consumption of rare or raw meat.

The nurse suspects herpes zoster (shingles) when which assessment finding is noted? 1. Clustered skin vesicles 2. A generalized body rash 3. Small blue-white spots with a red base 4. A fiery red, edematous rash on the cheeks

1 The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because the lesions follow nerve pathways, they do not cross the midline of the body. Options 2, 3, and 4 are incorrect descriptions of herpes zoster.

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? 1. Disorientation to time only 2. Heart rate of 95 beats/minute 3. +1 palpable peripheral pulses 4. Urine output of 30 mL over the past 2 hours

2 When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time.

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

2,3,5 The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 a.m. and 4 p.m. 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 cancerous or any precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

The nurse is performing an assessment on a client with a diagnosis of pemphigus vulgaris. How should the nurse assess for the presence of Nikolsky's sign? 1. Note a foul odor to the skin. 2. Look for blisters that are draining. 3. Look into the mouth for white patches. 4. Note skin blistering and sloughing with finger pressure.

4 Nikolsky's sign, epidermal blistering and sloughing precipitated by lateral finger pressure, commonly is present in pemphigus vulgaris. Option 3 identifies an assessment technique to determine the presence of a Candida infection in the mouth. Draining blisters are not characteristic of this disorder. Although a foul odor may be noted from the skin of a client with this disorder, this characteristic is not related to Nikolsky's sign.

The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder? 1. An athlete 2. An adolescent 3. An older client 4. A client who tans in an indoor tanning bed

4 Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme conditions can damage the skin, posing the highest risk for skin disorders. An athlete would be at low risk of developing an integumentary problem. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. An older client may be at a higher risk than a younger person.

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 1. The entire period of time during which rehabilitation occurs 2. The period from the time the client is stable to the time when all burns are covered with skin 3. The period from the time the burn was incurred to the time when the client is admitted to the hospital 4. The period from the time the burn was incurred to the time when the client is considered physiologically stable

4 The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society.

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? 1. Nerve damage 2. Hypertrophy of collagen fibers 3. Compromised circulation at the burn site 4. Increase in subcutaneous tissue at the burn site

2 Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve.

The nurse has provided home care instructions to a client after blepharoplasty. Which statement by the client indicates a need for further instruction? 1. "I need to keep ice on my eyes for at least 3 days." 2. "I need to avoid vigorous activities for about 1 month." 3. "I need to sleep on my back with at least 2 pillows under my head." 4. "I need to avoid activities requiring bending over at the waist for at least 48 hours."

1 Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Home care instructions after blepharoplasty include the administration of cool compresses for 24 (not 72) hours. Vigorous activities, such as sports, need to be avoided for 1 month. Because lying on the side increases the possibility of swelling in the dependent eye area, the client should sleep supine with at least 2 pillows to elevate the head. The client should understand the importance of not bending over at the waist for the first 48 hours after the procedure. Bending would increase pressure to the operative area.

The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? 1. Gastric lavage 2. Intravenous (IV) fluid therapy 3. Nothing by mouth (NPO) status 4. Preparation for laboratory studies

1 The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Positive patch test 2. Positive culture results 3. Abnormal biopsy results 4. Wood's light examination indicative of infection

2. With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

The nurse is providing skin care instructions to a female client with acne vulgaris. What should the nurse instruct the client to do? 1. Use oil-based cosmetics. 2. Vigorously rub her face when washing it. 3. Remove cosmetics from her face at bedtime. 4. Wash her face once daily with an astringent cleanser.

3 The client should be instructed to wash her face 2 or 3 times daily with a mild cleanser. Vigorous rubbing of the face is avoided, and cosmetics need to be removed from the face at bedtime. The client is instructed to use only water-based cosmetics and to avoid exposure to skin products that contain oils because products that are oily may cause skin flare-ups.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2. Bathroom privileges 3. Immobilization of the affected leg 4. Placing the affected leg in a dependent position

3. Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.

The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? 1. Brown-red macules with scales 2. Pustules on the trunk of the body 3. White patches noted on the elbows and knees 4. Multiple straight or wavy threadlike lines underneath the skin

4. Scabies can be identified by the multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.