Integumentary Management Davis Ch.29

The nurse is assessing a client. Which findings should the nurse associate with herpes zoster?

Painful vesicles and pruritus The nurse should associate pain and itching with herpes zoster. Herpes zoster follows the path of peripheral sensory nerves.

When assessing a burn victim skin the nurse notices the entire right and left upper extremities are red, moist, weeping, and blistered. How should the nurse document the degree and total body surface area burned?

Partial-thickness burn on 18% TBSA Partial thickness burns damage the dermis and epidermis, often resulting in loss of epidermis and/ or blistering. Each upper extremity is blistered.

The nurse is assessing the client newly diagnosed with psoriasis. Which findings should the nurse expect?

Pruritus at affected areas Lesions appear as red plaques with silvery scales Affected areas at elbows, knees, scalp, plus, or soles

The nurse is teaching a 24-year-old female with severe cystic acne who is prescribed a systemic retinoid acid drug. Which question is priority?

"Are you sexually active?" Sexually active female must be instructed to practice birth control while taking this class of drug to avoid pregnancy

The nurse completes teaching the client with a second-degree burn about silver sulfadiazine. Which client statements should indicate to the nurse that the teaching was effective?

"I apply the cream only to the opened areas of the burned area" "Silver sulfadiazine will prevent an infection of the burned area"

The client is scheduled for application of a cadaver homograph to a burn on the forearm. Which comment by the client demonstrates an accurate understanding of this procedure?

"I know this graft will only be a temporary measure to protect and heal my arm"

The nurse is obtaining a pre-operative health history on the client scheduled for revision of facial scars. Which client comment indicates an increased risk for poor cosmetic outcome?

"I plan to continue taking diclofenac for pain control"

After touching a hot oven great, the client telephone is the emergency department asking for advice for these singed fingers. Which financial statement by the nurse is most appropriate?

"Run cool water over the burned area on your fingers" Cool water will minimize skin redness, pain, and swelling and limit tissue drainage

The nurse is providing postoperative care for the client with a split thickness skin graft on the burn wound at the soul of the right foot. Which is appropriate care for this client?

Immobilization of the graft site The graft must be immobilized so that it can remain in place and be able to revascularize

The client experiences local burning and stinging when mafenide cream is applied to treat a burn injury. Which action should be taken by the nurse?

Inform the client that this is a normal response

The experienced nurse is observing the new nurse administer medications. Which actions by the new nurse required the experience nurse to intervene?

Applies tretinoin to an open wound on the face of a client with acne Withholds fluorouracil because the client's papule of actinic keratosis are worse Waits 2hrs after the client bathes and uses lotion to apply tacrolimus

The experienced nurse is supervising the new nurse. The nurse should intervene if observing the new nurse performing which intervention?

Applying skin lotion to the face, feet, and hands of the client with pemphigus The skin of a person with pemphigus is so fragile that touching the skin can cause it to tear

The nurse is caring for the immobile client who is at risk for developing pressure ulcers. Which food should the nurse recommend?

Baked chicken breast Chicken is high protein food. Proteins are needed to help meet the body's needs for tissue repair and to maintain skin integrity.

The nurse is irrigating the arm of the client with an acid burn. Which factors should prompt the nurse to continue with the irrigation?

Burning sensation is felt in the affected arm Pain reduced from 5 to 2 on scale of 0-10 Affected arm skin surface pH is 4.8

The nurse is concerned that a very dark skinned African-American client may be developing a pressure ulcer on the heel. What should the nurse due to assess for the presence of tissue injury?

Check to see if the area of pressure appears darker than the surrounding skin In a dark skinned client, injured skin may appear darker than surrounding skin.

The nurse is planning care for the client with a stage II pressure ulcer on the ball of the right foot. Which intervention should the nurse include in this client's care?

Cover the protective dressing Reposition q2h Elevate the right heel completely off the bed

The client is being admitted to the emergency department after a house fire. Place the clients problems in the order of priority in which they should be addressed by the nurse.

Inhalation injury from smoke Has 48% partial and full-thickness burn injury Laceration on the face that has stopped bleeding History of HTN

The client receives treatment for uncomplicated lower extremity cellulitis. The nurse notes improvement in the clients condition when which observation is noted on assessment?

Decreased swelling in lower extremity

Three days ago the client received circumferential, partial, and full thickness burns to 30% total body surface area of the chest and abdomen. The nurse monitor the client for restricted breathing due to which psychological response?

Development of a layer of eschar. A layer of eschar or deviated tissue commonly forms over partial and full thickness burns, which, when circumferential and combined with increased fluid retention, can restrict circulation and long expansion

The nurse is planning the care for clients recovering from second or third-degree burns. Which psychosocial nursing problem should be priority?

Disturb body image occurs during the recovering stages of the bone condition and should be priority

The client has a split thickness skin graft taken from the side to cover a burn on the back. Which intervention should the nurse expect to implement to help reduce the risk of infection at the donor and graft site?

Eliminate plants and flowers in the client's room

When assessing the clients skin the nurse notices a rounded area of hair loss with redness, pustules, and skills that appear greenish yellow when exposed to a black light (Wood's lamp). The nurse should plan to implement treatment for which condition?

Fungal infection A fungal infection that manifests on the scalp with red, scaly lesion and hair loss will appear or either greenish yellow or bluish green under a Wood's lamp

The nurse is assessing the client for possible scabies infestation. Which findings should the nurse expect?

Itching and papule-like rash

The nurse is caring for the client at increased risk for developing pressure ulcers. Which measure should the nurse take to limit shearing forces?

Keeping the HOB lower than 30 Keeping the HOB higher than 30° increases the shearing forces to the shoulders, sacrum, and heels. When higher than 30°, the client skin layers in these areas are pulled away from the underlying tissue and blood vessels maybe pinched.

The nurse is caring for the client with psoriasis taking methoxsalen. Which labs are most important for the nurse to monitor

Liver function WBC

The nurse is planning teaching for the client who is using miconazole cream topically for tinea pedis (athlete's foot). Which instruction should the nurse include?

Massage miconazole into the affected area of the foot

The client has an entrance wound on the right hand and an exit wound on the left hand after contact with a high power electrical line. Considering the nature introductory of the electrical current, which nursing action is the priority?

Obtain 12-lead ECG Electrical current will follow through the path of least resistance in the body, which is the bloodstream. The heart could have been damaged by the electrical current. Therefore obtaining a 12 lead ECG is priority

The nurse determines that the fluid status of the client with a second-degree burn is in adequate and immediately notifies the healthcare provider. The client is five hours post burn and weighs 60 kg. Which findings prompted the nurses action?The nurse determines that the fluid status of the client with a second-degree burn is in adequate and immediately notifies the healthcare provider. The client is five hours post burn and weighs 60 kg. Which findings prompted the nurses action?

Pulse 130 and urine output 25ml/hr

The nurse is caring for the client with problems of anxiety and confusion in the critical phase of burn injury. Which interventions should the nurse implement?

Repeat orientation statements of person, place and time Place familiar objects from home near the client Implement a schedule for regular sleep-wake cycles

The nurse is caring for a client with second and third-degree burns. Which medication should the nurse plan to apply topically to treat bacterial and yeast infections?

Silver sulfadiazine Silver sulfadiazine is a topical anti-infective agent for prevention and treatment of wound infection and second and third-degree burns

The nurse is assessing the client using desoximetasone topical cream for an abdominal rash. Which finding should indicate to the nurse that the client is experiencing a known side effect from this medication?

Skin discoloration

The nurse is assessing the clients grafted wound following a skin graft. Which information provided during shift report should prompt the nurse to carefully assess if the client has a wound infection?

Temp 103

The nurse is caring for the client with a burn injury. Which findings should prompt the nurse to notify the healthcare provider because the client may be developing sepsis?

Temperature 103.2 and HR 120

While the nurse is assessing the client hospitalized with recurrent lower extremity cellulitis, the client states, I have athletes foot, do you want to check it? The nurse concludes that this information is significant for what reason?

The skin disruption with tinea pedis may be the cause of cellulitis Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Chronic athletes foot causes minute breaks in the skin, allowing bacteria on the skin to enter the tissue and cause the infection process.

The nurse is caring for the client who is diagnosed with a carbuncle. Which home measures should the nurse discuss?

Use strict hand washing to prevent cross-contamination Cover the mattress and pillows with plastic covers Wash all linens, towels, and clothing after each use

The nurse is speaking with clients during a wellness fair. What information should the nurse provide to prevent or minimize burn injury?

Wear flame-retardant clothing, especially near flames Use stop, drop, and roll if on fire Install smoke detector, including one by the furnace

The client is receiving UV light treatments for psoriasis along with methoxsalen, a photosensitizing agent. What precaution should be followed the first day after treatment?

Wear ultraviolet B-protective sunglasses