Med Surg (summer) Exam 2

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which statement by the client indicates that she has adapted to her changed body image?

"May I go with my family to the visitor's lounge?"

Papule

a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter; common lesions of warts and elevated moles.

6 functions of the skin

protection (3 layers) sensation (feel pain, pressure, temp) fluid balance (sweat and diaphoresis) temperature regulation (98.6 F or 37 C) vitamin production (converts sunlight to vitamin D) immune response function

Erythema

redness of skin

Secondary lesion

result of initial injury

How to reveal jaundice for a colored person

sclera is yellow

Herpes zoster

shingles

Stage 1 pressure ulcer

skin is intact with an area of persistent, nonblanchable redness, usually over a bony prominence, that might feel warm or cool when touched the tissue is swollen and congested, and the client might report discomfort at the site with darker skin tones, the ulcer can appear blue or purple and different from other skin areas

A nurse is assesing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which stage?

stage 2

First degree burn

superficial and limited to the outer layer of dermis

A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which procedure?

surgical excision

Treatment for melanoma

surgical removal and chemotherapy

s/s Cellulitis

swelling, edema, erythema, acutely spread, warmth, tenderness

s/s of peripheral arterial disease

uneven pulses, shiny skin, circular unleration, ischemia

Nursing management of peripheral arterial disease

vasodilators, smoking cessation, avoiding trauma, avoid long periods of standing, use Doppler to detect pulses

Juandice

yellow/orange skin color revealing hepatic problem

Basal cell carcinoma

A tumor of the skin that rarely metastasizes but has the potential for local invasion and damage

A nurse is caring for a client with burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which statement indicates understanding of the teaching?

"I will be on a special shower table."

A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which instructions should the nurse include?

"Shift your weight in the wheelchair every 15 minutes."

Malignancy

A tendency to advance in strength

Silver sulfadiazine cream

A topical medication used in preventing and treating wound infections associated with burns of the skin

Candidiasis

(oral thrush) normal flora of the oral cavity depleted d/t ATB or chemotherapy

high risk Braden score

12 or less

moderate risk Braden score

13-14

low risk Braden score

15-16

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which medication?

Acyclovir

Herpes Zoster

An acute viral disorder characterized by inflammation of the nerve branch and by eruption of blisters The pain may be burning, sharply cutting, stabbing or aching and typically radiates over the entire region supplied by the nerve with accompanying lesions Complication in the eye results in ulceration and blindness

ABCDE method for detecting melanoma

Asymmetry: The mole has an irregular shape. Border: The edge is not smooth, but irregular or notched. Color: The mole has uneven shading or dark spots. Diameter: The spot is larger than the size of a pencil eraser. Evolving or Elevation: The spot is changing in size, shape or texture.

A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which instructions should the nurse include?

Avoid exposure to midday sun

Labs for pressure ulcers

CBC, wound culture

Cancer

Characterized by the excessive growth of malignant cells that invade healthy tissue

A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which trait places a client at risk for developing malignant melanoma?

Light skin

Frostbite

Damage to the skin and underlying tissues caused by extreme cold Distinguishable by the hard, pale, and cold quality of the skin that has been exposed to the cold for a length of time. The area is likely to lack sensitivity to touch, although there may be an aching pain or tingling. As the area thaws, the flesh becomes red and very painful. Hands, feet, nose and ears are the most vulnerable.

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which laboratory finding?

Leukopenia

A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which intervention should the nurse implement?

Immobilize the limb at the level of the heart

A nurse is assessing a client who has a lesion. Which is a clinical manifestation of a malignant Melanoma?

Irregularly shaped lesion with blue tones

Melanoma

Malignant neoplasms in which atypical melanocytes are present in both epidermis and the dermis and sometimes the subcutaneous cells

Most lethal of all skin cancers

Melanoma

A nurse is caring for a client who has a lesion on the back of his hand. The client asks the nurse which type of skin cancer is the most serious. Which response is appropriate?

Melanomas

A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which skin lesions?

Papules

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which source?

Pig skin

Stasis ulcer

Skin breakdown from inadequate circulation, usually on lower extremities toward ankle marked by irregular borders

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?

Sodium 132 mEq/L

A nurse on a surgical unit is caring for four clients who have healing wounds. Which wounds should the nurse expect to heal by primary intention?

Surgical incision

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider?

Temperature 39.1 C (102.4 F)

Pressure ulcer

The formation of a wound due to prolonged pressure on a particular point on the body

Metastases

The spread of cancerous cells from one location in the body to another site, where additional tumors may also develop

Hydrotherapy

The use of externally applied water in the treatment of disease

Burn

Thermal injury to the skin

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which?

Third-degree frostbite

Blanch

To become pale or lose color (usually in the face), usually suddenly and in the context of being saddened or frightened.

A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which finding should the nurse include as an indication of a potential malignancy of a mole?

Ulceration

Peripheral venous disorders

Virchow's triad: Endothelial damage Venous stasis Altered coagulation

A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which nutrient promotes wound healing?

Vitamin C

Diagnostic tests for cellulitis

WBC

Secondary intention

Wounds that are left to heal without approximating the edges, often done with bowel surgeries where feces may have contaminated the wound, such as with a ruptured appendix. The wound fills in with granulation tissue from the bottom up. The epithelium (skin) then fills in over the top of the granulation tissue and the result is a large, wide, scar.

Stage 2 pressure ulcer

partial-thickness skin loss involving the epidermis and the dermis the ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater edema persists, and the ulcer might become infected the client might report pain, and there might be a small amount of drainage.

Secondary skin infection

affects broken skin

Primary skin infection

affects healthy skin

How are chicken pox spread?

airborne

Lesion

an abnormal change in structure of an organ or body part due to injury or disease

Treatment of impetigo

antibiotics (topical or systemic)

Patch testing

applies allergens to skin to detect pruritus or rash

Tinea pedis

athlete's foot

Impetigo

bacterial infection

Cellulitis

bacterial skin infection; inflammatory response

What is hydrotherapy used for?

baths, showers, sits baths, foot baths, debridement and blood flow of wounds

Peripheral arterial disease

blockage of arteries carrying blood to the legs, arms, kidneys and other organs

Cyanosis

bluish discoloration of the skin reveals poor circulation or deoxygenation

Where does metastases from melanoma tend to occur?

bone, liver, lungs, spleen, CNS, and lymph node

Third degree burn

both the epidermis and dermis are destroyed with damage extending into the underlying tissues

Patients with stasis ulcers can develop

cellulitis

Arterial ulcers

circular, well defined, "punched out", usually on toes, foot, ankle covered in slough and necrotic tissue, associated with pain

How is shingles spread?

contact

Treatment for scabies

corticosteroids, oral antihistamines

Cause of peripheral arterial disease

nicotine, high blood pressure, diabetes

Treatment for tine pedis

ointment or cream

Treatment for shingles

pain meds, antiviral meds, Neurontin

Nursing interventions for pressure ulcers

daily assessment, manage moisture, optimize nutrition and hydration, minimize pressure

Second degree burn

damage extends into the dermis

Immunoflourescence

detect antibodies

Biopsy

diagnostic examination of a piece of tissue from the living body to establish malignant cancer cells

How is impetigo transmitted?

direct contact

Nursing management of cellulitis

dressing changes, IV ATB

Normal aging of skin

dryness, wrinkles, thinning, loss of subQ tissue

Nursing management for stasis ulcers

elevate legs, encourage ambulation and use of compression stockings

Nursing management of venous disorders

encourage patient not to use tobacco, wear shoes, stay out of hot tubs, ambulate, elevate extremities, check souls of feet

3 layers of skin

epidermis, dermis, subcutaneous

Stage 3 pressure ulcer

full-thickness tissue loss with damage to or necrosis of subcutaneous tissue the ulcer might extend down to, but not through, underlying fascia the ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone drainage and infection are common

Stage 4 pressure ulcer

full-thickness tissue loss, with destruction, tissue necrosis, and visible damage to muscle, bone, or supporting structures sinus tracts, deep pockets of infection, tunneling, and undermining can occur

Integumentary assessment

health history, onset, signs, symptoms, location, duration, pain, itching, changes in lotions, shampoos, soaps, etc.

Risk factors for venous disorders

heart disease, varicose veins, obesity

s/s venous disorders

heaviness, pain, tenderness, swelling, redness, warmth

Clubbing of the nails is caused by

hypoxemia

Scrapings

identify fungi and paracites

Primary lesion

initial injury

Venous ulcers

irregular bordered, toward ankle, covered with slough, large, minimally painful

Pruritus

itching

Scabies

mites that burrow under skin

Staphylococcus aureus

most common host of impetigo