saunders musckleskeletal and integument

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 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 primary health care provider.

3

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Eschar2Intact blisters3Liquefaction necrosis4Cherry-red, firm tissue

3

A client with a burn injury has undergone fasciotomy to treat compartment syndrome of the leg. The nurse would anticipate that which type of wound care to the fasciotomy site will be prescribed? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1Dry sterile dressings2Hydrocolloid dressings3Moist sterile saline dressings4One-half strength povidone-iodine dressings

3

A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1Sprained left ankle2Decreased calcium intake3Open trauma to the left leg4Starting to smoke cigarettes

3

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? Answer Options 1 18% 2 24% 3 36% 4 48%

3

A client with severe psoriasis has a problem of chronic low self-esteem. The nurse would incorporate which nursing action when working with this client? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Listening attentively2Keeping communications brief3Approaching the client in a formal manner4Avoiding looking at the affected skin areas

1

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 primary health care provider's prescriptions and would plan to question which prescription? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Gastric lavage2Intravenous (IV) fluid therapy3Nothing by mouth (NPO) status4Preparation for laboratory studies

1

The home care nurse is providing instructions to a client with a musculoskeletal injury regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How would the nurse accurately demonstrate this technique? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Crutches and the affected leg down, followed by the unaffected leg2Crutches and the unaffected leg down, followed by the affected leg3Unaffected leg down first, followed by the crutches and the affected leg4Affected leg down first, followed by the crutches and the unaffected leg

1

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? Answer Options 1The need for sensory stimulation2The amount of home care support available3The ability to perform activities of daily living4The type of transportation available for follow-up care

1

The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Applying warm compresses to the affected area2Placing iced compresses to the affected area every 4 hours3Alternating the application of hot and iced compresses every 2 hours4Placing antibiotic ointment on the affected site followed by continuous heat lamp application

1

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual limb and expects to note which finding? Answer Options 1Pink color to the skin flap2Hot feeling on palpation of the skin flap3Serous fluid leaking from the skin flap incision4Absent pulse at the proximal pulse point site closest to the skin flap

1

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Clustered skin vesicles2A generalized body rash3Small blue-white spots with a red base4A fiery-red edematous rash on the cheeks

1

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? Answer Options 1Return of distal pulses2Brisk bleeding from the site3Decreasing edema formation4Formation of granulation tissue

1

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

1

The nurse provides discharge instructions to a client after skin patch testing to assess for allergies. Which instruction would be included on the discharge sheet for the client? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Keep the test sites dry.2All activities can be continued.3Reapply the patch if it comes off.4Return to the clinic in 2 weeks for the initial reading.

1

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. Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Reposition every 2 hours.2Use a bed cradle as indicated.3Apply protective pads to heels and elbows.4Add a small amount of alcohol to the daily bath water.5Provide perineal care every 8 hours and after incontinence

1235

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 would be classified as which type? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Superficial2Full-thickness3Deep partial-thickness4Partial-thickness superficial

2

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? Answer Options 1An inflammation of the epidermis only2A skin infection of the dermis and underlying hypodermis3An acute superficial infection of the dermis and lymphatics4An epidermal and lymphatic infection caused by Staphylococcus

2

A client is diagnosed with a full-thickness burn. What would the nurse anticipate will be used for final coverage of the client's burn wound? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Biobrane2Autograft3Xenograft4Homograft

2

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1White color2Pink or red color3Weeping blisters4Insensitivity to pain and cold

2

Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the primary health care provider has prescribed which laboratory study? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1Platelet count2Alkaline phosphatase3White blood cell count4Complete blood cell count

2

The home care nurse has instructed a client with a ligament injury to the knee how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1The client moves both crutches forward and then swings both feet forward to the crutches.2The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward.3The client moves the right crutch forward, along with the left foot, and then brings the right foot and the left crutch forward.4The client moves the left crutch forward, along with the right foot, and then brings the left foot and the right crutch forward.

2

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Pillow2Foam pad3Folded blankets4Plastic-lined absorbent pad

2

The nurse has applied a hypothermia blanket to a client with an infection who has a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Frostbite2Skin breakdown3Venous insufficiency4Arterial insufficiency

2

The nurse has been working with a client diagnosed with candidiasis (thrush). What would the nurse assess for in this client? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1The presence of blisters2The presence of white patches3The presence of purple patches4The presence of numerous small red pinpoint lesions

2

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that they would report which early symptom of compartment syndrome? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Cold, bluish-colored fingers2Numbness and tingling in the fingers3Pain that increases when the arm is dependent4Pain that is out of proportion to the severity of the fracture

2

The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse would inquire about the last time the client had which done? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1Tuberculin test2Tetanus vaccine3Chest radiograph4Physical examination

2

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? Answer Options Your Answers:1Vital signs2Urine output3Mental status4Peripheral pulses

2

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and would include which action in the plan? Answer Options 1Ensure that the knots are at the pulleys .2Check the weights to ensure that they are off the floor 3Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4Monitor the weights to ensure that they are resting on a firm surface.

2

The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings would be listed in the care plan as a sign/symptom of fat embolism? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1Fever and chills2Dyspnea and chest pain3External rotation of the right leg4Pallor, paresthesia, and pulselessness of the right lower leg

2

The nurse is creating a plan of care for a client in skin traction. The nurse would monitor for which priority finding in this client? Answer Options 1Urinary incontinence2Signs of skin breakdown3The presence of bowel sounds4Signs of infection around the pin sites

2

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1Nerve damage2Hypertrophy of collagen fibers3Compromised circulation at the burn site4Increase in subcutaneous tissue at the burn site

2

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

2

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA? Answer Options 1Anemia2Anorexia3Amenorrhea4Night sweats

2

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 would the nurse recommend for the client to alleviate this discomfort? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Run a dehumidifier in the home.2Apply astringents to the skin twice daily.3Apply emollients to the skin after bathing.4Take baths twice daily using a dilute solution of alcohol and water.

3

The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings would the nurse identify as early signs of possible fat embolism? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Decreased heart rate and increased restlessness2Decreased heart rate and decreased respiratory rate3Increased heart rate and adventitious breath sounds4Increased heart rate and increased oxygen saturation

3

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? Answer Options 1Out-of-bed activities2Bathroom privileges3Immobilization of the affected leg4Placing the affected leg in a dependent position

3

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? Answer Options 1Apply restraints to the client.2Ask the family to stay with the client.3Place a clock and calendar in the client's room.4Ask the laboratory to perform electrolyte studies.

3

The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information would the nurse include in the teaching? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1"A bone fragment has injured the nerve supply in the area."2"An injured artery caused impaired arterial perfusion through the compartment."3"Bleeding and swelling caused increased pressure in an area that couldn't expand."4"The fascia expanded with injury, causing pressure on underlying nerves and muscles."

3

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse would suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1Capillary refill less than 3 seconds2Pulses present and with swollen, pink fingers3Client report of severe, deep, unrelenting pain4Client report of pain as nurse assesses finger movement5Client report of numbness and tingling sensation in the fingers

345

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? Answer Options 1A pink edematous hand2Fiery red skin with edema in the nail beds3Black fingertips surrounded by an erythematous rash4A white color to the skin, which is insensitive to touch

4

A client has sustained a superficial skin tear to the arm. The nurse would plan to apply which dressing as the best type of bandage for this wound? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Dry sterile dressing2Wet to dry dressing3Gelfoam sponge dressing4Semipermeable film dressing

4

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 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

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

4

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

4

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Allow the client to have full liquids.2Give the client small glasses of clear liquids.3Order the client a full meal tray with extra liquids.4Keep the client on NPO (nothing by mouth) status.

4

A fluorescent antinuclear antibody titer (FANA) is performed in a client suspected of having rheumatoid arthritis (RA). Which laboratory value is most consistent with RA? Answer Options 10:520:831:541:20

4

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 would the nurse expect to note if scabies is present? Answer Options 1Brown-red macules with scales2Pustules on the trunk of the body3White patches noted on the elbows and knees4Multiple straight or wavy thread-like lines underneath the skin

4

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? Answer Options Your Answers:1Intact skin2Full-thickness skin loss3Exposed bone, tendon, or muscle4Partial-thickness skin loss of the dermis

4

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1"I need to use tepid water for bathing."2"I need to keep my skin lubricated and cool."3"After bathing, I would pat my skin dry rather than rubbing it."4"I would apply a lubricant to my skin after bathing when my skin is thoroughly dry."

4

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? Answer Options 1Decreased heart rate2Increased urinary output3Increased blood pressure4Elevated hematocrit levels

4

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. The nurse plans care understanding that which is the most appropriate time frame for the emergent phase? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1The entire period of time during which rehabilitation occurs2The period from the time the client is stable to the time when all burns are covered with skin3The period from the time the burn was incurred to the time when the client is admitted to the hospital4The period from the time the burn was incurred to the time when the client is considered physiologically stable

4

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Elevate the casted leg.2Contact the primary health care provider.3Administer another dose of pain medication.4Check the neurovascular status of the toes on the casted leg

4

The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1The client's mobility status2The renal and endocrine systems3The cardiovascular and renal systems4The neurological and respiratory systems

4

The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture would be included by the nurse in the client's education? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Simple fracture2Greenstick fracture3Compound fracture4Comminuted fracture

4

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? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1An athlete2An adolescent3An older client4A client who tans in an indoor tanning bed

4

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options Your Answers:1A 25-year-old woman who runs2A 36-year-old man who has asthma3A 70-year-old man who consumes excess alcohol4A sedentary 65-year-old woman who smokes cigarettes

4

The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse would perform which action? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 1Assess the client's cognitive level.2Assess the temperature of the cast.3Monitor for the presence of drainage or odors on or beneath the cast.4Assess capillary refill, temperature, color, and amount of pain in the right hand.

4

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

4

The nurse provides home care instructions to a client diagnosed with impetigo. Which statement by the client indicates the need for further instruction? Rationale, Strategy, Tip Rationale Strategy Reference Labs Answer Options 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 need to 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 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. Answer Options 1Presence of striae2Palpable radial pulses3Absence of any ecchymosis on the extremities4Thinner and decrease in number of reddish papules5Scarce amount of silvery-white scaly patches on the arms

4,5

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. Answer Options 1An irregularly shaped lesion2A small papule with a dry, rough scale3A firm, nodular lesion topped with crust4A pearly papule with a central crater and a waxy border5Location in the bald spot atop the head that is exposed to outdoor sunlight

4,5

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?

54%