Chapter 60: Assessment of Integumentary Function, Chapter 61, Burns Ch.62 E2, Burns

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?

"Have you been eating a large amount of carotene-rich foods?"

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required? "I will not hold my infant while drinking coffee." "I will heat my infant's formula in the microwave." "I will set my water heater to 49° C (120° F)."hot "I will keep loose appliance cords tied up on the counter."

"I will heat my infant's formula in the microwave. Rationale: Infant formula should never be heated in the microwave; the formula may heat at different temperatures and can burn the infant's mouth. Plastic bottle liners may also burst with the heat. Setting your hot water heater a couple of degrees cooler will help keep hot water in the house cooler (recommended since 1974 by the Consumer Product Safety Commission). Small children are at risk for scald injury from hot tap water due to their decreased reaction time, their curiosity, and the thermal sensitivity of their skin. Avoiding holding infants while drinking coffee can prevent possible spills onto children. Keeping cords tied up on the counter prevents children from pulling on dangling cords and spilling hot liquids over themselves.

The nurse is caring for a client diagnosed with herpes zoster. Which statement by the client needs further clarification by the nurse? "Herpes zoster is a reactivation of the varicella virus." "Even though this is from a childhood disease, I am still contagious." "Once I get the infection, I cannot get it again." "Herpes zoster is caused by a viral infection."

"Once I get the infection, I cannot get it again." Explanation: The nurse is correct to clarify that even though the client has herpes zoster, the client can get herpes zoster again. The virus is contagious and can reoccur. All of the other options are correct.

The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client isn't reporting of more pain. Which of the following is the best response by the nurse?

"The severe burns have damaged nerves that sense pain." Rationale: Full-thickness burns damage nerve endings and initially may feel somewhat painless. Regeneration of the nerve endings in recovery may cause significant pain. Confusion, adequate pain medication, and burns that are not deep enough would not be the most likely explanation of the client's lack of reports of pain.

A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply. a) "This medication is an antibacterial." b) "This medication will stain my skin permanently." c) "This medication will help my burn heal." d) "This medication will be applied directly to the wound."

"This medication is an antibacterial." • "This medication will help my burn heal." • "This medication will be applied directly to the wound." Correct Explanation: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the patient's skin, but it will help heal the patient's burned areas.

When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA? a) 3 b) .5 c) 4 d) 2

.5 Explanation: In patients with scattered burns, or for a quick prehospital assessment, the palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 0.5% of the TBSA

When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)? a) 2 b) 4 c) 1 d) 3

1 Correct Explanation: In patients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 1% of the TBSA.

When a patient has been diagnosed with scabies, if the infection has spread, family members may complain of pruritus within which time frame? 1 month 2 weeks 3 weeks 6 weeks

1 month Explanation: If the infection has spread, other members of the family and close friends also complain of pruritus about 1 month later.

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? a) 8 weeks b) 1 week c) 6 weeks d) 2 to 4 weeks

2 to 4 weeks Correct Explanation: For deep partial-thickness burn injuries, recovery is expected in 2 to 4 weeks.

A patient has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? a) Within 12 hours after surgery b) As soon as sanguineous drainage is noted c) 2 to 5 days after surgery d) Within 24 hours after surgery

2 to 5 days after surgery Explanation: The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump? Record your answer as a whole number.

250mL *RATIONALE: *2,000 mL ÷ 8 hours = 250 mL/hour

The nurse administers 1500 ml of Lactated Ringers over six hours to a 12-year-old child with partial and full thickness burns over 40% of his body. How many milliliters per hour should this child receive? Record your answer using a whole number.

250mL Rationale: 1500/6=250

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 18% 9% 36% 27%

27% Rationale: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body

A client has received burns to the anterior and posterior lower extremities. In order to calculate the expected amount of fluid resuscitation, the nurse calculates the client's percentage of body area burned as what percent? Record your answer using a whole number

36 Rationale: Using the Rule of Nines, the clients surface area that has been burned is calculated as 9% for the anterior surface of the left leg, 9% for the posterior surface of the left leg, 9% for the anterior surface of the right leg, and 9% for the posterior surface of the right leg = 9% X 4 or 36%

A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following? a) 9% b) 36% c) 18% d) 27%

36% (questionable) Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%).

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

36. Rationale: The anterior and posterior portions of one leg are 18%, if both legs are burned, the total is 36

Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?

5 days

A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination can be used to determine if the rash is a fungal rash using ultraviolet light?

A Wood's light examination

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care? a. Initiating an antibiotic within 3 hours of the injury. b. Infusion of dextrose and water at 50 mL per hour to avoid overload of the circulatory system. c.A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. c.Monitoring urine output once a shift

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. Rationale: A client with electrical burns based on energy and potential damage to the heart needs cardiac monitoring. Dextrose is not useful for fluid volume expansion and infection would occur much later. Urine output needs hourly monitoring based on myoglobin release.

Which assessment finding indicates an increased risk of skin cancer? A dark mole on the client's back An irregular scar on the client's abdomen A deep sunburn White irregular patches on the client's arm

A deep sunburn Explanation: A deep sunburn is a risk factor for skin cancer. A dark mole or an irregular scar is a benign finding. White irregular patches are abnormal but aren't a risk for skin cancer.

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? An electrocardiogram (ECG) showing no arrhythmias. A weight gain of 4 lb (2 kg) in 24 hours. Body temperature readings all within normal limits. A urine output consistently above 40 ml/hour (40 mL/hour).

A urine output consistently above 40 ml/hour (40 mL/hour. Rationale: n a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb (70 kg) client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb (2 kg) weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath?

Administer an analgesic. Rationale: Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour before hand

The nurse is caring for a patient with extensive bullous lesions on the trunk and back. Prior to initiating skin care, what is a priority for the nurse to do? Wash the lesions vigorously. Rupture the bullous lesions. Administer analgesic pain medication. Apply cold compresses.

Administer analgesic pain medication. Explanation: The patient with painful and extensive lesions should be premedicated with analgesic agents before skin care is initiated.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated?

Administer pain medication 30 minutes before therapy to help manage pain. Rationale: Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from open wounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy unless it is an individualized need for a given client. Topical antibiotics are applied after hydrotherapy

Following a burn injury, which of the following areas is the priority for nursing assessment? a) Pulmonary system b) Cardiovascular system c) Nutrition d) Pain

Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

What body structures have keratin as part of their composition? nails hair skin all options are correct

All options are correct.

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Select the graft described as the following: a biologic source of skin similar to that of the client. a) Autograft b) Allograft c) Xenograft d) Slit graft

Allograft Explanation: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

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

Anemia

Which of the following measures can be used to cool a burn? a) Using cold soaks or dressings for at least 1 hour b) Application of cool water c) Wrapping the person in ice d) Application of ice directly to burn

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

A patient is brought to the ED by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse will complete which of the following interventions first? a) Take the patient's vital signs. b) Obtain a 12-lead ECG. c) Insert a urinary Foley catheter. d) Apply a cervical collar on the patient.

Apply a cervical collar on the patient. Correct Explanation: Until it is known that the patient has no fractures, it is imperative that a neck collar be applied and remain in place and that the patient is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.

The nurse documents the skin color change of a dark-skinned African American patient in cardiogenic shock as:

Ashen gray and dull.

A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which of the following actions action should the nurse take? Assess the client's blood pressure. Assess oxygen saturation using pulse oximetry. Administer lorazepam 4 mg IV. Administer morphine sulfate 2 mg IV

Assess oxygen saturation using pulse oximetry. Rationale: Confusion, anxiety, restlessness, and disorientation are signs of hypoxemia. Due to the recent fire and burn injuries, the client may have suffered an inhalation injury that could be causing hypoxia. Administration of medication may be indicated once hypoxemia or other medical causes are ruled out.

Which of the following uses the body's own digestive enzymes to break down necrotic tissues? Autolytic debridement Enzymatic debridement Wet to dry dressings Wet dressings

Autolytic debridement Explanation: Autolytic debridement is a process that uses the body's own digestive enzymes to break down necrotic tissue. Application of enzymatic debriding agents speeds the rate at which necrotic tissues is removed. A form of mechanical debridement is a wet to dry dressing, which removes necrotic tissue and absorbs small to large amounts of exudates.

The nurse caring for a client with repeated episodes of contact dermatitis is providing instruction to prevent future episodes. Which information should the nurse include? Avoid cosmetics with fragrance. Wash skin in very hot water. Use a fabric softener. Wear gloves during the day.

Avoid cosmetics with fragrance. Explanation: The nurse should teach the client to avoid cosmetics, soaps, and laundry detergents that contain fragrance. Other prevention methods include avoidance of heat and fabric softeners. Gloves used for cleaning and washing dishes should be worn to no longer than 15 to 20 minutes/day, and cotton-lined gloves should be used.

When teaching the diabetic client about foot care, what should the nurse instruct the client to do?

Avoid going barefoot. Rationale: The client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and decreased circulation. The client should be taught to avoid going barefoot to prevent injury. Shoes that do not fit properly should not be worn because they will cause blisters that can become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A heating pad should not be used because of the risk of burns due to insensitivity to temperature.

A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern? a) K+: 5.0 mEq/L b) BUN: 28 mg/dL c) Na+: 145 mEq/L d) Ca: 9 mg/dL

BUN: 28 mg/dL Correct Explanation: The elevated BUN would case the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, which is associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

Students are reviewing the cycle of hair growth in people, identifying that rate of hair growth varies on different parts of the body. The students demonstrate understanding of this information when they identify which area as having the most rapid rate?

Beard

A patient has developed a boil on the face and the nurse observes the patient squeezing the boil. What does the nurse understand is a potential severe complication of this manipulation? Scarring Brain abscess Erythema Cellulitis

Brain abscess Explanation: Nurses must take special precautions in caring for boils on the face because the skin area drains directly into the cranial venous sinuses. Sinus thrombosis with fatal pyemia can develop after manipulating a boil in this location. The infection can travel through the sinus tract and penetrate the brain cavity, causing a brain abscess.

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

Bronze

Burns Chapt. 62 PrepU

Burns Chapt. 62 PrepU

Which of the following complications is common for victims of electrical burns? a) Inhalation injury b) Infection c) Hypovolemic shock d) Cardiac dysrhythmia

Cardiac dysrhythmia Correct Explanation: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

A nurse is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. What should the nurse do to provide wound care? Remove the dressing and leave the incision open to air. Remove the drain if wound drainage is minimal. Clean the area around the drain moving away from the drain. Gently irrigate the drain to remove exudate.

Clean the area around the drain moving away from the drain. Rationale: The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

The nurse recommends which type of therapeutic bath for its antipruritic action? Sodium bicarbonate (baking soda) Colloidal (oatmeal) Water Saline

Colloidal (oatmeal) Explanation: Colloidal oatmeal baths are recommended to decrease itching associated with a dermatologic disorder such as psoriasis. Baking soda baths are cooling but dangerous because the tub gets very slippery and a bath mat must be used in the tub. Water and saline baths have the same effect as wet dressings and are not known to counteract itching.

During the recuperation phase, a client with severe burns has become withdrawn. What concerns should the nurse explore? Concerns regarding how the client's family will respond Concerns regarding dependence and unwillingness to be discharged Concerns regarding coping abilities. Concerns about body image and self esteem

Concerns about body image and self esteem. Rationale: During the recuperation phase, the client is likely to consider the body image implications of this injury. Sensitivity to body image and self-esteem issues are anticipated concerns. The client has suffered through the most difficult part. There are fewer concerns regarding dependence and coping abilities in the recuperation phase. The family will have been more concerned during the initial phase.

The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?

Conduction

When assessing pallor, the nurse understands that it is best observed on which of the following areas?

Conjunctivae

While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next? Notify the physician that the wound may be infected. Continue to monitor the suture line, and document findings. Apply normal saline solution to keep the wound moist. Prepare the client for debridement of the suture line.

Continue to monitor the suture line, and document findings Rationale: During the fibrinoplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This normal occurrence requires the nurse to continue to monitor the suture line. There is no evidence of wound dehiscence or necrotic tissue. There is also no indication that the wound is open or needs to be kept mois

The nurse is conducting an admission history and physical examination of a client with a history of contact dermatitis. The nurse assesses whether the client uses which medication classification? Corticosteroids Saline irrigations Antifungals Antivirals

Corticosteroids Explanation: Corticosteroids are used for contact dermatitis. Antifungals, antivirals, and saline irrigations are not used in the treatment of contact dermatitis.

Which of the following aggravates the condition caused by acne vulgaris? Sunlight Chocolates High-fat diet Cosmetics

Cosmetics Explanation: Acne vulgaris is aggravated by cosmetics. Any correlation with specific food items such as chocolate is more myth than fact. Sunlight does not aggravate the condition caused by acne vulgaris.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first? Have all visitors and family leave the room. Call the surgeon to come to the client's room immediately. Cover the abdominal organs with sterile dressings moistened with sterile normal saline. Press the emergency alarm to call the resuscitation team

Cover the abdominal organs with sterile dressings moistened with sterile normal saline. Rationale: When a wound eviscerates (abdominal organs protruding through the opened incision), the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. The nurse should not press the emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the visitors and family leave the room to decrease the chance of airborne contamination, but the primary focus should be on covering the wound with a moist, sterile covering.

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order? Culture. Irrigation. Debridement Incision and drainage

Debridement Rationale: Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture indentifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation — usually with an antibiotic solution — to treat the infection and clean the wound.

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to promote which of the following? a) Increased metabolic rate b) Increased skeletal muscle breakdown c) Decreased catabolism d) Increased glucose demands

Decreased catabolism Correct Explanation: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Full thickness b) Deep partial thickness c) Superficial partial thickness d) Superficial

Deep partial thickness Explanation: A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis? a) Fourth degree b) Full-thickness c) Deep partial-thickness d) Superficial partial-thickness

Deep partial-thickness Correct Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns? a) Protein cell coagulation b) All options are correct. c) Continuing inflammatory process d) Deep tissue cooling

Deep tissue cooling Explanation: Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.

The nurse is caring for an eight-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? Applying topical antibiotics. Debriding and grafting the burns. Diluting the chemicals. Applying sterile dressings.

Diluting the chemicals. Rationale: It will help to remove the chemicals, and stop the burning process. The rest of the treatments are initiated after diluting the chemicals.

Molly Baker has a third-degree burn on her leg from a house fire. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to her leg. What procedure would be done to relieve pressure on the affected area? a) Allograft b) Escharotomy c) Silvadene application d) Debridement

Escharotomy Correct Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

The client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN? Correct water and electrolyte imbalances. Provide supplemental vitamins and minerals. Ensure adequate caloric and protein intake. Allow the gastrointestinal tract to rest.

Ensure adequate caloric and protein intake. Rationale: Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.

Production of melanin is controlled by a hormone secreted which of the following glands?

Hypothalamus

Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation? a) Face, neck, chest b) Perineal c) All options are correct. d) Hands, major joints

Face, neck, chest Correct Explanation: Burns of the face, neck, or chest have the potential to impair ventilation.

Which of the following nonsedating antihistamines is appropriate for daytime pruritus? Diphenhydramine (Benadryl) Fexofenadine (Allegra) Lorazepam (Ativan) Hydroxyzine (Atarax)

Fexofenadine (Allegra) Explanation: Nonsedating antihistamine medications such as Allegra are more appropriate to relieve daytime pruritus. Benadryl or Atarax, when prescribed in a sedative dose at bedtime, may be beneficial in producing a restful and comfortable sleep. Ativan has sedating properties and is used as an antianxiety medication.

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following?

Freckles

Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have? a) Fourth degree b) Superficial (first degree) c) Full thickness (third degree) d) Superficial partial-thickness and deep partial-thickness (second degree)

Full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appears charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? a) Superficial partial-thickness b) Superficial c) Full-thickness d) Deep partial-thickness

Full-thickness Correct Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry

Which term refers most precisely to a localized skin infection of a single hair follicle? Furuncle Carbuncle Cheilitis Comedone

Furuncle Explanation: Furuncles occur anywhere on the body but are most prevalent in areas subjected to irritation, pressure, friction, and excessive perspiration, such as the back of the neck, the axillae, or the buttocks. A carbuncle is a localized skin infection involving several hair follicles. Cheilitis refers to dry cracking at the corners of the mouth. Comedones are the primary lesions of acne, caused by sebum blockage in the hair follicle.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst. Urine output of 70 ml the first hour. Moderate to severe pain. Hoarseness of the voice

Hoarseness of the voice Rationale: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

Which of the following provides clues about fluid volume status? Select all that apply.

Hourly urine output • Daily weights Explanation: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient.

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what prescription should the nurse request from the health care provider? furosemide IV rate increase fresh frozen plasma dextrose 5%

IV rate increase Rationale: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, normal saline, or albumin.

Which of the following reflect the pathophysiology of cutaneous signs of HIV disease? Genetic predisposition High CD4 count Decrease in normal skin flora Immune function deterioration

Immune function deterioration Explanation: Cutaneous signs may be the first manifestations of HIV, appearing in more than 90% of HIV-infected patients as immune function deteriorates. Common complaints include pruritus, folliculitis, and chronic actinic dermatitis. Cutaneous signs of HIV disease correlate to low CD4 counts. Cutaneous signs of HIV disease appear as immune function deteriorates.

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? Laterally, from the distal area to the center In a widening circle around the drain, outward from the center Laterally, from one side of the wound to the opposite side. From the superior portion of the wound to the inferior

In a widening circle around the drain, outward from the center Rationale: When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from top to bottom when cleaning a vertical incision.

What is the major cause of death in toxic epidermal necrolysis (TEN)? Infection Hemorrhage Renal failure Liver failure

Infection Explanation: The major cause of death from TEN is infection, and the most common sites of infection are the skin and mucosal surfaces, lungs, and blood. Hemorrhage, renal failure, and liver failure are not the major causes of TEN.

A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury? a) Inflammatory b) Intravascular fluid excess c) Neuroendocrine d) Hypertension

Inflammatory Correct Explanation: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

The nurse in the emergency department is caring for a 12-year-old child with full-thickness, circumferential burns to the chest, and has difficulty breathing. What is the priority intervention? Intubation. Escharotomy. Chest tube insertion. Needle thoracocentesis

Intubation. Rationale: Intubation is performed to maintain a patent airway Escharotomy is a surgical incision used to relieve pressure from edema. It's needed with circumferential burns that prevent chest expansion or cause circulatory compromise. Insertion of a chest tube and needle thoracocentesis are performed to relieve a pneumothorax.

Which drug is an oral retinoid used to treat acne? Isotretinoin Estrogen Tetracycline Benzoyl peroxide

Isotretinoin Explanation: Isotretinoin, an oral retinoid, is used in clients diagnosed with nodular cystic acne that does not respond to conventional therapy. Estrogen, tetracycline, and benzoyl peroxide are not oral retinoids.

A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient?

Jaundice

Which of the following is the preferred IV fluid for burn resuscitation? a) Lactated Ringer's (LR) b) D5W c) Total parenteral nutrition (TPN) d) Normal saline (NS)

Lactated Ringer's (LR) Correct Explanation: LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels. NS, D5W, and TPN are not the IV of choice for burn resuscitation.

Which of the following is a factor that causes wrinkles among older adults?

Loss of the subcutaneous tissue

Which of the following is the analgesic of choice for burn pain? a) Fentanyl b) Demerol c) Tylenol with codeine d) Morphine sulfate

Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

The client has a continuous bladder irrigation after a transurethral resection. A major goal related to the irrigation is to: Recognize signs of prostate cancer. Reduce incisional bleeding. Perform activities of daily living. Maintain catheter patency.

Maintain catheter patency. Rationale: Maintaining catheter patency during the immediate postoperative period after a transurethral resection is a priority because postoperative bleeding can occlude the catheter. Catheter occlusion can lead to urine retention, pain, bladder spasm, and the need to replace the catheter. Incisional bleeding is not expected unless a complication occurs. The client in the immediate postoperative period is not ready for teaching about the signs of prostate cancer. Performing activities of daily living, such as bathing, is not a priority immediately after surgery.

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.

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? a) Chemical debridement b) Mechanical debridement c) Natural debridement d) Surgical debridement

Mechanical debridement Explanation: Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tiss

Which of the following pigments influences hair color?

Melanin

The nurse is changing the dressing of a client after an abdominal hysterectomy. If the dressing adheres to the client's incisional area, what should the nurse do? Remove part of the dressing, and then remove the remainder gradually over a period of several minutes. Pull off the dressing quickly, and then apply slight pressure over the area. Moisten the dressing with sterile normal saline solution, and then remove it. Lift an easily moved portion of the dressing, and then remove it slowly.

Moisten the dressing with sterile normal saline solution, and then remove it. Rationale: When a dressing sticks to a wound, it is best to moisten the dressing with sterile normal saline solution and then remove it carefully. Trying to remove a dry dressing is likely to irritate the skin and wound. This may contribute to tension or tearing along the suture line.

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? a) Moisten with sterile water only. b) Moisten with saline. c) Keep Acticoat saturated. d) Use topical antimicrobials with Acticoat burn dressing.

Moisten with sterile water only. Explanation: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.

The nurse is caring for a patient in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury? a) Clammy skin b) Decreased pulse rate c) Hyperthermia d) Narrowing pulse pressure

Narrowing pulse pressure Explanation: Patients with burns are hypermetabolic. This results in tachycardia, tachypnea, and elevated body temperature. These physiological norms in patients with burns make the diagnosis of sepsis more challenging. The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the patient's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas.

A client had an appendectomy 2 days ago and is now presenting with purulent drainage, pain in the mid-incision, and a temperature of 101.3°F (38.5°C). What would be the most appropriate action by the nurse? No action is necessary because these are normal findings. Administer acetaminophen and reassess in 2 hours. Notify the surgeon as soon as possible. Ambulate the client in the hall.

Notify the surgeon as soon as possible. Rationale: The client is exhibiting signs of a wound infection, which results in systemic temperature elevation. The drainage of purulent exudate also indicates a wound infection. The other choices are not appropriate actions at this time.

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

A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?

Patch test

A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the nurse anticipate as being most likely

Patch testing

Which condition is an autoimmune disease involving immunoglobulin G? Stevens-Johnson syndrome (SJS) Toxic epidural necrolysis (TEN) Pemphigus Bullous pemphigoid

Pemphigus Explanation: Pemphigus is an autoimmune disease involving immunoglobulin G. TEN, SJS, and bullous pemphigoid do not involve immunoglobulin G.

A 23-month-old child pulls a pan of hot water off the stove and spills it onto her chest and arms. Her mother is right there when it happens. What should the mother do immediately? Place the child in a bathtub of cool water. Apply antibiotic ointment to the burned areas. Apply ice directly to the burned areas. Call the neighbor to come over and help her.

Place the child in a bathtub of cool water. Rationale: The emergency treatment of both minor and major burns includes stopping the burning process by immersing the burned area in cool, but not cold, water. Thus, the mother should place the child in a bathtub of cool water. Applying ice directly to the burned area is inappropriate at this time because more tissue damage can result. Antibiotic ointment should not be applied to the burned area at this time because the burning process must be stopped first. Calling a neighbor for help is appropriate after the mother has placed and then removed her child from the bathtub.

The nurse is assessing a patient with a primary skin lesion called a macule. What does the nurse understand is a clinical example of this lesion?

Port-wine stains

A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following? a) Premedicating the patient with an analgesic prior to application b) Monitoring the patient's Na+ and K+ serum levels and replace as prescribed c) Monitoring the patient for the development of respiratory acidosis d) Protecting the bed linens and patient's clothing from contact to prevent staining

Premedicating the patient with an analgesic prior to application Correct Explanation: Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the patient is an appropriate intervention. The other nursing implications are not associated with mafenide.

A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client? Semi-private room with a client diagnosed with pneumonia Isolation room with negative airflow Semi-private room with a client who had chickenpox and was admitted with a GI bleed Private room

Private room Explanation: Herpes zoster, a highly contagious infection, is transmitted by direct contact with vesicular fluid or airborne droplets from the infected host's respiratory tract. Placing the client with a client diagnosed with pneumonia places that client at risk for contracting herpes zoster. An isolation room with negative airflow isn't necessary for the client with herpes zoster. The nurse should assign the client to a private room. The client could safely room with the client who already had chickenpox; however, visitors might be unnecessarily exposed.

Which of the following is a potential cause of a superficial partial-thickness burn? a) Scald b) Flash flame c) Sunburn d) Electrical current

Sunburn Correct Explanation: A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

A nurse is assessing a client 2 days after surgery for infection. Which sign or symptom is most indicative of infection? The presence of pain at the incision site. Rectal temperature of 100° F (37.8° C). White blood cell (WBC) count of 8,000/μl. Red, warm, swollen, tender incision with foul drainage

Red, warm, swollen, tender incision with foul drainage Rationale: Redness, warmth, swelling, tenderness, and foul drainage in the incision area indicate a postoperative infection. Pain at the incision site would be expected on postoperative day 2. A rectal temperature of 100° F would be a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/μl. This client's WBC count falls within this normal range.

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? a) Reduction in blood volume b) Sodium excess c) Increased urinary output d) Potassium deficit

Reduction in blood volume Correct Explanation: A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.

An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition?

Reduction in sebum production

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to infection Related to fat emboli Related to circumferential eschar Related to femoral artery occlusion

Related to circumferential eschar Rationale: As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

A patient is scheduled for Mohs microscopic surgery for removal of a skin cancer lesion on his forehead. The nurse knows to prepare the patient by explaining that this type of surgery requires: Destruction of the tissue by electrical energy. Removal of the tumor, layer by layer. A process of deep-freezing the tumor, thawing and refreezing. The use of radiation therapy.

Removal of the tumor, layer by layer. Explanation: Mohs micrographic surgery removes the tumor layer by layer. The first layer excised includes all evident tumor and a small margin of normal-appearing tissue. The specimen is frozen and analyzed by section to determine if all the tumor has been removed. If not, additional layers of tissue are shaved and examined until all tissue margins are tumor-free.

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority? Beginning range of motion exercises Preventing contractures of extremities Preparing for an escharotomy. Replacing fluid and electrolytes

Replacing fluid and electrolytes. Rationale: After establishing a patent airway, fluid resuscitation is critical for the client with a burn injury. Positioning to prevent contractures and removing dead skin (escarotomy) are important interventions, but are not the priority. It is too soon to begin range of motion exercises.

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

Scale

A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas?

Sclerae

In a toddler, which injury is most likely the result of child abuse? A 1-inch forehead laceration. A hematoma on the occipital region of the head. Several small, dime-sized circular burns on the child's back . A small isolated bruise on the right lower extremity

Several small, dime-sized circular burns on the child's back. Rationale: Small circular burns on a child's back are no accident and may have been caused by cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren't uncommon. A small area of ecchymosis isn't suspicious in this age-group.

A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following? a) Stains clothing b) Severe burning pain for up to 20 minutes c) Blood levels of sodium and potassium will be monitored. d) Can be left in place for 3 to 5 days

Severe burning pain for up to 20 minutes Explanation: The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored

Which of the following topical burn preparations act as wick for sodium and potassium? a) Silver nitrate solution b) Silver sulfadiazine (Silvadene) c) Mafenide acetate (Sulfamylon) d) Acticoat

Silver nitrate solution Correct Explanation: Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.

What should be a priority for a 6-year-old child admitted with third-degree burns? Start an IV line. Insert an indwelling urinary (Foley) catheter. Obtain baseline laboratory studies. Administer prescribed antibiotics orally.

Start an IV line. RATIONALE: The child will need fluid replacement therapy as soon as possible, primarily due to the shift of plasma from intravascular to interstitial spaces at burn sites. Blisters and edema resulting from this process lead to fluid and electrolyte loss. Severe burns are usually sterile. Antibiotic treatment, if used at all, would not be a priority at this time. Insertion of an indwelling urinary (Foley) catheter would be done once the intravenous line is started. Laboratory studies would be drawn after the intravenous line is started.

A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the incision is separating. What is the nurse's priority action? Apply warm compresses to the painful area before removing the remaining staples. Stop the staple removal, cover the incision, and report the findings to the physician. Apply butterfly tapes to the separated area and redress the wound immediately. Remove the remaining staples, apply butterfly tapes, and document the findings.

Stop the staple removal, cover the incision, and report the findings to the physician. Rationale: If there are signs of dehiscence while removing staples, it is important to stop the removal of staples and to dress the open wound. It is very important to relay the observations of mid-incision pain and separation of the wound to the physician as soon as possible. Continuing the staple removal is not appropriate. A dehiscence presenting with other signs of pain could indicate the presence of an abscess. It is not enough to apply butterfly tapes. The observations need to be relayed to the physician.

Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation? Skin intact over bony prominences. Staples intact to the incision. Minimal serous wound drainage. A temperature of 102° F (38.9°C

Temperature of 102° F (38.9°C) Rationale: A variance is a deviation from what is expected on a critical pathway. An elevated temperature is a variance on the third postoperative day. A nurse must report the finding to the physician, who must determine source of the fever. Minimal serous drainage, intact skin over bony prominences, and intact staples are expected on the third post-operative day.

All of the following are antimicrobials commonly used to treat burns except: a) Tetracycline b) Silver sulfadiazine (Silvadene) c) Mafenide (Sulfamylon) d) Silver nitrate (AgNO3) 0.5% solution

Tetracycline Correct Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

The nurse is performing triage in the emergency department. Which client should be seen first?

The client with burns to his chest and neck with singed nasal hair. Rationale: The client with burns to the chest and neck has the potential to develop decreased lung expansion. Singed nasal hair is indicative of inhalation injury and delayed respiratory distress syndrome. Flank pain and open fractures will not take precedence over the client with airway problems. The primipara still has time before the baby comes.

The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak? College dormitory Shopping mall Gymnasium Swimming pool

The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak? You Selected: Gymnasium Correct response: College dormitory Explanation: The nurse is correct to anticipate a potential scabies outbreak in a college dormitory. Outbreaks are common where large groups of people are confined or housed. Spread of scabies is from skin-to-skin contact. Although there are groups of people at the shopping mall, swimming pool, and gymnasium, typically, there is no personal contact.

A client is brought to the emergency department having been involved in a fire while putting lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be dry and pale white with some areas that are brown and leathery. Which of the following types of burns does the nurse determine are present?

Third degree (full thickness) Rationale: Third-degree burns involve the epidermis, dermis, and sometimes subcutaneous tissue. They are insensate and usually present as dry, pale, white, red brown, leathery, or charred. First degree or superficial burns involve the outer layer of the skin and are similar to sunburn, reddened without blisters. Second degree burns or partial thickness burns involve the dermis and have a reddened, blistered appearance. Fourth degree burns involve the dermal layers as well as the fat, fascia, muscle, and may also include bone.

The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following? a) Tissue edema may interfere with drug absorption via other routes. b) The patient can experience nausea and emesis when given oral medications. c) Bleeding may occur at injection sites when the intramuscular route is used. d) Pain resulting from a burn injury requires relief by the fastest route available.

Tissue edema may interfere with drug absorption via other routes. Explanation: IV administration is necessary because of altered tissue perfusion from the burn injury.

The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder? To reduce abdominal pain through pressure support To maintain blood flow and circulation in the abdominal incision To assist in collection of wound drainage products from the incision To reduce stress on the abdominal incision

To reduce stress on the abdominal incision Rationale: Applying an abdominal binder will reduce further stress on the incision and prevent another dehiscence, thus allowing the skin and tissue to heal. The other choices are not accurate reasons to use a binder.

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

Tzanck smear

A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal? Transurethral resection of the prostate (TURP) Transurethral laser incision of the prostate. Retropubic prostatectomy. Suprapubic prostatectomy

Transurethral resection of the prostate (TURP) Rationale: TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; each requires an incision.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? Zinc oxide gelatin Tretinoin (retinoic acid [Retin-A]) Fluorouracil (5-fluorouracil, 5-FU [Efudex]) Minoxidil (Rogaine)

Tretinoin (retinoic acid [Retin-A]) Explanation: Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.

Which drug is a topical corticosteroid used to treat psoriasis? Triamcinolone Coal tar Neutrogena Methotrexate

Triamcinolone Explanation: Triamcinolone is a topical corticosteroid used to treat psoriasis. Coal tar is used for mild to moderate lesions of psoriasis. Neutrogena is a medicated shampoo. Methotrexate is a systemic therapy for psoriasis.

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

Vesicle

Which of the following terms refers to a condition characterized by destruction of the 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 a symptom of what?

Vitiligo

What advice should the nurse give a client with dermatitis until the etiology of the dermatitis is identified? Rub the skin vigorously to dry. Wear rubber gloves when in contact with soaps. Use hot water for bathing. Use wool, synthetics, and other dense fibers.

Wear rubber gloves when in contact with soaps. Explanation: The nurse should advise the client to wear rubber gloves when coming in contact with any substance such as soap or solvents. The client should avoid wool, synthetics, and other dense fibers. The client should use tepid bath water and should pat rather than rub the skin dry.

Which of the following are yellowish waxy deposits on the upper and lower eyelids?

Xanthelasma

The nurse is reading the physician's report of an elderly patient's physical examination. The patient demonstrates xanthelasma, which refers to which of the following symptoms?

Yellowish waxy deposits on upper eyelids

The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. The nurse's best response based on the clinical findings is which of the following? a) Apply an elastic stocking to the extremity and administer SQ heparin per order. b) Document the findings and instruct the patient to report numbness of the extremity. c) Contact the primary care provider and prepare for an escharotomy. d) Elevate the leg on pillows and reassess the leg in 1 hour.

You selected: Contact the primary care provider and prepare for an escharotomy. Correct Explanation: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.

The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? a) Liquid blood component is lost into extravascular space b) Fluid loss c) Decreased renal blood flow d) Sodium and water retention caused by increase adrenocortical activity

You selected: Liquid blood component is lost into extravascular space Correct Explanation: Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The following describes one of the injury zones: the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. What is the name of that zone? a) Zone of stasis b) Zone of coagulation c) Zone of hyperemia d) Zone of hypotension

Zone of stasis Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. This is not the name of one of the zones.

A patient is being evaluated for nodular cystic acne. What systemic pharmacologic agent may be prescribed for the treatment of this disorder? Isotretinoin (Accutane) Benzoyl peroxide Retin-A Salicylic acid

a furuncle. Explanation: Furuncles are localized skin infections of a single hair follicle. They can occur anywhere on the body but are most prevalent in areas subjected to irritation, pressure, friction, and excessive perspiration, such as the back of the neck, the axillae, or the buttocks. A carbuncle is a localized skin infection involving several hair follicles. Cheilitis refers to dry cracking at the corners of the mouth. Comedones are the primary lesions of acne, caused by sebum blockage in the hair follicle.

When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing? scheduled periods of rest. adequate circulatory status. fluid intake of 1,500 mL/day. balanced nutritional diet

adequate circulatory status. Rationale: Adequate circulatory status is the most important factor in the healing process of an infected decubitus ulcer. Blood flow to the area must be present to bring nutrients and prescribed antibiotics to the tissues

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection? a 42-year-old with a recent, uncomplicated appendectomy. an 86-year-old with burns from using a heating pad. a 6-year-old with a simple fracture of the femur. an 18-year-old with diabetes mellitus

an 86-year-old with burns from using a heating pad. Rationale: The very young and the elderly are more susceptible to infection. An elderly client with a break in skin integrity, such as the 86-year-old with a burn, is at an increased risk for infection. The 6-year-old does not have a compound fracture (protruding through the skin) and is not at high risk for infection. A client with an appendectomy is at risk for infection of the surgical site but not as high a risk as the client with burns. While a client with diabetes is at risk for infection, this adolescent is not at high risk at this time.

The nurse is assigning tasks to unlicensed assistive personnel (UAP) for a client with an abdominal hysterectomy on the first postoperative day. Which task cannot be delegated to the UAP? assessing the incision site. recording intake and output. giving perineal care. taking vital signs

assessing the incision site Rationale The registered nurse is responsible for monitoring the surgical site for the condition of the dressing, status of the incision, and signs and symptoms of complications. Unlicensed assistive personnel who have been trained to report abnormalities to the registered nurse supervising the care may take vital signs, record intake and output, and give perineal care.

Which of the following actions is a quick assessment technique that the nurse might use to assess the percentage of a small or scattered burn injury? a) Checking the patient's vital signs b) Comparing the patient's palm with the size of the burn wound c) Observing the patient's level of consciousness d) Observing the color of the patient's wound

b

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to: wash the area with soap and water to disinfect it. apply a weakened alcohol solution to clean the area. clean the area with normal saline solution and cover it with a protective dressing. remove the raised skin because the blister has already broken.

clean the area with normal saline solution and cover it with a protective dressing. Rationale: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.

A client's abdominal incision eviscerates. The nurse should first: take the client's vital signs and call the health care provider (HCP). cover the incision with a dressing moistened with sterile normal saline solution. start an emergency infusion of IV fluids. lower the client's head and elevate the feet.

cover the incision with a dressing moistened with sterile normal saline solution. Rationale: When an incision eviscerates, it is a medical emergency. The nurse's first response is to apply a sterile dressing that has been moistened with sterile normal saline solution. The client should also be placed in semi-Fowler's position to release any tension on the abdominal area. Vital signs should be taken, and an IV line may be started for emergency treatment; however, the first action is to protect the wound and abdominal contents.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: increase edema in the arms. increase the amount of scarring. decrease circulation to the fingers. dislodge the autografts.

dislodge the auto grafts. Rationale: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: examination of the fundus of the eye. evaluation of bowel and bladder functions. assessment of the client's gait. evaluation of the corneal reflex response.

evaluation of the corneal reflex response. Rationale: During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment.

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? every 5 minutes every 15 minutes every 10 minutes every 20 minutes

every 15 minutes Rationale: In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.

While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for: gastrointestinal ulceration. gastric distention. paralytic ileus. hiatal hernia.

gastrointestinal ulceration. Rationale: Also known as Curling's ulcer, occurs in about half of clients suffering from severe burns. The ulceration is proportional to the extent of the burns and due to hypersecretion of gastric acid and compromised gastrointestinal perfusion. Gastrointestinal ulceration, also known as Curling's ulcer, occurs in about half of clients suffering from severe burns. The incidence of ulceration appears proportional to the extent of the burns and is believed to be due to hypersecretion of gastric acid and compromised gastrointestinal perfusion. Paralytic ileus, gastric distention, and hiatal hernia are not caused by hypersecretion of gastric acid. Gastric distention is not caused by hypersecretion of gastric acid. Hiatal hernia is not caused by hypersecretion of gastric acid

The classic lesions of impetigo manifest as comedones in the facial area. honey-yellow crusted lesions on an erythematous base. abscess of skin and subcutaneous tissue. patches of grouped vesicles on red and swollen skin.

honey-yellow crusted lesions on an erythematous base. Explanation: The classic lesions of impetigo are honey-crusted lesions on an erythematous base. Comedones in the facial area are representative of acne. A carbuncle is an abscess of skin and subcutaneous tissue. Herpes zoster is exhibited by patches of grouped vesicles on red and swollen skin.

Which of the following is the key sign of onset of ARDS? a) Tachypnea b) Stridor c) Hypoxemia d) Chest pain

hypoxemia Explanation: The key sign of the onset of ARDS is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.

A client with a history of diabetes mellitus has recently developed furunculosis. What is causing the client's condition? infection diet hygiene unknown

infection Explanation: Furuncles and carbuncles are caused by skin infections with organisms that usually exist harmlessly on the skin surface.

A physician has ordered a wet-to-damp dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to: prevent the spread of the infection. debride the wound. keep the wound moist. reduce pain.

keep the wound moist. Explanation: Wet-to-damp dressings keep the wound bed moist, which helps promote the growth of granulation tissue. Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. Wet-to-damp dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.

The nurse notes that the client's lower extremities are covered with very dry skin and that the horny layer of the skin has become thickened. The nurse notes the finding as dermatitis. acantholysis. lichenification. pyodermas.

lichenification. Explanation: The nurse should note this as being lichenification, also called scaling. Dermatitis is an inflammation of the skin. Acantholysis is a separation of the epidermal cells from each other, and pyodermas is a bacterial skin infection.

Which finding is expected when the nurse is assessing a child who has sustained full-thickness burns? excessive bleeding minimal pain blanching to the touch blistering and a moist appearance

minimal pain Rationale: Full-thickness burns are serious injuries in which all the skin layers are destroyed. Lack of pain is characteristic of full-thickness burns. With full-thickness burns, blanching and bleeding are absent because blood supply is destroyed. Blisters and a moist appearance characterize partial-thickness burns.

There is an increase in the incidence of skin cancer being reported. Which have been identified as factors that predispose to malignant changes in the skin? Select all that apply. thinning ozone layer residence in high-altitude areas where the atmosphere is thinner than at sea level prolonged, repeated exposure to UV rays in those who do farming, fishing, road construction, etc. use of sun block

orrect response: thinning ozone layer residence in high-altitude areas where the atmosphere is thinner than at sea level prolonged, repeated exposure to UV rays in those who do farming, fishing, road construction, etc. Explanation: Contributing factors include the thinning ozone layer; residence in high-altitude areas where the atmosphere is thinner than at sea level; and prolonged, repeated exposure to UV rays in those who do farming, fishing, road construction, etc. Use of sunblock is a protector from UV rays

A 15 year-old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum?

prevents drying and cracking of the skin and hair

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: promote drainage of wound exudates. provide access for wound irrigation. minimize the development of scar tissue. decrease postoperative discomfort.

promote drainage of wound exudates Rationale: Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

Which action would be most helpful in preventing pressure ulcer formation in an at-risk client? massaging reddened areas on the sacrum repositioning every hour. ensuring a generous fluid intake. providing a low-protein diet

repositioning every hour Rationale Because pressure ulcers (decubitus ulcers) are caused by pressure to the tissues, the most important measure in preventing them is to relieve the pressure by repositioning the client every 1 to 2 hours. A low-protein diet will not prevent pressure ulcer formation. Rather, the client should receive a diet that ensures an adequate intake of calories and protein. While essential to ensure adequate hydration, a generous fluid intake alone will not prevent ulcer formation. The underlying cause is pressure. Massaging reddened areas and bony prominences, once thought to reduce risk of pressure ulcer formation, is now known to increase the risk of pressure ulcer formation.

The mother calls the nurse to report that her toddler just been burned on the arm. The nurse should advise the mother to first: pack the arm in ice, and then take the child to the closest emergency department. call the child's health care provider (HCP) immediately, and then wrap the arm in a clean cloth. run cool water over the burned area, and then wrap it in a clean cloth. rub the burned area with an antibacterial ointment, and then call the child'

run cool water over the burned area, and then wrap it in a clean cloth. Rationale: The best advice for the nurse to give the child's mother is to run cool water over the burned area to stop the burning process. Then the area should be wrapped in a clean cloth. Once these initial actions are completed, the mother can call the child's HCP. Packing the arm in ice may cause more damage to the burned area because cold can cause burns just as heat can. For most burns, it is not advised to apply ointment until the area has been evaluated.

During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? serum albumin level of 3.8 g/dL (38 g/L). hourly urine output of 60 mL. serum creatinine level of 2.5 mg/dL (221 µmol/L). little fluctuation in daily weight

serum creatinine level of 2.5 mg/dL (221 µmol/L). Rationale: Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/dL (35 to 50 g/L).

A patient is being evaluated for nodular cystic acne. What systemic pharmacologic agent may be prescribed for the treatment of this disorder? Isotretinoin (Accutane) Benzoyl peroxide Retin-A Salicylic acid

sotretinoin (Accutane) Explanation: Synthetic vitamin A compounds (i.e., retinoids) are used with dramatic results in patients with nodular cystic acne unresponsive to conventional therapy. One compound is isotretinoin, which is used for active inflammatory popular pustular acne that has a tendency to scar. Isotretinoin reduces sebaceous gland size and inhibits sebum production. It also causes the epidermis to shed (epidermal desquamation), thereby unseating and expelling existing comedones.

Which statement is accurate regarding isotretinoin? It is teratogenic in humans. Contraceptives are not needed during treatment. To achieve the full effect of the medication, the client should take vitamin A supplements. The side effects are irreversible.

t is teratogenic in humans. Explanation: Isotretinoin is teratogenic in humans, meaning that it can have an adverse effect on a fetus, causing central nervous system and cardiovascular defects, and structural abnormalities of the face. Contraceptives are needed during treatment. The client should not take vitamin A supplements while taking this drug. Side effects are reversible with the withdrawal of the medication.

Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has

thermal burns to the head, face, and airway resulting in hypoxia. Rationale: Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.

A 42-year-old client suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. Which of the following conditions create the need for intensive care by specifically trained personnel? a) Fluid shift b) Fluid loss c) All options are correct. d) Hypotension

• All options are correct. • Fluid shift • Fluid loss • Hypotension Explanation: Fluid shift, fluid loss, and hypotension can lead to irreversible shock. These changes usually happen rapidly and the client's status may change from hour to hour, requiring that clients with burns receive intensive care by skilled personnel.

Which of the following is to be expected soon after a major burn? Select all that apply. a) Bradycardia b) Anxiety c) Hypertension d) Hypotension e) Tachycardia

• Anxiety • Hypotension • Tachycardia Correct Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply. a) Heart rate b) Urine output c) Oxygen saturation d) Blood pressure

• Blood pressure • Heart rate • Urine output Explanation: Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Choose all that apply. a) Open door and encourage air in an enclosed space. b) Place the client in a horizontal position. c) Place the client in a vertical position. d) Roll the client in a blanket to smother the fire.

• Place the client in a horizontal position. • Roll the client in a blanket to smother the fire. Explanation: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. a) Facial burns b) Yellow sputum c) Hoarseness d) Singed nasal hair e) Bradypnea

• Singed nasal hair • Hoarseness • Facial burns Explanation: Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

The nurse is caring for a 30-year-old female patient who suffered severe head and facial burn injuries. Which of the following actions, if completed by the patient, indicates she is adapting to her altered body image? Select all that apply. a) Reports absence of sleep disturbance b) Wears hats and wigs c) Covers her face with a scarf d) Participates actively in daily activities

• Wears hats and wigs • Participates actively in daily activities Correct Explanation: The following are indicators that a patient is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the patient is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured patient but is not related to body image disturbance.

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is: "Just be careful not to share linens and towels with family members." "All family members need to be treated." "If someone develops symptoms, tell him to see a physician right away." "After you're treated, family members won't be at risk for contracting scabies."

"All family members need to be treated." Explanation: When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage? "Apply sunscreen even on overcast days." "Minimize sun exposure from 1 to 4 p.m., when the sun is strongest." "Use a sunscreen with a sun protection factor of 6 or higher." "When at the beach, sit in the shade to prevent sunburn."

"Apply sunscreen even on overcast days." Explanation: Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 3 p.m. (11 a.m. to 4 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn't guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun's rays onto the skin.

A client has severe psoriasis and is scheduled to receive photochemotherapy. The client is to take psoralen methoxsalen prior to exposure to the ultraviolet A. When is the client informed that the medication should be taken?

1 to 2 hours prior to the procedure

A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination can be used to determine if the rash is a fungal rash using ultraviolet light? Potassium hydroxide test Skin biopsy A Wood's light examination Fungal culture

A Wood's light examination Explanation: A Wood's light is also known as a black light and is a handheld device that can identify certain fungal infections that fluoresce under long-wave ultraviolet light. In a darkened room, when a physician or nurse aims the light at a lesion caused by a fungus that fluoresces, the lesion emits a blue-green color. It is the only test that uses a light, the others use skin scrapings.

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions? Antiviral Antipyretics Analgesics Corticosteroids

Antiviral Explanation: Oral acyclovir (Zovirax), when taken within 48 hours of the appearance of symptoms, reduces their severity, and prevents the development of additional lesions. Corticosteroids, analgesics,, and antipyretics are not used for this purpose.

The nurse is caring for a geriatric client with thin, chapped, itchy skin. Which nursing intervention should the nurse alter in the plan of care? Daily bathing with warm-hot water Maintenance of foam pad on wheelchair Use of a gait belt for ambulation Applying lanolin ointment

Applying lanolin ointment Explanation: Lanolin ointment is good to apply to dry skin because it helps moisturize. Bathing a geriatric client is unnecessary, and hot water will dry the skin further. Due to a decrease in epidermal replacement rates, excessive drying of an older person's skin can lead to pruritus, dryness, and infection. The nurse would not alter the plan of using a gait belt for ambulation or using a foam pad on the wheelchair.

Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body? Autograft Allograft Homograft Heterograft

Autograft Explanation: Full-thickness autografts and pedicle flaps are commonly used for reconstructive surgery, months or years after the initial injury. An allograft is a graft transferred from one human (living or cadaveric) to another human. A homograft is a graft transferred from one human (living or cadaveric) to another human. A heterograft is a graft obtained from an animal of a species other than that of the recipient.

A patient is diagnosed with seborrheic dermatitis on the face and is prescribed a corticosteroid preparation for use. What should the nurse educate the patient about regarding use of the steroid on the face? Use very warm water to clean the face prior to applying the medication. Wash the face several times a day and reapply the medication. Scrape the scaly patches off prior to applying the medication. Avoid using the medication around the eyelids because it may cause cataracts and glaucoma.

Avoid using the medication around the eyelids because it may cause cataracts and glaucoma. Explanation: Seborrheic dermatitis of the body and face may respond to a topically applied corticosteroid cream, which allays the secondary inflammatory response. However, this medication should be used with caution near the eyelids because it can lead to glaucoma and cataracts.

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?

Beau's line

A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp? Temporal area Top of the head Behind the ears Middle area

Behind the ears Explanation: Adult lice usually bite the scalp behind the ears and along the back of the neck. Because such lice are tiny (1 to 2 mm) with grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions. Although lice may bite any part of the scalp, bites are less common on the temporal area, top of the head, and middle area.

The nurse is caring for a patient with a suspected malignancy of the skin. The nurse anticipates that the patient will undergo which of the following diagnostic tests?

Biopsy

The nurse is providing instruction to a client with acne. The nurse promotes avoidance of which food(s)? Select all that apply. Chocolate Onions Bananas Ice cream

Chocolate Ice cream Explanation: The nurse should promote avoidance of foods associated with flare-up of acne, particularly those high in refined sugars, including chocolate, cola, and ice cream.

Which medication classification may be used for contact dermatitis? Corticosteroids Saline irrigations Antifungals Antivirals

Corticosteroids Explanation: Corticosteroids are used for contact dermatitis. Antifungals, antivirals, and saline irrigations are not used in the treatment of contact dermatitis.

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?

Dermis

A dermatologist recommends an over-the-counter suspension to relieve pruritus. The nurse advises the patient that the lotion should be applied: Hourly to prevent evaporation. Twice a day to prevent crusting on the skin. Overnight to enhance absorption. Every 3 to 4 hours for sustained effectiveness.

Every 3 to 4 hours for sustained effectiveness. Explanation: Lotions are frequently used to replenish lost skin oils or to relieve pruritus. They are usually applied directly to the skin, but a dressing soaked in the lotion can be placed on the affected area. Lotions must be applied every 3 or 4 hours for sustained therapeutic effect because if left in place for a long period, they may crust and cake on the skin.

Which of the following superficial fungal infections begins in the skin between the toes and spreads to the soles of the feet? Tinea corporis Tinea capitis Tinea pedis Tinea cruris

Explanation: Tinea pedis is an infection that begins in the skin between the toes and spreads to the soles of the feet. Tinea corporis is a skin infection of the body. Tinea capitis invades the hair shaft below the scalp. Tinea cruris is a skin infection of the groin.

Which is the primary preventable cause of skin cancer? Fair skin Exposure to UV radiation Skin disease Excess melanin

Exposure to UV radiation Explanation: Skin cancer is caused by exposure to UV radiation, both artificial and in sunlight. Fair-skinned individuals are more susceptible because they do not have as many melanin-producing cells within their skin. Skin diseases do not cause cancer.

The nurse is conducting a community education program on malignant melanoma. The nurse knows that the participants understand the teaching when they identify which characteristic as a risk factor? History of suntans Dark skin Mediterranean descent Family history of pancreatic cancer

Family history of pancreatic cancer Explanation: A family history of pancreatic cancer is a risk factor for malignant melanoma. Additional risk factors include fair skin, freckles, blue eyes, blond hair, Celtic or Scandinavian descent, history of sunburns, previous melanoma, family history of melanoma, and a family or personal history of multiple atypical nevi.

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?

Fluid retention

A client with scabies has been prescribed a scabicide. Which of the following advice should the nurse give the client before beginning the treatment? Wear clean clothing. Avoid contact with others who have scabies. Expect itching to continue for 2 to 3 weeks after the treatment. Have a thorough bath.

Have a thorough bath. Explanation: Before any treatment begins, the nurse advises the client to bathe thoroughly. Wearing clean clothing and avoiding contact with others who have scabies are essential in preventing a recurrence. As a part of client teaching, the nurse explains that itching may continue for 2 to 3 weeks after the treatment.

Development of malignant melanoma is associated with which risk factor? History of severe sunburn African American heritage Skin that tans easily Residence in the Northeast

History of severe sunburn Explanation: Ultraviolet rays are strongly suspected as the etiology of malignant melanoma. Fair-skinned, blue-eyed, light-haired people of Celtic or Scandinavian origin are at higher risk for developing malignant melanoma. People who burn and do not tan are at risk for developing malignant melanoma. Elderly individuals who retire to the southwestern United States seem to have a higher incidence of developing malignant melanoma.

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria? Scabies Pediculosis capitis Poison ivy Impetigo

Impetigo Explanation: Impetigo is seen at all ages but is particularly common among children living under poor hygienic conditions. Scabies is caused by the itch mite. Pediculosis capitis is caused by head lice. Poison ivy is a contact dermatitis caused by the oleoresin given off by a particular form of ivy

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria? Scabies Pediculosis capitis Impetigo Poison ivy

Impetigo Explanation: Impetigo is seen at all ages but is particularly common among children living under poor hygienic conditions. Scabies is caused by the itch mite. Pediculosis capitis is caused by head lice. Poison ivy is a contact dermatitis caused by the oleoresin given off by a particular form of ivy.

The nurse is conducting a community education program on basal cell carcinoma (BCC). Which statement should the nurse make? It is more invasive than squamous cell carcinoma (SCC). It metastasizes through blood or the lymphatic system. It begins as a small, waxy nodule with rolled translucent, pearly borders. It is a malignant proliferation arising from the epidermis.

It begins as a small, waxy nodule with rolled translucent, pearly borders. Explanation: BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders. It is less invasive than SCC. It does not metastasize through the blood or lymphatic system. SCC is a malignant proliferation arising from the epidermis.

The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition? Platelet disorders Allergic reactions Kaposi sarcoma Syphilis

Kaposi sarcoma Explanation: Kaposi sarcoma is a frequent comorbidity of clients with AIDS. With platelet disorders, the nurse observes ecchymosis (bruising) and purpura (bleeding into the skin). Urticaria (wheals or hives) is the manifestation of allergic reactions. A painless chancre or ulcerated lesion is a typical finding in clients with syphilis.

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?

Keloid

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

Which of the following is the principal hardening ingredient of the hair and nails?

Keratin

Which of the following information regarding the transmission of lice would the nurse identify as a myth? Lice can be spread by sharing of hats, caps, and combs. Lice can jump from one individual to another. Lice need to be removed from the hair with a fine comb. Lice can be seen without magnification.

Lice can jump from one individual to another. Explanation: The nurse is correct to identify that lice cannot jump from one individual to another. Direct contact is needed for transmission. The other options are correct.

The nurse and nursing assistant are moving a client who slid down in the chair. What does the nurse encourage the assistant to avoid shearing when moving the client to a higher position in the chair?

Lift the client, do not slide them

Which of the following could be a possible cause of cyanosis?

Low tissue oxygenation

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following?

Macule

Which procedure done for skin cancer conserves the most amount of normal tissue? Moh's micrographic surgery Electrosurgery Cryosurgery Surgical excision

Moh's micrographic surgery Explanation: Moh's micrographic surgery is the technique that is most accurate and that best conserves normal tissue. The procedure removes the tumor layer by layer. Electrosurgery, cryosurgery, and surgical excision do not conserve the amount of normal tissu

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? A. Dry sterile dressing B. Sterile petroleum gauze C. Moist, sterile saline gauze D. Povidone-iodine-soaked gauze

Moist sterile saline gauze Explanation: Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

What advice should the nurse give a client with a furuncle to prevent the spread of the infection? Keep hair short, clean, and away from the face and forehead. Never pick or squeeze a furuncle. Avoid the use of cosmetics. Use tepid bath water.

Never pick or squeeze a furuncle. Explanation: The client with a furuncle should never pick or squeeze it as the drainage is infectious and this practice favors the spread of the infection. Infections by organisms that usually exist harmlessly on the skin surface cause furuncles. Keeping the hair short, clean, and away from the face and forehead, avoiding cosmetics, and using tepid bath water do not help in preventing the spread of a furuncle.

he nurse is caring for a client with questionable lice infestation. The nurse is using a bright light focused on an area of the head to confirm the presence of lice. In which manner is it easiest to differentiate nits from dandruff? Dandruff is throughout the hair. Nits are difficult to move from hair shafts. Nits are located near the scalp. Dandruff looks white and flakey.

Nits are difficult to move from hair shafts. Explanation: The nurse is correct to use the difference of the nits being securely attached to the hair shaft as a guide to confirmation of lice infestation. Dandruff is fine, white particles of dead, dry scalp cells that can be easily picked from the hair.

Dry, rough, scaly skin with the presence of itching is best described as: Candidiasis Shingles Pruritus Seborrhea

Pruritus Explanation: Pruritus (itching) is one of the most common symptoms of patients with dermatologic disorders. Itch receptors are unmyelinated, penicillate (brush-like) nerve endings that are found exclusively in the skin, mucous membranes, and cornea.

A patient is diagnosed with psoriasis after developing scales on the scalp, elbows, and behind the knees. The patient asks the nurse where this was "caught." What is the best response by the nurse? Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin. Psoriasis is an inflammatory dermatosis that results from a superficial infection with Staphylococcus aureus. Psoriasis results from excess deposition of subcutaneous fat. Psoriasis comes from dermal abrasion.

Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin. Explanation: Current evidence supports an autoimmune basis for psoriasis (Porth & Matfin, 2009). Periods of emotional stress and anxiety aggravate the condition, and trauma, infections, and seasonal and hormonal changes may also serve as triggers. In this disease, the epidermis becomes infiltrated by activated T cells and cytokines, resulting in both vascular engorgement and proliferation of keratinocytes. Epidermal hyperplasia results.

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?Pustule

Pustule

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect? Impetigo Scabies Contact dermatitis Dermatophytosis

Scabies Explanation: Signs and symptoms of scabies include gray-brown burrows, epidermal curved or linear ridges, and follicular papules. Clients complain of severe itching that usually occurs at night. Scabies commonly occurs in school-age children. The most common areas of infestation are the finger webs, flexor surface of the wrists, and antecubital fossae. Impetigo is a contagious, superficial skin infection characterized by a small, red macule that turns into a vesicle, becoming pustular with a honey-colored crust. Contact dermatitis is an inflammation of the skin caused by contact with an irritating chemical or allergen. Dermatophytosis, or ringworm, is a disease that affects the scalp, body, feet, nails, and groin. It's characterized by erythematous patches and scaling.

With repeated reactions of contact dermatitis, which of the following can occur? Pain along the sensory nerve Sepsis Secondary bacterial infection Hemorrhage

Secondary bacterial infection Explanation: If repeated reactions occur, or if the patient continually scratches the skin, lichenification (thickening of the horny layer of the skin) and pigmentation occur. Secondary bacterial invasion may follow. During shingles, there will be pain along the sensory nerve. Sepsis and hemorrhage would not occur from repeated bouts of contact dermatitis.

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

Petechiae are associated with which of the following disorders?

Thrombocytopenia

A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response?

Through the application of extreme cold, the tissue is destroyed.

A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response? Through the application of extreme cold, the tissue is destroyed. Freezes the growth, so the physician can remove it at the next appointment Removes the entire growth Lasers the growth off

Through the application of extreme cold, the tissue is destroyed. Explanation: Cryosurgery is the application of extreme cold to destroy tissue. The other statements are false.

A young college student recently had her tongue and lip pierced. She has developed a superinfection of candidiasis from the antibacterial mouthwash. Which of the following would be the correct recommendation for her? Use an antifungal mouthwash or salt water. Use a soft-bristled toothbrush. Rinse the mouth after eating food. Move the piercing back and forth during washing.

Use an antifungal mouthwash or salt water. Explanation: The client can substitute an antifungal mouthwash or salt water if a superinfection of candidiasis develops from the antibacterial mouthwash. A soft-bristled toothbrush should be used to avoid additional oral injury, but it is not the recommended solution for this problem. After eating, the client should rinse her mouth for 30 to 60 seconds with an antifungal mouthwash or salt water. Moving the jewelry at the piercing area back and forth during washing helps clean the pierced tract but does not solve the problem.

A client is being treated for acne vulgaris. What warning must be given to this client regarding the application of benzoyl peroxide? Use gloves with application. Only use with contact dermatitis. Apply a thick layer to assure coverage. Use with over-the-counter drying agents.

Use gloves with application. Explanation: Warn clients using acne preparations containing benzoyl peroxide that this ingredient is an oxidizing agent and may remove the color from clothing, rugs, and furniture. Thorough handwashing after drug use may not remove all the drug and permanent fabric discoloration may still occur. Users of products containing benzoyl peroxide should wear disposable plastic gloves when applying the drug.

The home health nurse is caring for a client with scabies. When instructing on the proper procedure to wash preworn contaminated clothing, which nursing instruction is essential? Use commercial grade laundry detergent. Pretreat clothing where scabies contact existed. Wash clothes through two laundry cycles. Use hot water throughout wash cycle.

Use hot water throughout wash cycle. Explanation: The nurse is correct to use hot water throughout the wash cycle. Using hot water kills scabies and infectious agents on the laundry. If using the correct wash settings, the client does not need to use commercial-grade laundry detergent, the clothing does not need pretreated nor washed through two cycles.

The nurse is instructing the parents of a child with head lice. Which statement should the nurse include? Use shampoo with piperonyl butoxide. Use shampoo with Kwell. Wash clothes in cold water. Disinfect brushes and combs with bleach.

Use shampoo with piperonyl butoxide. Explanation: The nurse's instructions should include shampooing with piperonyl butoxide, washing clothes in hot water, and disinfecting brushes and combs with piperonyl butoxide shampoo.

Which is not a category of medications used for treatment of the skin?

inhaled steroids

Which is not a category of medications used for treatment of the skin? inhaled steroids topical corticosteroids antihistamines antibiotics

inhaled steroids Explanation: Inhaled steroids are not used for skin disorders. Topical corticosteroids, antihistamines, and antibiotics are all used in the treatment of skin disorders.

A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should: wash her hands, apply a pediculicide to the client's scalp, and remove any observable mites. isolate the client's bed linens until the client is no longer infectious. notify the nurse in the day surgery unit of a potential scabies outbreak. place the client on enteric precautions.

isolate the client's bed linens until the client is no longer infectious. Explanation: To prevent the spread of scabies to other hospitalized clients, the nurse should isolate the client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client's condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn't require enteric precautions because the mites aren't found in feces.

A client is being treated for acne vulgaris. What contributes to follicular irritation? overproduction of sebum chocolate stress potato chips

overproduction of sebum Explanation: The overproduction of sebum provides an ideal environment for bacterial growth within the irritated follicle. The follicle becomes further distended and irritated, causing a raised papule in the skin.

The nurse teaches the client who demonstrates herpes zoster (shingles) that once the client has had shingles, they will not have it a second time. a person who has had chickenpox can contract it again upon exposure to a person with shingles. the infection results from reactivation of the chickenpox virus. no known medications affect the course of shingles.

the infection results from reactivation of the chickenpox virus. Explanation: It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity. It is believed that the varicella zoster virus lies dormant inside nerve cells near the brain and spinal cord and is reactivated with weakened immune systems and cancers. A person who has had chickenpox is immune and therefore not at risk of infection after exposure to a client with herpes zoster. Some evidence indicates that infection is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

The nurse is caring for a patient with herpes zoster. The nurse describes the lesions in the patient's chart as which of the following?

vesicles