Silvestri - Chapter 42 - Integumentary Problems of the Adult Client

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? a. an inflammation of the epidermis only b. a skin infection of the dermis and underlying hypodermis c. an acute superficial infection of the dermis and lymphatics d. an epidermal and lymphatic infection caused by Staphylococcus

b. a skin infection of the dermis and underlying hypodermis 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, edmatous, 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.

A client returns tot he clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed a week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. a. lesion is painful to touch b. lesion is highly metastatic c. lesion is a nevus that has changes in color d. skin under the lesion is reddened and warm to touch e. lesion occurs in body areas exposed to outdoor sunlight

b. lesion is highly metastatic c. lesion is a nevus that has changes in color 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 may occur any place on the body, especially where birthmarks or new moles are apparent.

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) int he 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? a. positive patch test b. positive culture results c. abnormal biopsy results d. Wood's light examination indicative of infection

b. positive culture results 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 that administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of the tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

A client calls the emergency department and tells the nurse that he cam 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? a. "come to the emergency department" b. "apply calamine lotion immediately to the exposed skin areas" c. "take a shower immediately lathering and rinsing several times" d. "it is not necessary to do anything if you cannot see anything on your skin"

c. "take a shower immediately lathering and rinsing several times" 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 posison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis deveops. The client does not need to be seen in the ED at this time.

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a patient with herpes zoster? Select all that apply a. the nurse who never had roseola b. the nurse who never had mumps c. the nurse who never had chicken pox d. the nurse who never had German measles e. the nurse who never received the varicella-zoster vaccine

c. the nurse who never had chicken pox e. the nurse who never received the varicella-zoster vaccine The nurses who have not had chickenpox or did not receive the varicella zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the causitive virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus or who did not receive the varicella zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.

When assessing a lesion diagnosed as a basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply a. an irregularly shaped lesion b. a small papule with a dry, rough scale c. a firm nodular lesion topped with crust d. a pearly papule with a central crater and a waxy border e. location in the bald spot atop the head that is exposed to outdoor sunlight

d. a pearly papule with a central crater and a waxy border e. location in the bald spot atop the head that is exposed to outdoor sunlight 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 red-, white-, or blue-toned color. Actinic karatosis, a pre-malignant 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.

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would he nurse note on assessment of the client's hand? a. a pink, edematous hand b. fiery red skin with edema in the nailbeds c. black fingertips surrounded by an erythematous rash d. a white color to the skin, which is insensitive to touch

d. a white color to the skin, which is insensitive to touch Assessment findings in frostbite include a white or blue 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.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention int he event of this occurrence is which action? a. immobilize the affected extremity b. remove jewelry and constricting clothing from the victim c. place the extremity in a position so that it is below the level of the heart d. move the victim to a safe area away from the snake and encourage the victim to rest.

d. move the victim to a safe area away from the snake and encourage the victim to rest. Rationale In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. Te victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may spread the absorption of the venom. The victim should be transported to an emergency facility as soon as possible

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? a. intact skin b. full-thickness skin loss c. exposed bone, tendon, or muscle d. partial-thickness skin loss of the dermis

d. partial-thickness skin loss of the dermis In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulceration 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 1. Full thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV

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 manifestation of psoriasis? Select all that apply a. presence of striae b. palpable radial pulses c. absence of any ecchymosis on the extremities d. thinner and decrease in number of reddish papules e. scarce amount of silvery-white scaly patches on the arms

d. thinner and decrease in number of reddish papules e. scarce amount of silvery-white scaly patches on the arms 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.