Saunders NCLEX Integumentary

The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply. 1.Simple or (dermal) phase 2.Inflammatory or (lag) phase 3.Superficial or (intact skin) phase 4.Rehabilitative (recovery) phase 5.Maturation or (remodeling) phase 6.Proliferative or (connective tissue repair) phase

2.Inflammatory or (lag) phase 5.Maturation or (remodeling) phase 6.Proliferative or (connective tissue repair) phase

The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas? Select all that apply. 1.Face 2.Knees 3.Elbows 4.Abdomen 5.Base of the spine

2.Knees 3.Elbows 5.Base of the spine

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? 1.Oily skin 2.Silvery-white scaly lesions 3.Patchy hair loss and round, red macules with scales 4.The presence of wheal patches scattered about the trunk

2.Silvery-white scaly lesions

The nurse is reinforcing instructions to a client diagnosed with eczema about measures that decrease itching and moisturize the skin. Which should the nurse include in the instructions? Select all that apply. 1.Keep humidity at 10% to 12%. 2.Use moisturizers and sunscreens. 3.Wash new clothing before it is worn. 4.Use mild detergent and rinse clothes twice. 5.Maintain room temperature at 68° F to 75° F. 6.Wear open-weave fabrics and loose clothing.

2.Use moisturizers and sunscreens. 3.Wash new clothing before it is worn. 4.Use mild detergent and rinse clothes twice. 5.Maintain room temperature at 68° F to 75° F. 6.Wear open-weave fabrics and loose clothing.

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1.Sunscreen should be applied every 8 hours. 2.Use sunscreen when participating in outdoor activities. 3.Wear a hat, opaque clothing, and sunglasses when in the sun. 4.Avoid sun exposure in the late afternoon and early evening hours. 5.Examine your body monthly for any lesions that may be suspicious.

2.Use sunscreen when participating in outdoor activities. 3.Wear a hat, opaque clothing, and sunglasses when in the sun. 5.Examine your body monthly for any lesions that may be suspicious.

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching? 1."I need to bathe using a mild soap and to rinse thoroughly." 2."I need to avoid direct sunlight on the newly healed skin area." 3."I should never wear warm clothing over the newly healed skin area." 4."I need to avoid the use of lanolin products to the newly healed skin area."

3."I should never wear warm clothing over the newly healed skin area."

The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching? 1."I will use the antibiotic ointment as prescribed." 2."I will return in 7 days to have the sutures removed." 3."I will remove the dressing when I get home and wash the site with tap water." 4."I will call the health care provider (HCP) if I see any drainage from the wound."

3."I will remove the dressing when I get home and wash the site with tap water."

The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown? 1.A client incontinent of urine and feces 2.A client with chronic nutritional deficiencies 3.A client with a lowered mental awareness status 4.A client who is unable to move about and is confined to bed

3.A client with a lowered mental awareness status

A client is undergoing radiation therapy to treat lung cancer. Which instructions should the nurse reinforce to the client with regard to skin care? Select all that apply. 1.Place a thin film of lotion over the area daily. 2.Use a cold pack on the area if feeling discomfort. 3.Do not remove any of the markings for radiation treatment. 4.Use the hand to wash the affected area rather than a washcloth. 5.Shower or wash the area once a day using warm water and mild soap.

3.Do not remove any of the markings for radiation treatment. 4.Use the hand to wash the affected area rather than a washcloth. 5.Shower or wash the area once a day using warm water and mild soap.

The nurse is caring for a client on transmission-based precautions who has herpes zoster, or shingles. Which are some of the most important skin issues associated with this condition? Select all that apply. 1.There is no pattern or segmental assignment of the lesions. 2.Skin eruptions occur before any discomfort or pain appears. 3.Lesions are very contagious when they are fluid-filled blisters. 4.Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. 5.To reduce the risk of transmitting the virus to others, clients with lesions are separated from other clients until lesions have crusted.

3.Lesions are very contagious when they are fluid-filled blisters. 4.Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. 5.To reduce the risk of transmitting the virus to others, clients with lesions are separated from other clients until lesions have crusted.

A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure? 1."I need to have clear fluids only on the morning of the test." 2."I need to take my prednisone on the morning of the test." 3."I need to shower on the morning of the test using povidone-iodine." 4."I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

4."I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response should the nurse give to the client's question? 1."It is just a superficial infection." 2."It is an inflammation of the lymphatic system." 3."It is due to an infection caused by Staphylococcus." 4."It is a skin infection that involves the deeper skin layers and subcutaneous fat."

4."It is a skin infection that involves the deeper skin layers and subcutaneous fat."

The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder? 1.An adolescent 2.An active elderly client 3.A physical education teacher 4.An outdoor construction worker

4.An outdoor construction worker

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with the early stage of cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should expect which assessment finding? 1.Swelling in the genital area 2.Swelling in the lower extremities 3.Large open plaques in the facial area 4.Appearance of reddish-blue lesions on the lower extremities

4.Appearance of reddish-blue lesions on the lower extremities

The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription? 1.Obtain blood cultures. 2.Administer antibiotics. 3.Administer acetaminophen for fever. 4.Apply cold compresses to the affected area.

4.Apply cold compresses to the affected area.

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area? 1.Intact skin 2.The presence of tunneling 3.A deep, crater-like appearance 4.Partial-thickness skin loss of the epidermis

4.Partial-thickness skin loss of the epidermis

The nurse in a health care provider's office has scheduled a client with a possible allergen-causing dermatitis to be seen in 1 week for a patch test. The nurse explains the procedure for the patch test and includes which in the explanation? Select all that apply. 1.An intradermal injection of allergens will be done. 2.The results most likely will be evaluated in the office the next day. 3.The skin will be scratched and the allergen dropped onto the area. 4.The allergen will be placed on the skin and covered with an airtight dressing. 5.A negative reaction occurs when there is no erythema, swelling, or complaint of itching.

4.The allergen will be placed on the skin and covered with an airtight dressing. 5.A negative reaction occurs when there is no erythema, swelling, or complaint of itching.

A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions should the nurse take before transferring the client to the burn center? Select all that apply. 1.Apply cool water to the area. 2.Place ice packs over the area. 3.Apply an absorbent material to the area. 4.Wrap burned fingers separately to prevent sticking together. 5.Cover the burns with a clean dry cloth as directed by a burn center.

1.Apply cool water to the area. 4.Wrap burned fingers separately to prevent sticking together. 5.Cover the burns with a clean dry cloth as directed by a burn center.

The client is receiving a full-thickness graft to a burn on the hand. The nurse understands that a full-thickness graft is being applied instead of a split-thickness graft because of which reason? 1.It provides better cosmetic results. 2.It allows the extremity to be mobilized sooner. 3.It allows the graft to be stretched to cover more area. 4.It allows for wound exudate to be absorbed by the cover dressing.

1.It provides better cosmetic results.

A client has a noninfected pressure injury on the left heel. The nurse should use which sterile solution to cleanse the wound as part of a dressing change procedure? 1.Warm water 2.Normal saline 3.Povidone-iodine 4.Hydrogen peroxide

2.Normal saline

The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). The nurse assesses a rash on the client's face. What is the name of the major skin manifestation of discoid lupus erythematosus (DLE) and SLE? 1.Spider rash 2.Butterfly rash 3.Lilac bush rash 4.Christmas trees rash

2.Butterfly rash

The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client? 1.Get out a robe and slippers for the client. 2.Administer an opioid analgesic last taken 6 hours ago. 3.Immediately place the client on nothing-by-mouth (NPO) status. 4.Gather dressing supplies to send with the client to hydrotherapy.

2.Administer an opioid analgesic last taken 6 hours ago.

A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem? 1.Fear 2.Appearance 3.Self-esteem 4.Ability to keep a job

2.Appearance

The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which interventions in the plan of care for the client? Select all that apply. 1.Administering prescribed acyclovir 2.Applying prescribed topical antibiotic 3.Administering prescribed corticosteroid 4.Administering prescribed oral amphotericin B 5.Applying Domeboro solution to the affected skin

2.Applying prescribed topical antibiotic 3.Administering prescribed corticosteroid 5.Applying Domeboro solution to the affected skin

The client recovering from a third-degree burn asks the nurse about grafts. The nurse explains to the client that the best type of graft is which? 1.Allograft 2.Autograft 3.Xenograft 4.Biosynthetic

2.Autograft

An African-American client has been admitted for a skin rash on his lower back. Which techniques should the nurse best rely on when assessing the skin rash? Select all that apply. 1.Palpation 2.Induration 3.Percussion 4.Auscultation 5.Visualization

1.Palpation 2.Induration

A client with jaundice is complaining of pruritus. Which strategy should the nurse institute to help control the problem and prevent injury? 1.Pat the skin dry after bathing. 2.Maintain a warm environment. 3.Bathe the client with hot water only. 4.Avoid application of emollient creams.

1.Pat the skin dry after bathing.

The nurse reviews a client's chart and notes that the health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which should the nurse expect to note during data collection? 1.Red, shiny skin around the nail bed 2.White, taut skin in the popliteal area 3.White, silvery patches on the elbows 4.Swelling of the skin near the parotid gland

1.Red, shiny skin around the nail bed

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? 1.The return of distal pulses 2.Decreasing edema formation 3.Brisk bleeding from the injury site 4.The formation of granulation tissue

1.The return of distal pulses

The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply. 1.Wound from repair of a perforated appendix 2.Surgical wound after an open cholecystectomy 3.Gunshot wound that punctured the small intestine 4.Sterile wound resulting from a total radical mastectomy 5.Traumatic wound to the abdomen and intentionally left open for several days 6.Wound related to debridement of a chronic pressure injury resulting in a cavity-like defect

1.Wound from repair of a perforated appendix 3.Gunshot wound that punctured the small intestine 5.Traumatic wound to the abdomen and intentionally left open for several days 6.Wound related to debridement of a chronic pressure injury resulting in a cavity-like defect

The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching? 1."I need to keep the test sites dry." 2."If the patch comes off, I need to reapply it." 3."I need to avoid activities that will cause me to sweat." 4."I will return to the clinic in 2 days for the initial reading."

2."If the patch comes off, I need to reapply it."

The nurse is reinforcing sun exposure precautions to a group of older clients. Which should the nurse include in the instructions? Select all that apply. 1.Sunscreen is not needed on cloudy days. 2.Wear loosely woven clothing for protection. 3.Apply sunscreen liberally 15 to 30 minutes before sun exposure. 4.Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. 5.It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm.

3.Apply sunscreen liberally 15 to 30 minutes before sun exposure. 4.Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. 5.It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm.

An older client is transferred to the nursing unit following a graft to a stage 4 pressure injury. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing? 1.Spaghetti, bread, cola 2.Salad, watermelon, tea 3.Baked potatoes, Jell-O, water 4.Chicken breast, broccoli, strawberries, milk

4.Chicken breast, broccoli, strawberries, milk

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client should monitor for which sign/symptom during the first 24 hours after the burn injury? 1.Decreased heart rate 2.Increased urinary output 3.Decreased blood pressure 4.Elevated hematocrit levels

4.Elevated hematocrit levels

The client, diagnosed with Lyme disease stage 2, asks the nurse "what is indicative of stage 2?" The nurse explains to the client that which sign or symptom is assessed in stage 2? 1.Arthralgias 2.Joint enlargement 3.Erythematous rash 4.Neurological deficits

4.Neurological deficits

The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information? 1.Sacrum 2.Earlobes 3.Back of the hands 4.Palms of the hands

4.Palms of the hands

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action? 1.Use tweezers to remove the insect stinger. 2.Apply an occlusive dressing over the stinger. 3.Apply a warm compress to relieve the discomfort. 4.Use the edge of a sterile surgical tool to scrape out the stinger.

4.Use the edge of a sterile surgical tool to scrape out the stinger.

A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? 1."It is caused by oily skin." 2."The exact cause of acne is not known." 3."It occurs as a result of exposure to heat and humidity." 4."Acne is caused by eating chocolate, nuts, and fatty foods."

2."The exact cause of acne is not known."

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client? 1."There is no pain associated with this procedure." 2."The local anesthetic may cause a burning or stinging sensation." 3."A preoperative medication will be given so you will be sleeping and will not feel any pain." 4."There is some pain, but the health care provider will prescribe an analgesic following the procedure."

2."The local anesthetic may cause a burning or stinging sensation."

The nurse is reinforcing instructions to a client on how to care for a punch biopsy site after the procedure is done. Which should the nurse include in the instructions? Select all that apply. 1.Leave the area open to air. 2.Change the bandage daily until site is healed. 3.Apply topical antibiotic ointment as prescribed. 4.Return to the office in 7 days for suture removal. 5.Take prescribed oxycodone as prescribed for pain.

2.Change the bandage daily until site is healed. 3.Apply topical antibiotic ointment as prescribed.

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure injury in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure injury? Select all that apply. 1.Utilize a rubber ring. 2.Clean with mild soap and water. 3.Encourage adequate nutritional intake. 4.Massage the area around the affected area. 5.Apply a dressing that allows oxygen to pass through.

2.Clean with mild soap and water. 3.Encourage adequate nutritional intake. 5.Apply a dressing that allows oxygen to pass through.

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome? 1.Common 2.Suggestive of anemia 3.Characteristic of a thrush infection 4.Indicative of a need to improve oral hygiene

3.Characteristic of a thrush infection

The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which? 1.A rash 2.Dermatitis 3.Reddened skin 4.Weeping of the skin

4.Weeping of the skin

The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial-thickness skin loss and the formation of a blister. The nurse should document the pressure injury as which category? 1.Stage I 2.Stage II 3.Stage III 4.Stage IV

2.Stage II

The nurse is reviewing a focused assessment done on a client's integumentary system. Which physical examination assessments are related to inspection? Select all that apply. 1.Biopsy results 2.Nails for shape, contour, color, thickness and cleanliness 3.Skin for color, integrity, scars, lesions, and signs of breakdown 4.Facial and body hair for distribution, color, quantity and hygiene 5.Skin temperature, texture, moisture, thickness, turgor, and mobility

2.Nails for shape, contour, color, thickness and cleanliness 3.Skin for color, integrity, scars, lesions, and signs of breakdown 4.Facial and body hair for distribution, color, quantity and hygiene 5.Skin temperature, texture, moisture, thickness, turgor, and mobility

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1.Positive patch test 2.Positive culture results 3.Abnormal biopsy results 4.Wood's light examination indicative of infection

2.Positive culture results

A client comes to a health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick? 1.Bull's-eye rash 2.Patch of oval lesions 3.Painful rash around a necrotic lesion 4.Line of papules and vesicles that appear 1 to 3 days after exposure

1.Bull's-eye rash

The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client? 1.Placing the affected leg flat 2.Elevating and immobilizing the affected leg 3.Immobilizing the client in a dependent position 4.Placing the affected leg in a dependent position

2.Elevating and immobilizing the affected leg

The nurse documents that the client has a stage 2 pressure injury on the decubitus area. Which describes a stage 2 pressure injury? 1.The area has a deep crater-like appearance. 2.There is tissue necrosis with damage to the muscle. 3.The ulcer is superficial and characterizes an abrasion. 4.The area is red and does not blanch with external pressure.

3.The ulcer is superficial and characterizes an abrasion.

A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion? 1.This is a normal expectation. 2.Heat should be applied to the area. 3.Venous circulation is being impaired. 4.The client is exhibiting generalized hypoxia.

3.Venous circulation is being impaired.