quizlet foe med surg exam 3 prep us

The school nurse is approached by a teenage student. The student says that she learned in science class that the outer layer of the skin is dead cells. The student wants to know which of her cells is going to die so they can be covered with skin. What would be the nurse's best response?

"All cells die and the body replaces most of them. The cells thought to form the barrier of the outer layer of the skin are called keratin cells."

The nurse is doing a shift assessment on several patients after first taking report. An elderly patient is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new reddened rash on the patient's chest. The patient should be asked what priority question regarding the presence of a reddened rash?

"Are you allergic to any food or medication?"

A middle-aged female patient has sought care because she has itchy, reddened areas on the backs of both of her hands and most of her fingers. On closer inspection, the nurse notes several cracks in the skin on these regions and observes that the patient's skin is exceptionally dry. What question should the nurse prioritize during this patient's assessment?

"When did you first begin having this problem?"

Which layer of the skin is made of primarily adipose tissue?

Hypodermis

Production of melanin is controlled by a hormone secreted by which gland?

Hypothalamus

The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as?

Keloid

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Lichenification

While reviewing an older adult's medical record, the nurse notes that the patient has solar lentigo. he nurse interprets this as which of the following?

Liver spots

Which factor causes wrinkles among older adults?

Loss of subcutaneous tissue

The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do?

Make sure that the room is darkened.

The nurse notes several very small, round, red and purple macules on a patient's skin. The patient has a history of anticoagulant use. The nurse records this finding as which of the following?

Petechiae

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when picked off. What does the nurse suspect that this patient may have?

Psoriasis

The nurse is assessing the periwound skin of an African American client for inflammation. The nurse determines that inflammation is present when which characteristic is noted?

Purple-gray cast

When assessing a patient with risk factors related to human immunodeficiency virus (HIV), what does the nurse know can be the first manifestation of the disease?

Purplish cutaneous lesions

A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as:

Pus-filled vesicles; circumscribed and elevated masses >0.5 cm.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn?

Serum sodium level of 140 mEq/L

The nurse is preparing a teaching tool on the functions of the skin. Which information about the skin will the nurse include on this tool? Select all that apply.

Serves as a sensory organ Aids in maintaining fluid balance Helps regulate body temperature Protects the body from microorganisms

Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion?

Spider angioma

When describing the functions of the skin to a group of nursing students, which skin layer would the instructor include as having the capacity to absorb water?

Stratum corneum

The epidermis consists of four layers as listed below. Place the layers in the proper order from outermost to innermost.

Stratum corneum Stratum lucidum Stratum granulosum Stratum germinativum

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?

Sulfadiazine, silver (Silvadene)

Which of the following diagnostics is used to examine cells from herpes zoster?

Tzanck smear

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?

Vesicles

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin?

Vitiligo

While assessing a patient at the clinic the nurse notes patchy, milky white spots. The nurse knows that this finding is:

Vitiligo

Nursing students are reviewing information about primary and secondary lesions. The students demonstrate understanding of the information when they identify which of the following as a primary lesion?

Wheal

The nurse documenting an acute open wound should include which characteristic(s)? Select all that apply.

Wound size Periwound skin Wound bed

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of

anemia.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

beaus line

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?

bronze

The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?

conduction

bruise

ecchymosis

A nurse is preparing a presentation for a group of high school athletes about temperature regulation during activity such as practice. When describing the mechanisms of heat loss, which of the following would the nurse identify as primarily responsible when environmental temperatures are very high?

evaporation

The nurse is reviewing data collected during the assessment of a client. Which finding about the client's skin condition is genetically based?

ezxma

The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as

fissure.

lentigines

freckles

A client has been diagnosed with liver disease. The nurse would expect which skin variation?

jaundice

The nurse is assessing an African American client and notes a streak of pigmentation in the client's fingernails. The nurse determines that this finding indicates

normal variation.

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as

petechiae.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

scale

Sudoriferous

sweat

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?

vesicle

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?

2,400 mL

The nurse has administered a subcutaneous injection of low-molecular-weight heparin to a patient who is recovering from surgery. This injection will be primarily deposited into:

Adipose tissue

A teenage boy has been brought by ambulance to the emergency department from a house fire in which he has suffered extensive injuries. In addition to burns, early blood tests reveal carbon monoxide poisoning. This assessment finding will be treated by what intervention?

Administration of 100% oxygen

The nurse assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing?

Carbon monoxide poisoning

A nurse on assesses a client with dark skin and notes new purple-gray cast to the skin on the chest, back, and arms. Which priority nursing intervention should the nurse implement?

Check the client's oral temperature.

Which type of heat loss is caused by a cool breeze that blows across the body surface?

Convection

A nurse's assessment of a newly admitted patient is remarkable for an area of erythema on the patient's upper thigh. The nurse is aware that erythema is the physiological result of:

Dilation and congestion of capillaries