NCLEX Integumentary
The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching?
"I can sit in my favorite chair all day."
The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions?
"I need to assess my skin for lesions that appear net-like."
The nurse has provided home care instructions to a client after blepharoplasty. Which statement by the client indicates a need for further instruction?
"I need to keep ice on my eyes for at least 3 days."
The nurse has provided home care instructions to a client after dermabrasion. Which statement by the client indicates a need for further instruction?
"I need to keep my skin dry to allow it to heal."
A client has undergone laser surgery to remove 2 nevi. The nurse determines that the client has understood discharge instructions if the client makes which statement?
"I need to protect the operated areas from direct sunlight for at least 3 months."
The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction?
"I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."
The nurse is providing home care instructions to a client after rhinoplasty. Which statement by the client indicates a need for further instruction?
"I should be sure to run a dehumidifier in my home."
Collagenase is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication?
"I will apply the ointment once a day and cover it with a sterile dressing."
A client is seen in the health care clinic 2 weeks after rhinoplasty. The client tells the nurse that the upper lip is numb. Which nursing response would be appropriate?
"In many cases the nose and upper lip are numb for up to 6 months."
The nurse provides home care instructions to a client diagnosed with impetigo. Which statement by the client indicates the need for further instruction?
"It is not necessary to separate my linens and towels from those of other household members."
The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response?
"Leaking blood vessels have led to decreased protein amounts in the blood."
A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?
"Take a shower immediately, lathering and rinsing several times."
Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction?
"The UV light treatments are given on consecutive days."
The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction?
"The client should be maintained in a standing position."
Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?
"The medication is likely to cause stinging every time it is applied."
A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis?
"This skin infection involves the deep dermis and subcutaneous fat."
The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions?
"You will need to wear dark eye goggles during the treatment."
When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply.
-A pearly papule with a central crater and a waxy border -Location in the bald spot atop the head that is exposed to outdoor sunlight
The nurse in the ambulatory care clinic is reviewing a plan of care for a client who will be returning from the postanesthesia care unit after a blepharoplasty. Which nursing interventions should be a component of the postoperative care plan for this client? Select all that apply.
-Instructing the client to avoid Valsalva maneuvers -Assessing the function of the extraocular eye muscles -Monitoring for swelling -Elevating the head of the bed
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply.
-Lesion is highly metastatic. -Lesion is a nevus that has changes in color.
A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply.
-Lesion is highly metastatic. -Lesion is a nevus that has changes in color.
The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply.
-Thinner and decrease in number of reddish papules -Scarce amount of silvery-white scaly patches on the arms
The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply.
-Thinner and decrease in number of reddish papules -Scarce amount of silvery-white scaly patches on the arms
The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.
-Use sunscreen when participating in outdoor activities. -.Wear a hat, opaque clothing, and sunglasses when in the sun. -Examine your body monthly for any lesions that may be suspicious.
An adult client with a burn injury just arrived at the emergency department. Place the nursing actions in the care of this client in order of priority. All options must be used.
1, 3, 2, 6, 4, 5
The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply.
1.Exercise the feet daily by walking and flexing at the ankle. 2.Use a mild soap when washing the feet. 3.Use lanolin on the feet to prevent dryness.
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?
100% oxygen via a tight-fitting, nonrebreather face mask
A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The primary health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank.
14,940
Which individuals are most likely to be at risk for development of psoriasis? Select all that apply.
2.A woman experiencing menopause 3.A client with a family history of the disorder 4.An individual who has experienced a significant amount of emotional distress
An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank.
22.5
An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply.
3.Elbows 4.Sacrum 5.Back of the head Heels
An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?
36%
A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.
54
A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn?
9600 mL of lactated Ringer's solution
The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder?
A client who tans in an indoor tanning bed
A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?
A skin infection of the dermis and underlying hypodermis
A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?
A white color to the skin, which is insensitive to touch
A burn-injured client is receiving treatments of topical mafenide acetate to the site of injury. The nurse should monitor the client for which systemic effect that can occur from the use of this medication?
Acidosis
The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition?
Acne
In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem?
Altered body image
A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse should tell the client to take which measure?
Avoid bathing in the shower or tub more than once daily.
The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder?
An outdoor construction worker
The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record?
Appears to have cherry angiomas on trunk and thighs
The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure?
Apply an emollient lotion to the skin to enhance softening.
The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort?
Apply emollients to the skin after bathing.
Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions?
Apply once a day and cover it with a sterile dressing.
The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication?
Apply saline-soaked dressings over the medication.
The nurse expects to note which prescription for a client with a skin infection that extends into the dermis?
Applying warm compresses to the affected area
A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.
Assess for airway patency. 3.Administer oxygen as prescribed. Elevate extremities if no fractures are present.
The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client?
Assessing peripheral pulses
The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?
At least 30 minutes before exposure to the sun
A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound?
Autograft
The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period?
Between 18 and 24 hours after the injury
A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem?
Blotchy brown macules across the cheeks and forehead
A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint?
Chronic kidney disease
The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin?
Clustered skin vesicles
The nurse suspects herpes zoster (shingles) when which assessment finding is noted?
Clustered skin vesicles
A client with a burn injury is applying mafenide acetate cream to the wound. The client calls the primary health care provider's (PHCP's) office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action?
Continue with the treatment, as this is expected.
The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action?
Cooling the injury with water
A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What should the nurse include in client teaching to maximize the effects of the treatment?
Cover the application with a warm, moist dressing and an occlusive outer wrap.
The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?
Immobilization of the affected leg
The nurse prepares to assist a primary health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include in the plan for this procedure?
Darken the room for the examination.
A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term?
Ecchymosis
The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?
Elevate and immobilize the grafted extremity.
A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.
Elevate extremities if no fractures are present. Assess for airway patency. Administer oxygen as prescribed.
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?
Elevated hematocrit levels
The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure?
Ensure that the consent form has been signed.
The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity?
Erythema
A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply.
Fever Vasodilation Inflammation Excessively high environmental temperature
The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client?
Foam pad
The nurse in the postanesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring?
Frequent swallowing
A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type?
Full-thickness
The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and should plan to question which prescription?
Gastric lavage
A client taking calcium carbonate chewable tablets and ranitidine is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment?
Gastric pH of 3
An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area?
Greater trochanter
The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation?
Heart rate of 95 beats/minute
The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report?
Hematocrit 60% (0.60)
The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary?
High pressure alarm keeps sounding on the ventilator
The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition?
Hypertrophy of collagen fibers
A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?
Hyperventilation
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription?
Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour
The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease?
It is caused by a tick bite.
Mafenide acetate is prescribed for a client with a burn injury to the hand. Which should the nurse include in the instructions to the client regarding the use of this medication?
It is normal to experience local discomfort and stinging and burning after the medication is applied.
A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?
Keep the client on NPO (nothing by mouth) status.
The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client?
Keep the test sites dry
The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"?
Leave the dressing intact for 3 to 5 days.
The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for?
Lesions with well-defined geometric margins
A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing?
Liquefaction necrosis
A client with severe psoriasis has a problem of chronic low self-esteem. The nurse should incorporate which nursing action when working with this client?
Listening attentively
The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item?
Lung sounds
The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care?
Monitor mental status every hour.
The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action?
Monitor the radial pulse every hour.
The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present?
Multiple straight or wavy thread-like lines underneath the skin
The presence of which finding leads the home health nurse to suspect infestation of a client with scabies?
Multiple straight or wavy, thread-like lines beneath the skin
The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first?
Nails
The nurse is performing an assessment on a client with a diagnosis of pemphigus vulgaris. How should the nurse assess for the presence of Nikolsky's sign?
Note skin blistering and sloughing with finger pressure.
The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client?
Oral mucosa
The evening nurse reviews the nursing documentation in a 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 finding would the nurse expect to note on assessment of the client's sacral area?
Partial-thickness skin loss of the dermis
The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?
Partial-thickness skin loss of the dermis
A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe?
Pink or red color
The clinic nurse notes that the primary health care provider 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 by which diagnostic test?
Positive culture results
The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition?
Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs
The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply.
Red, raised papules Large plaques covered by silvery scales
The nurse is providing skin care instructions to a female client with acne vulgaris. What should the nurse instruct the client to do?
Remove cosmetics from her face at bedtime.
The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care?
Removing all clothing, including gloves, shoes, and any undergarments
The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply.
Reposition every 2 hours. 2.Use a bed cradle as indicated. 3.Apply protective pads to heels and elbows. 5.Provide perineal care every 8 hours and after incontinence.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?
Return of distal pulses
A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound?
Semipermeable film dressing
The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use?
Skin breakdown
An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions?
Spider angioma
A client is admitted to the hospital with a partial-thickness skin loss and blister on the sacrum. The nurse should develop a plan of care for which stage of pressure ulcer? Refer to figure.
Stage II ulcer
The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure.View Figure
Stage IV pressure ulcer
The nurse prepares to assist the primary health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care?
Tell the client that the procedure is painless.
The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply.
The exact cause of acne is unknown. 2.Acne requires active treatment for control until it resolves. 3.Oily skin and a genetic predisposition may be contributing factors for acne. The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules.
Which information should the nurse include while providing education for a client scheduled for a rhinoplasty?
The nasal bone is fractured, and the cartilage and bone are remolded into the desired shape.
The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase?
The period from the time the burn was incurred to the time when the client is considered physiologically stable
The nurse has been working with the client diagnosed with candidiasis (thrush). What should the nurse assess for in this client?
The presence of white patches
The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?
Urine output
The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?
Urine specific gravity of 1.032
The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply.
Warm compresses to the affected area Antibiotic therapy
The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?
Wearing gloves and a gown only when giving direct care to the client
A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the past 3 days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication?
White blood cell count of 3000 mm3 (3 × 109/L)
Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse?
White blood cell count of 3000 mm3 (3.0 × 109/L)
