Exam 6 Integumentary

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:

isolate the client's bed linens until the client is no longer infectious.

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 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.

A nurse is admitting a client with toxic epidermal necrolysis. What is the nursing priority in preventing sepsis?

Preventing infection

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?

Private room

Photochemotherapy has been used as a treatment for which of the following skin disorders?

Psoriasis

A patient is complaining of severe itching that intensifies at night. The nurse decides to assess the skin using a magnifying glass and penlight to look for the "itch mite." What skin condition does the nurse anticipate finding?

Scabies

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

With repeated reactions of contact dermatitis, which of the following can occur?

Secondary bacterial infection

The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?

The skin is ashen gray and dull.

The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?

clubbing

Specific potential complications are common to specific types of burns. Which burns can impair ventilation?

face, neck, chest

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

fissure.

The classic lesions of impetigo manifest as

honey-yellow crusted lesions on an erythematous base.

The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies?

hyperkalemia

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

inflammatory

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

inhaled steroids

Which term describes the transfer of heat from the body to a cooler object in contact with it?

Conduction

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?

Wear rubber gloves when in contact with soaps.

Which term refers to yellowish waxy deposits on the upper and lower eyelids?

Xanthelasma

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

Antiviral

Which of the following measures can be used to cool a burn?

Application of cool water

In a client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

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

Ashen gray and dull.

The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak?

College dormitory

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:

"All family members need to be treated."

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."

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?

"Are the burns associated with chemicals used in the plant?"

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

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?"

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area?

1

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27%

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr

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?

A urine output consistently above 40 ml/hour

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?

Administer analgesic pain medication.

Certain medications are photosensitizing and increase the skin damage that results from sun exposure in the elderly. Therefore, a history of medication use is part of assessing age-related conditions of the skin. Which of the following medications are known to be photosensitizing? Select all that apply.

Antihistamines Antibiotics Diuretics

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

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL

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

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test?

Biopsy

Which of the following is a disadvantage of surgical debridement?

Bleeding

A client has joined a rowing team and has been enjoying the activity for approximately 1 month. The client comes to the clinic for a routine physical examination and shows the nurse the hands, which are observed to have thickened areas in several areas. What does the nurse recognize these are in response to the repeated friction of the oars?

Calluses

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

Chocolate Ice cream

A nurse is teaching a client about vitamins. What vitamin would the nurse recommend the client attain by exposing the skin to ultraviolet light on a daily basis?

Cholecalciferol

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client 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. What is the nurse's best response based on the clinical findings?

Contact the primary care provider and prepare for an escharotomy.

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

Which medication classification may be used for contact dermatitis?

Corticosteroids

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted?

Elevated and palpable

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Epidermis and a portion of deeper dermis.

Which sedative medication is effective for treating pruritus?

Hydroxyzine

A dermatologist recommends an over-the-counter suspension to relieve pruritus. The nurse advises the patient that the lotion should be applied:

Every 3 to 4 hours for sustained effectiveness.

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply.

Fingernails Hair Skin

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

Gastric ulcers

Which of the following actions helps the nurse to determine the quality of the skin turgor?

Grasping the skin

Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn?

Hyperglycemia

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?

Identification by the destruction of the dermis and epidermis

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria?

Impetigo

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

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?

Kaposi sarcoma

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

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

Lactated Ringer's solution

Which factor causes wrinkles among older adults?

Loss of subcutaneous tissue

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

Low tissue oxygenation

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.

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?

Moist sterile saline gauze

Which of the following is the analgesic of choice for burn pain?

Morphine

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?

Music therapy may provide reality orientation, distraction, and sensory stimulation.

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

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding?

Pearly white substance that is attached to the hair shaft that is not removed with brushing

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

Which of the following observations helps the nurse in determining adequate oxygenation?

Pink nail beds

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 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

The nurse is assessing a patient for psoriatic lesions after treatment with a nonsteroidal cream. What type of lesion does the nurse know is characteristic of psoriasis?

Red, raised patch covered with silver scales

Which of the following is a true statement regarding the purposes of skin grafts?

Reduces scarring and contractures.

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 circumferential eschar

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:

Removal of the tumor, layer by layer.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:

Replace lost fluids and electrolytes.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?

Risk for Impaired Gas Exchange

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?

Roll the client in a blanket.

A patient has been prescribed mafenide acetate cream for burn treatment. The nurse should educate the patient regarding which of the following?

Severe burning pain for up to 20 minutes

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?

Skin grafting will be necessary.

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

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

Superficial

Which term describes a fungal infection of the scalp?

Tinea capitis

The nurse is triaging a client over the phone who states having a contact dermatitis rash. Which treatment option of over-the-counter preparations does the nurse suggest for the client? Select all that apply.

Topical antihistamines Hydrocortisone cream Moisturizing cream Lanolin based ointment

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?

Tretinoin (retinoic acid [Retin-A])

The nurse working at a physician's office is providing teaching to the parent of a child diagnosed with Tinea capitis (ringworm of the head). How often should the nurse instruct the parent to shampoo the child's hair with ketoconazole or a selenium sulfide shampoo?

Twice weekly

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.

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.

The nurse is instructing the parents of a child with head lice. Which statement should the nurse include?

Use shampoo with piperonyl butoxide.

As the first priority of care, a patient with a burn injury will initially need:

a patent airway established.

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

anemia.

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 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 is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have?

psoriasis

The nurse teaches the client who demonstrates herpes zoster (shingles) that

the infection results from reactivation of the chickenpox virus.