Saunder NCLEX 7th ed: Ch 39-40: Integumentary System & Medications

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

"I need to avoid sun exposure before 10 A.M. and after 4:00 P.M." *The client should be instructed to avoid sun exposure between the hours of approximately 10:00 AM and 4:00 PM. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible or precancerous lesions

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? A. "The medication is an antibacterial." B. "The medication will help heal the burn." C. "The medication is likely to cause stinging initially." D. "The medication should applied directly to the wound."

"The medication is likely to cause stinging initially." *Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? (select all that apply) A. Back B. Axilla C. Eyelids D. Soles of the feet E. Palms of the hands

1. Back 2. Soles of the feet 3. Palms of the hands *Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to preven systemic absorption

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? (select all that apply) A. metastasis is rare B. It is encapsulated C. It is highly metastasic D. It is characterized by local invasion E. Lesion is a nevus that has changed in color

1. It is highly metastasic 2. Lesion is a nevus that has changed in color *Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. The skin cancer is highly metastic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? (select all that apply) A. Lesion has a waxy border B. An irregularly shaped lesion C. Papule, with a red, central crater D. A small papule with a dry, rough scale E. A firm nodular lesion topped with a crust

1. Lesion has a waxy border 2. An irregularly shaped lesion *Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a white, or blue color. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale

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

1. Use sunscreen when participating in outdoor activities 2. Wear a hat, opaque clothing, and sunglasses when in the sun 3. Examine your body monthly for any lesions that may be suspicious *The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 AM and 4 PM. 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 precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating otherwise, the duration of protection is reduced

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

100% oxygen via a tight-fitting, nonrebreather face mask *If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined

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

36% *According to the rule of 9s, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the posterior torso, which equals 9%. This totals 36%

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

A white color of the skin which is sensitive to touch *The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? A. A staff member who has never had roseola B. A staff member who has never had mumps C. An unlicensed assistive personnel who has never had chickenpox D. An unlicensed assistive personnel who has never had german measles

An unlicensed assistive personnel who has never had chickenpox *Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? A. Immediately before swimming B. 5 minutes before exposure to the sun C. Immediately before exposure to the sun D. At least 30 minutes before exposure to the sun

At least 30 minutes before exposure to the sun *Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? A. A dependent position B. Elevation of the knees C. Flat, without elevation D. Elevation above the level of the heart

Elevation above the level of the heart *Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation

The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client knowing that which indicates the occurrence of a systemic effect? A. Hyperventilation B. Elevated blood pressure C. Local rash at the burn site D. Local pain at the burn site

Hyperventilation *Mafenifide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatement should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Elevated Blood pressure and local pain at the burn site describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with the used of this medication? A. Itching B. Euphoria C. Drowsiness D. Frequent urination

Itching *Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? A. Positive patch test B. Positive culture results C. Abnormal biopsy results D. Wood's light examination indicative of infection

Positive culture results *With the classic presentation of herpes zoster, the clinical examination is diagnositc. 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 allergens. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under UV light to identify superficial infections of the skin (fungal infections)

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

Silvery-white scaly lesions *Psoriatic patches are covered with silvery white scales. There is no patchy hair or round, red macules with scales. There is not patchy hair loss or round, red macules with scales. The skin is dry and there is no presence of wheal patches scattered about the trunk

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expecting sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make? A. The client is hypotensive B. Pain is present from the burn injury C. The burn has probable caused laryngeal edema, which has occluded the airway D. The client is afraid and is having a panic attack as a result of the unfamiliar surroundings

The burn has probable caused laryngeal edema, which has occluded the airway *The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? A. The return of distal pulses B. Decreasing edema formation C. Brisk bleeding from the injury site D. The formation of granulation tissue

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

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? A. Tinnitus B. Diarrhea C. Constipation D. Decreased respirations

Tinnitus *Salicylic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed A. Potassium level B. Triglyceride level C. Hemoglobin A1C D. Total cholesterol level

Triglyceride level *Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measures before treatment and periodically thereafter until the effect on triglycerides has been evaluated. there is no indication that isotretinoin affects potassium, hemoglobin A1, C, or total cholesterol levels

A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contract the PHCP if the client is also taking which medication? A. Digoxin B. Phenytoin C. Vitamin A D. Furosemide

Vitamin A *Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxcity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? A. Wear gloves only B. Wear a mask and gloves C. Wear a gown and gloves D. Avoid touching the client's clothes

Wear a gown and gloves *The CDC recommends the wearing of gowns and glvoes when in close contact with a person who has MRSA. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. MRSA is contagious and is spread to others by direct contact with infected skin or infected articles

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurses? A. Glucose level of 99 mg/dL B. Platelet level of 300,000 mm3 C. Magnesium level of 1.5 mEq/L D. White blood cell count of 3000 mm3

White blood cell count of 3000 mm3 *Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and instititial nephritis. The nurse should a complete blood count, particularly the white blood cells, frequently fot the client taking this medication. If leukopenia develops, the PHCP is notified and the medication is usually discontinued. The white blood cell count noted is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits

The evening nurse reviews the nursing documentation in the client chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area? A. intact skin B. the presence of tunneling C. a deep, crater-like appearance D. partial-thickness skin loss of the epidermis

partial-thickness skin loss of the epidermis *With a stage 2 pressure injury, the skin is not intact. There is a partial-thickness skin loss of the epidermis or dermis. The other is superficial and it may look like an abrasian, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3 and tunneling develops during stage 4

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fliuid resuscitation? A. vital signs B. urine output C. mental status D. peripheral pulses

urine output *Successful or adequate fluid resuscitation in the adult is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and a clea sensorium. The most reliable indicator for determining the adequacy of fluid rescuscitation is the urine output. For an adult, the hourly urine volume should be 30 mL to 50 mL