Integumentary

When caring for a client, what clinical indicators should the nurse immediately report to the health care provider? (Select all that apply.) 1. Weakness 2. Diaphoresis 3. Tachycardia 4. Cold extremities 5 . Flushed skin tone

1. Weakness 2. Diaphoresis 3. Tachycardia 4. Cold extremities

When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating: 1. Eggs." 2. Shellfish." 3. Fried poultry." 4. Cottage cheese."

2. Shellfish."

A client newly diagnosed with scleroderma states, "Where did I get this from?" The nurse's best response is "Although no cause has been determined for scleroderma, it is thought to be the result of: 1. Autoimmunity." 2. Ocular motility." 3. Increased amino acid metabolism." 4. Defective sebaceous gland formation."

1 Autoimmunity."

A health care provider prescribes bed rest, loperamide (Maalox), and esomeprazole (Nexium) for a client who just had major surgery. After several days of this regimen, the client complains of diarrhea. The nurse concludes that the most likely cause of the diarrhea is: 1. Loperadine 2. Esomeprazole 3. Bed rest 4. Diet alteration

1. Loperadine **Loperadine, a combination antacid, contains magnesium hydroxide, which may cause diarrhea; it also contains aluminum hydroxide, which may cause constipation.

A client has a basal cell epithelioma that is scheduled to be removed. The client expresses concerns that the cancer has spread. What is the best response by the nurse? 1. "You are a low surgical risk." 2. "I can understand how you must feel." 3. "Basal cell tumors usually do not spread." 4. "The health care provider probably caught it just in time."

3. "Basal cell tumors usually do not spread."

A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should: 1. Cover the cast with plastic wrap until dry 2. Assist with weight bearing when the client ambulates 3. Elevate the affected leg above the level of the heart 4. Insert a finger inside the edges of the cast to check for skin abrasions

3. Elevate the affected leg above the level of the heart

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately? 1. Small amount of yellowish green oozing 2. Moderate area of serosanguineous oozing 3. Epithelialization under the nonadherent dressing 4. Separation of the edges of the nonadherent dressing

1. Small amount of yellowish green oozing

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. The nurse's best response is: 1. "This type of schedule gives noncancerous cells time to recover." 2. "The department only operates from Monday through Friday." 3. "Your energy level will be increased greatly by a five day schedule." 4. "Side effects are eliminated when treatment is administered for five rather than seven days."

1 "This type of schedule gives noncancerous cells time to recover."

A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? (Select all that apply.) 1. Eat foods high in vitamin C. 2. Take your temperature daily. 3. Balance periods of rest and activity. 4. Use a strong soap when washing the skin. 5. Expose the skin to the sun as often as possible.

1. Eat foods high in vitamin C. 2. Take your temperature daily. 3. Balance periods of rest and activity. **Vitamin C should be encouraged because it is essential for the biosynthesis of collagen. A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not necessary.Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.

A client is admitted with the diagnosis of tetanus. For which clinical indicators should the nurse assess the client? (Select all that apply.) 1. Restlessness 2. Muscular rigidity 3. Atony of facial muscles 4. Respiratory tract spasms 5. Spastic voluntary muscle contractions

1. Restlessness 2. Muscular rigidity 4. Respiratory tract spasms 5. Spastic voluntary muscle contractions

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? (Select all that apply.) 1. Scaly lesions 2. Pruritic lesions 3. Reddened papules 4. Multiple petechiae 5 . Erythematous macules

1. Scaly lesions 2. Pruritic lesions 3. Reddened papules

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? 1. Oral 2. Topical 3. Intravenous 4. Intramuscular

2 Topical

A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aide station. The nurse encourages the client to seek medical attention but the client refuses. The nurse advises the person to go to a health care provider if: 1. Blisters appear 2. Urinary output decreases 3. Edema and redness occur 4. Low-grade fever develops

2 Urinary output decreases

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? (Select all that apply.) 1. Age 2. Anorexia 3. Hemiplegia 4. History of diabetes 5 . Urinary incontinence

2. Anorexia 3. Hemiplegia 5 . Urinary incontinence

A client receives a scalding burn to the chest and arms. The nurse assesses that the burned areas are painful, mottled red, weeping, and edematous. These burns are classified as: 1. Eschar 2. Full-thickness burns 3. Deep partial-thickness burns 4. Superficial partial-thickness burns

3 Deep partial-thickness burns

The nurse is providing care for a client that is on bed rest. The nurse can prevent skin breakdown for this client by: 1. Massaging the bony prominences 2. Maintaining a sheepskin pad under the client 3. Promoting range-of-motion activities 4. Encouraging the client to move around as much as possible

4 Encouraging the client to move around as much as possible

An older client is brought to the hospital by a family member because of deep partial-thickness burns on thearms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse? 1. "You sound upset, but your health care provider knows best. You should do what is prescribed." 2. "Your spouse is very capable, but if your burns get infected, a family member can't give you the injections you will need." 3. "Your burns are more serious than you think, and we have specially trained people here just to take care of you." 4. "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

4. "You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is: 1. 20 2. 25 3. 30 4. 36

4. 36 **Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% for both arms) and 18% for the chest; thus the total body surface area burned is 36%. Twenty percent, 25%, and 30% are too low.

A client with burns is to receive the exposure method of treatment with application of mafenide (Sulfamylon) twice a day. With this type of treatment the nurse plans to: 1. Use medical asepsis 2. Apply a dry sterile dressing 3. Monitor liver function studies 4. Administer prescribed pain medication

4. Administer prescribed pain medication

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? 1. Readiness to discuss the client's deformities 2. Indication of a change in family relations 3. Need for more time to think about the future 4. Beginning realization of implications for the future

4. Beginning realization of implications for the future

The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered to a person that suffers extensive burns. An appropriate response by the nurse is to call 911 and: 1. Apply ice to burned areas; the intervention will decrease pain 2. Use first aid cream to burned areas 3. Do nothing; attempting to treat the burned areas may cause further damage 4. Cover the burned areas with a bed sheet

4. Cover the burned areas with a bed sheet

A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiological response to the radiation should the nurse assess the client during the return visit to the radiology department? 1. Ataxia 2. Hypoxia 3. Arthralgia 4. Dysphagia

4. Dysphagia

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the Rule of Nines. Record your answer using one decimal place. ________%

The front of the head is 4.5%, and the anterior torso is 18%, for a total of 22.5%.

A nurse is assessing a client with second-degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage of the body that was burned using the Rule of Nines. Record your answer using one decimal place. ________%

The front of the head is 4.5%, and the anterior torso is 18%, for a total of 22.5%.

A client is recovering from full-thickness burns and the nurse provides counselling on how to best meet nutritional needs. When which foods are selected does the nurse identify that the client understands the teaching? 1. Cheeseburger and a malted 2. Beef barley soup and orange juice 3. Bacon and tomato sandwich and tea 4. Chicken salad sandwich and soft drink

1. Cheeseburger and a malted

A client is recovering from full-thickness burns and the nurse provides counselling on how to best meet nutritional needs. When which foods are selected does the nurse identify that the client understands the teaching? 1. Cheeseburger and a malted 2. Beef barley soup and orange juice 3. Bacon and tomato sandwich and tea 4. Chicken salad sandwich and soft drink

1. Cheeseburger and a malted **Of the selections offered, a cheeseburger and a malted have the highest calories and protein, which are needed for the increased basal metabolic rate associated with burns and for tissue repair.

A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath? 1. 92° to 94° F 2. 95° to 97° F 3. 98° to 100° F 4. 101° to 103° F

3. 98° to 100° F

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care? 1. Cool, moist towels 2. Dry, sterile dressings 3. Analgesic sunburn spray 4. Vitamin A and D ointment

1 Cool, moist towels

A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes? 1. Deep breathing exercises 2. Progressive muscle relaxation 3. Active range-of-motion exercises 4. Important elements of wound care

1 Deep breathing exercises

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound? 1. In the preoperative period 2. Two days before discharge 3. On the first postoperative day 4. During the first dressing change

1 In the preoperative period

A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man's hand in a soiled cloth and drives him to the nearest hospital. The nurse is: 1. Negligent and can be sued for malpractice 2. Practicing under guidelines of the nurse practice act 3. Protected for these actions, in most states, by Good Samaritan legislation 4. Treating a health problem that can and should be addressed by a primary health care provider

1 Negligent and can be sued for malpractice

A client who has been diagnosed with Lyme disease is started on doxycycline (Vibramycin) as part of the therapy. What should the nurse do when administering this drug? 1. Administer the medication with meals or a snack. 2. Provide orange or other citrus fruit juice with the medication. 3. Give the medication an hour before milk products are ingested. 4. Offer antacids 30 minutes after administration if gastrointestinal side effects occur.

3. Give the medication an hour before milk products are ingested.

A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. The nurse calculates that the hourly intravenous (IV) fluid should be: Record your answer using a whole number. __________ mL/hr

300 mL/hr is the correct rate that the IV should be set at based on the health care provider's prescription. 7200 mL ÷ 24 hours = 300 mL/hr. 175 mL/hr and 200 mL/hr are too slow and are incorrect calculations. 325 mL/hr is too fast and is an incorrect calculation.

A client sustains full-thickness and deep partial-thickness burns. The client asks, "What is the difference between my full-thickness and deep partial-thickness burns?" The nurse explains that full-thickness burns: 1. Extend into the subcutaneous tissue; deep partial-thickness burns affect only the epidermis 2. Involve superficial layers of the epidermis; deep partial-thickness burns extend through the epidermis 3. Extend through the epidermis and only part of the dermis; deep partial-thickness burns extend into the subcutaneous tissue 4. Extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis

4. Extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase? 1. Alleviate pain 2. Prevent infection 3. Replace blood loss 4. Restore fluid volume

4. Restore fluid volume

A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). The plan should include the importance of: 1. Trimming toenails so that they are short and rounded 2. Checking bathwater temperature by putting the toes in first 3. Using alcohol to rub hands, feet, legs, and arms at least two times a day 4. Securing professional treatment for any minor injuries to the extremities

4. Securing professional treatment for any minor injuries to the extremities

A health care provider prescribes 2 L of intravenous (IV) fluid to be administered every 12 hours to a client who sustained a burn injury. The drop factor of the tubing is 10 gtts/mL. The nurse should set the flow rate at how many drops per minute? Record your answer using a whole number. __________ gtts/min

Multiply the amount to be infused (2000 mL) by the drop factor (10), and divide the result by the amount of time in minutes (12 hours × 60 min).

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. The nurse's best response is: 1. "This type of schedule gives noncancerous cells time to recover." 2. "The department only operates from Monday through Friday." 3. "Your energy level will be increased greatly by a five-day schedule." 4. "Side effects are eliminated when treatment is administered for five rather than seven days."

1. "This type of schedule gives noncancerous cells time to recover."

A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force? 1. 30 degrees 2. 45 degrees 3. 60 degrees 4. 90 degrees

1. 30 degrees

What are expected changes that the nurse might identify when assessing the skin of an older adult? (Select all that apply.) 1. Scaly skin 2. Increased wrinkles 3. Signs of ecchymosis 4. Marked flaking of skin 5. Hyperpigmented patches

2. Increased wrinkles 5. Hyperpigmented patches

A nurse is caring for a client with severe burns. The nurse determines that this type of client is at risk for hypovolemic shock because of the: 1. Decreased rate of glomerular filtration 2. Excessive blood loss through the burned tissues 3. Plasma proteins moving out of the intravascular compartment 4. Sodium retention occurring as a result of the aldosterone mechanism

3. Plasma proteins moving out of the intravascular compartment

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. The nurse determines that further teaching is necessary when the client states that to avoid skin irritation and breakdown the client will: 1. Leave the skin markings intact 2. Protect the skin from sources of heat 3. Wear soft clothing over the upper body 4. Use an oatmeal-based lotion after each treatment

4. Use an oatmeal-based lotion after each treatment

When assessing a wound that is healing by secondary intention, the nurse can classify it according to its condition and color. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate? 1. Red 2. Black 3. Green 4. Yellow

4. Yellow

A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist: 1. Helps health care providers to control infections 2. Decides what antibiotics should be prescribed for infections 3. Works in the laboratory identifying bacteria that cause infection 4. Is responsible for collecting specimens of potentially infectious drainage

1. Helps health care providers to control infections

A health care provider tells a client that vitamin E and beta-carotene are important for healthier skin. Which foods should the nurse recommend that are excellent sources of both of these substances? 1. Spinach and mangoes 2. Fish and peanut butter 3. Oranges and grapefruits 4. Carrots and sweet potatoes

1. Spinach and mangoes

A client is admitted to the hospital with severe burns. What client response should the nurse anticipate when caring for the client during the acute phase of burn recovery? 1. Stable vital signs 2. Decreased urinary output 3. High serum potassium levels 4. Intravascular fluid volume deficits

1. Stable vital signs

A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. The best initial response by the nurse is: 1. "Why did you sign the consent?" 2. "Can you tell me why you decided to refuse the procedure?" 3. "You are obviously afraid about something concerning the procedure." 4. "Although the procedure is very important, I understand why you changed your mind."

2. "Can you tell me why you decided to refuse the procedure?"

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? (Select all that apply.) 1. Age 2. Anorexia 3. Hemiplegia 4. History of diabetes 5. Urinary incontinence

2. Anorexia 3. Hemiplegia 5. Urinary incontinence

A client is scheduled for surgery. Legally, the client may not sign the operative consent if: 1. Ambivalent feelings are present and acknowledged 2. Any sedative type of medication has been given recently 3. A discussion of alternatives with two health care providers has not occurred 4. A complete history and physical has not been performed and recorded

2. Any sedative type of medication has been given recently

A client is admitted for malignant melanoma that was discovered during a routine eye examination. For which preferred treatment does the nurse expect the client to be scheduled? 1. Radiation 2. Enucleation 3. Cryosurgery 4. Chemotherapy

2. Enucleation

During the first 48 hours after a client has sustained a thermal injury, the nurse should assess for: 1. Hypokalemia and hyponatremia 2. Hyperkalemia and hyponatremia 3. Hypokalemia and hypernatremia 4. Hyperkalemia and hypernatremia

2. Hyperkalemia and hyponatremia

What are expected changes that the nurse might identify when assessing the skin of an older adult? (Select all that apply.) 1. Scaly skin 2. Increased wrinkles 3. Signs of ecchymosis 4. Marked flaking of skin 5 . Hyperpigmented patches

2. Increased wrinkles 5 . Hyperpigmented patches

In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. The nurse identifies that the client understands the instructions when the client states, "I will: 1. Sit in a chair for several hours every day." 2. Inspect the incision for healing when I change the dressing." 3. Check to see whether the staples have dissolved within a few days." 4. Call the health care clinic if I see any clear drainage coming from the incision."

2. Inspect the incision for healing when I change the dressing."

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care? 1. Use calamine lotion for pruritus 2. Keep skin lubricated with lotion 3. Apply warm soaks to inflamed areas 4. Take frequent baths to remove scaly lesions

2. Keep skin lubricated with lotion

A nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the primary concern of the nurse when caring for this client? 1. Fluid volume 2. Skin integrity 3. Physical mobility 4. Urinary elimination

2. Skin integrity

A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? 1. Bananas 2. Strawberries 3. Green beans 4. Sweet potatoes

2. Strawberries **Strawberries contain 88 mg of vitamin C (ascorbic acid) per cup. One banana contains 12 mg of ascorbic acid. One cup of green beans contains 21 mg of ascorbic acid. One baked sweet potato contains 25 mg of ascorbic acid.