INTEGUMENTARY SYSTEM

4. A female client is brought to the emergency department with second- and third-degree 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? A. 18% B. 27% C. 30% D. 36%

D

Nurse Mary is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect? A. Polyurethane foam mattress B. Ring or donut C. Gel flotation pad D. Water bed

B

Which assessment finding calls for the most immediate further assessment or interventions? A. Bilateral erythema of the face and neck. B. Bluish color around the earlobes and lips. C. Dark brown spotting on the back and chest. D. Yellow color of the skin and sclera.

B

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

A

Which of the following clients would least likely be at risk of developing skin breakdown? A. A client incontinent of urine feces B. A client with chronic nutritional deficiencies C. A client with decreased sensory perception D. A client who is unable to move about and is confined to bed

C

2. In a female client with burns on the legs, which nursing intervention helps prevent contractures? A. Applying knee splints B. Elevating the foot of the bed C. Hyperextending the client's palms D. Performing shoulder range-of-motion exercises

A

.Dr. Martinez prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond? A. "This makes the skin feel soft." B. "This prevents evaporation of water from the hydrated epidermis." C. "This minimizes cracking of the dermis." D. "This prevents inflammation of the skin."

B

The nurse is assessing a male client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem? A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B. Urine output of 20 ml/hour C. White pulmonary secretions D. Rectal temperature of 100.6° F (38° C)

B

The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to: A. use cosmetic camouflage techniques. B. protect the graft from direct sunlight. C. continue physical therapy. D. apply lubricating lotion to the graft site.

B

A female client with cellulites of the lower leg has had cultures done on the affected area. The nurse reading the culture report understands that which of the following organisms is not part of the normal flora of the skin? A. Staphylococcus epidermidis B. Staphylococcus aureus C. Escherichia coli (E. coli) D. Candida albicans

C

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed one (1) week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion? A. Melanoma is characterized by local invasion. B. Melanoma is highly metastatic. C. Metastasis is rare. D. Melanoma is encapsulated.

B

Nurse Tamara 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: A. wash hands, apply a pediculicide to the client's scalp, and remove any observable mites. B. isolate the client's bed linens until the client is no longer infectious. C. notify the nurse in the day surgery unit of a potential scabies outbreak. D. place the client on enteric precautions.

B

The clinic nurse notes that the physician has documented a diagnosis of herpes zoster (shingles) in the male client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made following which diagnostic test? A. Patch test B. Skin biopsy C. Culture of the lesion D. Woo's light examination

C

The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching? A. "To make the bandage tightly wrapped ." B. "My foot should feel cold." C. "I'll include fruits and vegetables in my meal plan." D. "I'll restrict my intake of protein."

C

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following? A. A firm, nodular lesion topped with crust. B. A pearly papule with a central crater and a waxy border. C. An irregularly shaped lesion. D. A small papule with a dry, rough scale.

C

A male client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction? A. "Avoid sexual intercourse until you've completed treatment, which takes 14 to 21 days." B. "Wash your hands thoroughly to avoid transferring the infection to your eyes." C. "If you have intercourse before treatment ends, tell sexual partners of your status and have them wash well after intercourse." D. "If you don't get treatment, you may develop meningitis and suffer widespread central nervous system (CNS) damage."

B

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

Nurse Imee is implementing a teaching plan to a group of adolescents regarding the causes of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder? A. "Acne is caused by oily skin" B. "The actual cause is not known" C. "Acne is caused by eating chocolate" D. "Acne is caused as a result of exposure to heat and humidity"

B

Nurse Keith is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. He should inform those attending the session that the first priority intervention in the event of this occurrence is which of the following? A. Remove jewelry and constricting clothing from the victim. B. Move the victim to a safe area away from the snake and encourage the victim to rest. C. Immobilize the affected extremity. D. Place the extremity in a position so that it is below the level of the heart.

B

18. A male client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribe: A. an I.V. corticosteroid. B. an I.V. antibiotic. C. an oral antibiotic. D. a topical agent.

D

A client calls the emergency department and tells the nurse that he had been cleaning a wooden area in the backyard and came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and ask the nurse what to do. Which of the following is the appropriate nursing response? A. "Apply calamine lotion immediately to the exposed skin areas." B. "It is not necessary to do anything if you cannot see anything on your skin." C. "Come to the emergency department." D. "Take a shower immediately, lathering, and rinsing several times."

D

A female client went to the emergency department states that she is having burning and intense itching on the skin. A further assessment made by the nurse notes that the client is having red and white patches in the mouth. Based on this, the nurse understand that the client is most likely is suffering from? A. Shingles. B. Erysipelas. C. Eczema. D. Candida Albicans.

D

The nurse prepares discharge instructions for a male client following cryosurgery for the treatment of a malignant skin lesion. Which of the following should the nurse include in the instruction? A. Avoid showering for 7 to 10 days B. Apply ice to the site to prevent discomfort C. Apply alcohol-soaked dressing twice a day D. Clean the site with hydrogen peroxide to prevent infection

D

Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? A. Turn and reposition the client at least once every 8 hours. B. Vigorously massage lotion into bony prominences. C. Post a turning schedule at the client's bedside .D. Slide the client, rather than lifting, when turning.

C

Nurse Luis is caring for a client who has just had a squamous cell carcinoma removed from the face. Which activities can you delegate to an experienced nursing LPN/LVN? A. Monitoring the surgical site for swelling, bleeding or pain. B. Teaching the client about risk factors for squamous cell carcinoma. C. Discussing the reasons for avoiding aspirin use for a week after surgery. D. Showing the client how to take care for the surgical site at home.

A

The client arrives at the emergency department and has experienced frostbite to the right hand. Which of the following would the nurse note on assessment of the client's hand? A. A white color to the skin, which is insensitive to touch. B. A pink, edematous hand. C. A fiery red skin with edema in the nail beds. D. Black fingertips surrounded by an erythematous rash.

A

The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment? A. Lips B. Sacrum C. Earlobes D. Back of the hands

A

The nurse is assigned to care for a female client with herpes zoster (Shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection? A. Clustered skin vesicles B. A generalized body rash C. Small blue-white spots with a red base D. A fiery red, edematous rash on the cheeks

A

The nurse manager is planning the clinical assignments for the day. Which staff members can be assigned to care for a client with herpes zoster? Select all that apply A. The nurse who never had German Measles. B. The nurse who never received the varicella zoster vaccine. C. The nurse who never had mumps. D. The nurse who never had roseola.E. The nurse who never had chicken pox.

A

When assessing a lesion diagnosed as malignant melanoma, the nurse in-charge most likely expects to note which of the following? A. An irregular shaped lesion B. A small papule with a dry, rough scale C. A firm, nodular lesion topped with crust D. A pearly papule with a central crater and a waxy border

A

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

JT being the charge nurse for today is providing orientation to Nurse Brad, a newly hired employee. Which of the following action by Nurse Brad requires the most immediate action? A. Educating a newly admitted burn client regarding the use of pressure garments. B. Obtaining an anaerobic culture specimen from a superficial burn wound. C. Administering tetracycline with a glass of milk to a client with cellulitis .D. Discussing the use of herpes zoster vaccine with a 20-year-old client.

C

Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest How should the nurse apply this topical agent? A. With a circular motion, to enhance absorption B. With an upward motion, to increase blood supply to the affected area C. In long, even, outward, and downward strokes in the direction of hair growth D. In long, even, outward, and upward strokes in the direction opposite hair growth

C

Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first? A. Assess the drainage in the dressing .B. Slowly remove the soiled dressing C. Wash hands thoroughly. D. Put on latex gloves.

C

A male client arrives at the emergency room and has experienced frostbites to the right hand. Which of the following would the nurse note on assessment of the client's hand? A. A pink, edematous hand B. A fiery red skin with edema in the nail beds C. Black fingertips surrounded by an erythematous rash D. A white color to the skin, which is insensitive to touch

D

A male client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: A. fluid resuscitation. B. infection .C. body image. D. pain management.

D

A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions. The nurse expects that these lesions will appear to be: A. Ring-shaped B. Linear C. Shaped like an arc D. Net-like appearance

D

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

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

D

The clinic nurse is assessing the skin of a white client who is diagnosed with psoriasis. Which of the following characteristic is associated with this skin disorder? A. Clear, thin nail beds B. Red-purplish scaly lesions C. Oily skin and no episodes of pruritus D. Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions

D

The clinic nurse notes that the physician has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made following which diagnostic test? A. Wood's light examination .B. Patch test. C. Skin biopsy .D. Culture of the lesion

D

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? A. Intact skin B. Full-thickness skin loss C. Exposed bone, tendon, or muscle D. Partial-thickness skin loss of the dermis

D

The nurse is reviewing the healthcare record of a male clients scheduled to be seen at the health care clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder? A. An adolescent B. An older female C. A physical education teacher D. An outdoor construction worker

D

A female client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid exercise because it may: A. dislodge the autografts. B. increase edema in the arms. C. increase the amount of scarring. D. decrease circulation to the fingers.

A

Nurse Harry 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. Proliferative D. Maturation

B

15. A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause: A. palpitations. B. dizziness. C. diarrhea. D. metallic taste.

C

3. A male 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 would best prevent skin damage? A. "Minimize sun exposure from 1 to 4 p.m. when the sun is strongest." B. "Use a sunscreen with a sun protection factor of 6 or higher." C. "Apply sunscreen even on overcast days." D. "When at the beach, sit in the shade to prevent sunburn."

C

A client with a severe cellulitis on the left hand was ordered to have cultures done on the affected area. After few days, the culture report was released. The nurse understands that which of the following organisms is not part of the normal flora of the skin? A. Staphylococcus aureus. B. Candida albicans. C. Campylobacter jejuni. D. Staphylococcus epidermidis.

C

A client has been taking prednisone (Deltasone) 20 mg once a day to treat severe seborrheic dermatitis. Which of the following assessment findings is of most concern? A. Complaints of epigastric pain B. Blood pressure 145/90 mm Hg. C. Blood glucose level 129 mg/dL. D. Complaints of increase appetite.

A

1. When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Ineffective airway clearance related to edema of the respiratory passages B. Impaired physical mobility related to the disease process C. Disturbed sleep pattern related to facility environment D. Risk for infection related to breaks in the skin

A

A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true? A. During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery. B. Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days C. Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms. D. A client with genital herpes lesions can have sexual contact but must use a condom.

A

A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should: A. turn him frequently. B. perform passive range-of-motion (ROM) exercises. C. reduce the client's fluid intake. D. encourage the client to use a footboard.

A

An older client's physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin? A. Cherry angioma B. Spider angioma C. Venous star D. Purpura

A

Which of the following individuals is least likely to be at risk of developing psoriasis? A. A 32 year-old-African American B. A woman experiencing menopause C. A client with a family history of the disorder D. An individual who has experienced a significant amount of emotional distress

A

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

A

A 30-year old woman who has been taking isotretinoin (Accutane) to treat severe cystic acne make all these statements while being seen for a follow-up examination. Which statement is of most concern? A. "Sometimes I get nauseated after taking the medication." B. "My husband and I are thinking of starting a family soon." C. "I have been having problems driving when it gets dark." D. "I don't think there has been much improvement in my skin."

B

7. A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? A. Related to potential interactions between the topical corticosteroid and other prescribed drugs B. Related to vasodilatory effects of the topical corticosteroid C. Related to percutaneous absorption of the topical corticosteroid D. Related to topical corticosteroid application to the face, neck, and intertriginous sites

C

A client is being admitted for the treatment of acute cellulitis of the thigh. The client asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that the characteristics of cellulitis include: A. An epidermal and lymphatic infection caused by Staphylococcus. B. An inflammation of the epidermis only. C. A skin infection into the subcutaneous tissue and dermis. D. An acute superficial infection of the lymphatics and dermis.

C

A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of: A. cancer of the ovaries. B. cancer of the uterus. C. cancer of the cervix. D. cancer of the vagina.

C

A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide? A. "Apply one applicator of terconazole intravaginally at bedtime for 7 days." B. "Apply one applicator of tioconazole intravaginally at bedtime for 7 days." C. "Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days." D. "Apply sulconazole nitrate twice daily by massaging it gently into the lesions."

C

A nurse is developing a care plan for a client suffering from shingles. Which of the following cranial nerve should the nurse assess as part of the client's care? A. Cranial nerve number I B. Cranial nerve number IV C. Cranial nerve number VII D. Cranial nerve number XI

C

Following a small-bowel resection, a male client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is: A. erythema. B. leukocytosis. C. pressure-like pain. D. swelling.

C

Nurse Chael is performing a skin assessment on a new resident in a long-term care facility. Which finding is of most concern? A. All the toenails are thickened and yellow .B. Silver scaling is present on the elbows and knees. C. An irregular border is seen on a black mole on the scalp D. Numerous striae are noted across the abdomen and buttocks.

C

Nurse JV is performing wound care. Which of the following practices violates surgical asepsis? A. Holding sterile objects above the waist B. Considering a 1″ edge around the sterile field as being contaminated C. Pouring solution onto a sterile field cloth D. Opening the outermost flap of a sterile package away from the body

C

Nurse Jeff is performing skin assessment on a client with a facial lesion. It appears as a well-defined, red, scaling, thickened bump. This type of skin lesion refers to? A. Kaposi's Sarcoma. B. Melanoma. C. Squamous cell .D. Basal cell.

C

.A male client seen in an ambulatory clinic has a butterfly rash across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders? A. Hyperthyroidism B. Pernicious anemia C. Cardiopulmonary disorders D. Systemic lupus erythematosus (SLE)

D

16. A female client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief complaint was intertrigo. This term refers to which condition? A. Spontaneously occurring wheals B. A fungus that enters the skin's surface, causing infection C. Inflammation of a hair follicle D. Irritation of opposing skin surfaces caused by friction

D

A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms? A. Purpura B. Petechiae C. Ecchymosis D. Erythema

C

6. 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

Following a full-thickness (third-degree) burn of his left arm, a male 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

Following a full-thickness (third-degree) burn of his left arm, a male 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

In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client? A. A urine output consistently above 100 ml/hour B. A weight gain of 4 lb (2 kg) in 24 hours C. Body temperature readings all within normal limits D. An electrocardiogram (ECG) showing no arrhythmias

A

Nurse Kevin reviews the client's chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during the assessment? A. Red shiny skin around the nail bed B. White taut skin in the popliteal area C. White silvery patches on the elbows D. Swelling of the skin near the parotid gland

A

The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse anticipates that which of the following will be prescribed for the client? A. Cold compress to the affected area B. Warm compress to the affected area C. Intermittent heat lamp treatments four times daily D. Alternating hot and cold compresses continuously

B

A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to this drug? A. Aplastic anemia B. Ototoxicity C. Cardiac arrhythmias D. Seizures

B

A female client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse teaches the client about the importance of protecting the skin from ultraviolet light before drug administration and for 8 hours afterward and stresses the need to protect the eyes. After administering medication for photochemotherapy, the client must protect the eyes for: A. 4 hours. B. 8 hours. C. 24 hours .D. 48 hours.

D

The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching? A. "I'll limit my intake of protein." B. "I'll make sure that the bandage is wrapped tightly." C. "My foot should feel cold." D. "I'll eat plenty of fruits and vegetables."

D

Which of the following is the initial intervention for a male client with external bleeding? A. Elevation of the extremity B. Pressure point control C. Direct pressure D. Application of a tourniquet

C

Nurse Sierra is assessing the skin of a client suffering from psoriasis. She understands that which characteristic is associated with this skin disorder? A. Red-purplish scaly lesions. B. Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions. C. Clear, thin nail beds. D. Oily skin and absence of pruritus.

B

20. When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care? A. Placing mitts on the client's hands B. Administering systemic antibiotics as prescribed C. Applying topical antibiotics as prescribed D. Continuing to administer antibiotics for 21 days as prescribed

B