Integumentary system NCLEX Question style

During the acute phase of a burn, the nurse in-charge should assess which of the following? a. Client's lifestyle b. Alcohol use c. Tobacco use d. Circulatory status

D) During the acute phase of a burn, the nurse should assess the client's circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client's lifestyle and alcohol and tobacco use may be obtained later when the client's condition has stabilized.

The friend of a friend asks you if they should take antibiotics to help get rid of their shingles. You tell them: 1. what do I look like, a doctor? 2. a hammer would probably work better 3. yes they would work fine as shingles are a bacterial infection 4. no because shingles are a virus

no because shingles are a virus

You are assessing a baby and notice small, pimplelike protrusions on her cheeks. These protrusions are called: 1. pustules 2. papules 3. vesicles 4. macules

papules

you are helping in an elementary school and the parents want to know what you are looking for when you are looking for parasitic skin infections. You would tell them (select all that apply) 1. scabies 2. carbuncles 3. lice 4. keloids 5. bed bugs

scabies, lice and bed bugs. carbuncles are bacterial skin infections keloids are raised scars

Giving discharge instructions to a burn patient, the topical agent she is to apply to her wound will cause permanent staining of clothes, linen, walls and floors. Which of the following will she be using: 1. mafenide acetate ( Sulfamylon) 2. silver sulfadiazine (Silvadene) 3. bacitracin ointment 4. silver nitrate 5. O-wutagufiam

silver nitrate

when considering the nutritional needs of the patient, you would include which of the following: (select all that apply) 1. decrease caloric intake 2. increase protein 3. increase vitamin C 4. consider enteral supplementation

increase protein increase vitamin C consider enteral supplementation you would increase caloric intake to meet the metabolic demands of the patient

the victim of a chemical burn received second and third degree burns both her arms, both her legs, her entire torso and her groin. what percentage of burn has she suffered? 1. 90% 2. 91% 3. 64% 4. 99%

91% both arms = 18 both legs = 36 torso = 36 groin = 1

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? a. Scale b. Crust c. Ulcer d. Scar

A) A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't accompany psoriasis.

Which nursing intervention can help a client maintain healthy skin? a. Keep the client well hydrated. b. Avoid bathing the client with mild soap. c. Remove adhesive tape quickly from the skin. d. Recommend wearing tight-fitting clothes in hot weather.

A) Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body's first line of defense. To help a client maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn't remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.

Following a full-thickness (third-degree) burn of his left arm, a female client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict: a. range of motion. b. protein intake. c. going outdoors. d. fluid ingestion.

A) To prevent disruption of the artificial skin's adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn't be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is. The appropriate response by the nurse is: a. "There is no pain associated with this procedure" b. "The local anesthetic may cause a burning or stinging sensation" c. A preoperative medication will be given so you will be sleeping and will not feel any pain" d. "There is some pain, but the physician will prescribe an opioid analgesic following the procedure"

B) Depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. The most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation. Preoperative medication is not necessary with this procedure.

The nurse documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing? a. Inflammatory b. Migratory c. Proliferation d. Maturation

B) The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells, synthesis of scar tissue by fibroblasts, and development of new cells that grow across the wound. In the inflammatory phase, a blood clot forms, epidermis thickens, and an inflammatory reaction occurs in the subcutaneous tissue. During the proliferative phase, the actions of the migratory phase continue and intensify, and granulation tissue fills the wound. In the maturation phase, cells and vessels return to normal and the scab sloughs off.

A client has a pressure ulcer with a large amount of necrotic tissue. Which of the following physician's orders or nursing interventions might you carry out? (select all that apply) a. enzymatic debridement b. wet-to-dry or wet-to-moist dressings c. application of a closed dressing d. a therapeutic bath e. rub the skin vigorously with gauze

a. enzymatic debridement such as with collagenase b. wet-to-dry or wet-to-moist to remove eschar as the dressing dries NOT c. because the tissue needs oxygen d. a therapeutic bath, to help soften eschar NOT e. because that would hurt we should not rub skin even to dry

Which of these statements by the client with pruritus requires the need for reteaching? a. "I will avoid using fabric softeners because harsh chemicals may irritate" b. "I will shower after I get out of the pool" c. "I will take only cool or lukewarm baths" d. "I will wear wool gloves to prevent scratching my skin"

d. wool is iiiiiitchy! the gloves aren't a bad idea though

Your significant other has developed scaly, crusty areas on their lower leg. They tell you that "the itching is driving me batty!" Since you are so smart, you suspect which of the following: 1. eczema 2. psoriasis 3. impetigo 4. shingles

eczema

your niece asks you about the rash she "has grossed out for about a year" on her arm. You have knowledge of chronic skin disorders and would suspect which of the following? (select all that apply) 1. vitiligo 2. dermatitis 3. urticaria 4. psoriasis

vitiligo, dermatitis, psoriasis urticaria is a symptom, not a disorder

a recent recipient of a xenograft asked what the heck it was, so you told him: 1. we took a piece of your skin from somewhere else and put it where you needed it 2. we took a piece of skin from your twin and placed it where you needed it 3. we took a piece of skin from an animal and placed it where you needed it 4. we took a piece of skin from another person and placed it where you needed it

we took a piece of skin from an animal and placed it where you needed it: xenograft 1. autograft 2. isograft 4. homograft