Skin Disorders Saunders

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding should the nurse note in this condition?

White skin that is insensitive to touch - Findings in frostbite include white or blue skin that is hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, blisters or blebs, or tissue edema appears. Gangrene develops in 9 to 15 days.

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? ***

Elevation above the level of the heart - Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation

Sodium hypochlorite is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan?

Ensure that the solution is freshly prepared before use - Sodium hypochlorite solution is a chloride solution that is used for irrigating and cleaning necrotic or purulent wounds. It can be used for packing necrotic wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. It should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. Solutions are unstable, and the nurse must ensure that the solution has been prepared fresh before use.

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client idnicates the need for further teaching? ***

"I need to avoid sun exposure before 10:00 am and after 4:00 pm"

Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client 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."

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?

"I will remove the dressing when I get home and wash the site with tap water" - After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After the dressing is removed, the site is cleaned once a day with tap water or saline to remove any dry blood or crusts. The HCP may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy.

A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which should the nurse include in the plan of care? Select all that apply. (2)

1. Administering pain medications as prescribed 2. Monitoring the donor site and the graft site for signs of infection

Which clients are at risk for developing skin breakdown? Select all that apply. (3)

1. A client who is underweight 2. A client diagnosed with heart failure 3. A client diagnosed with spinal cord injury -The client who is underweight does not have any cushioning to protect bony prominences. A client with a spinal cord injury has decreased mobility, which can cause skin breakdown to develop. Many clients with heart failure have edema, which can also lead to the development of skin breakdown. Sinusitis and benign prostatic hypertrophy do put the client at risk for skin breakdown.

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury should be which percentage?

36% - According to the rule of nines, the entire right leg equals 18%, and the anterior thorax equals 18%.

The nurse is checking her clients for skin breakdown. Which client should have the lowest priority for concern in the development of skin breakdown?

A client with a lowered mental awareness status

S/S of Actinic keratosis

A premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale

What are lesions?

A skin lesion is a part of the skin that has an abnormal growth or appearance compared to the skin around it; A skin lesion is a part of the skin that has an abnormal appearance compared to the skin around it. Skin lesions can be inherited or caused by inflammation, - Primary skin lesions are abnormal skin conditions present at birth or acquired over a person's lifetime. - Secondary skin lesions are the result of irritated or manipulated primary skin lesions. (https://www.healthline.com/symptom/skin-lesion)

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? ***

A white color of the skin which is insensitive to touch - Findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.

The nurse, eployed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? ***

An unlicensed assistive personnel who has never had chickenpox

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?

Appearance of reddish-blue lesions on the lower extremities - Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They also can spread to the lymphatic system, lungs, and gastrointestinal (GI) tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions.

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?

Autograft - It is most desirable to graft the client's own skin (autograft), but when this is not possible, a homograft (the skin of another person [allograft], obtained from a cadaver), a heterograft (xenograft, usually obtained from a pig), or artificial (biosynthetic) skin, such as Biobrane, can be used as a temporary measure.

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?

Characteristic of a thrush infection - Candidiasis is a fungal infection caused by Candida albicans. When it occurs in the mouth, it is called thrush and appears as white plaques. Although it can occur in an immunocompromised client, it is not considered to be common.

The nurse prepares to assist a health care provider examine the client's skin with a Wood's light. Which action should be included in the plan for this procedure?

Darken the room for the examination - The examination of the skin under a Wood's light is always carried out in a darkened room. This is a noninvasive examination; therefore, informed consent is not required. A hand-held, long-wavelength ultraviolet light or Wood's light is used. The skin does not need to be shaved, and a local anesthetic is not necessary. Areas of blue-green or red fluorescence are associated with certain skin infections. The procedure is painless.

The nruse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nruse anticipate being prescribed for the client?

Elevating and immbolizing the affected leg - Autografts placed over joints or on the lower extremities are often elevated and immobilized after surgery for 3 to 7 days. This period of immobilization allows time for the autograft to adhere and attach to the wound bed.

The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8° F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action?

Monitor the client for signs of infection - The client is recovering from extensive burns. The burn client is prone to several complications such as infection and sepsis. A temperature of 102.8° F is significant. On the fourth hospital day, infection may be the problem. The site of the infection may be the burns, the parenteral nutrition infusion or parenteral nutrition site, or other problems. As an initial action, the nurse needs to check the client for signs of infection and then notify the registered nurse, who will contact the health care provider for further prescriptions.

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?

Neurological deficits - Stage 2 of Lyme disease develops within 1 to 6 months in most untreated individuals. The most serious problems include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. These problems are not usually permanent. Arthralgias and joint enlargements are noted in stage 3. A rash appears in stage 1.

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?

Normal saline - Normal saline (0.9%) should be used for cleansing pressure injuries, unless there is a specific prescription for another solution. Normal saline is isotonic (unlike water) and does not damage cells that are needed for healing (as povidone-iodine and hydrogen peroxide do).

The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area should provide the best information?

Palms of the hands - In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms and soles at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge.

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 nruse expect to find when checking the client's sacral area? ***

Partial-thickness skin loss of the epidermis - With a stage 2 pressure injury, the skin is not intact. There is partial- thickness skin loss of the epidermis or dermis. The ulcer is superficial and it may look like an abrasion, blister, or shallow crater. - The skin is intact with a stage 1 pressure injury. - A deep, crater-like appearance occurs during stage 3 - Tunneling develops during stage 4

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which should the nurse anticipate to be prescribed for this condition?

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs - Frostbite is ideally treated with rapid and continual rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Hot or cold water is not used in the treatment of frostbite.

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?

Red, shiny skin around the nail bed - Paronychia or infection around the nail is characterized by red, shiny skin, often associated with painful swelling. These infections frequently result from trauma, picking at the nail, or disorders such as dermatitis. Often these become secondarily infected with bacteria or fungus, which later involves the nail.

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? ***

Silvery-white scaly lesions

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restles and his color is becoming dusky. Based on this data, which interpretation should the nurse make? ***

The burn has probably caused a laryngeal edema, which has occluded the airway.

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? ***

The return of distal pulses

Which individual is least likely to be at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible - Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder. It is a common acquired immunodeficiency syndrome (AIDS) indicator. Malignancy is seen most frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma but could be related to mesothelioma.

The nurse determines that which individual presenting to the clinic is at the greatist risk for development of an integumentary disorder?

An outdoor construction worker - Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. An older client may be at a higher risk than a younger individual because immobility and lack of nutrition may increase the older person's risk. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. The physical education teacher is at low or no risk of developing an integumentary problem.

S/S of Basal cell carcinoma

Appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color.

S/S of Squamous cell carcinoma

Firm nodular lesion that is topped with a crust or a central area of ulceration.

The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching?

"If the patch comes off, I need to reapply it." - The nurse instructs the client to keep the test site dry at all times. The nurse also discourages excessive physical activity that will result in sweating. Reapplying the patch can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later.

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and elft arm. Which statement by the client indicates the need for further teaching?

"I should never wear warm clothing over the newly healed skin area." - Newly healed skin is more sensitive to the cold, and the client should be instructed to wear warm clothing. The client should wash with a mild soap, rinse thoroughly, and pat the skin dry with a clean towel. Newly healed skin sunburns easily, and direct sunlight needs to be avoided. Products that contain perfume, alcohol, or lanolin should be avoided because they tend to irritate newly healed skin.

The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching?

"I should use a dehumidifier, especially during the winter months." - The client should avoid using a dehumidifier because this will further dry the room air. Instead, the client should use a room humidifier during the winter months or whenever the furnace is in use. The client should be taught to maintain a daily fluid intake of 3000 mL, unless contraindicated, and to avoid alcohol and caffeine. The client should avoid applying rubbing alcohol, astringents, or other drying agents to the skin. One bath or shower per day for 15 to 20 minutes with warm water and a mild soap would be immediately followed by the application of an emollient to prevent the evaporation of water from the hydrated epidermis.

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?

"It is a skin infection that involves the deeper skin layers and subcutaneous fat." - Cellulitis is a skin infection into the deeper dermis and the subcutaneous fat, usually caused by Streptococcus pyogenes; it results in deep red erythema without sharp borders, and it spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and the lymphatics.

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?

"My clothes can be laundered with other household members' clothes."

A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and sks the nurse what to do. The nurse makes which statement to the client?

"Take a shower immediately, and lather and rinse several times." - When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the skin. The client should be instructed to shower immediately, to lather the skin several times, and to rinse each time in running water. Calamine lotion is a treatment that is used when dermatitis develops. It is not necessary for the client to be seen in the emergency department at this time.

A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client?

"The exact cause of acne is not known" - The exact cause of acne is unknown. Exacerbations that coincide with the menstrual cycle result from hormonal activity. Oily skin alone is not the cause of acne. Heat, humidity, and excessive perspiration also play a role in exacerbation of acne. There is no evidence that consumption of foods such as chocolate, nuts, or fatty foods affects acne.

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client?

"The local anesthetic may cause a burning or stinging sensation." - Depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. The most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation.

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. Wrap burned fingers separately to prevent sticking together 3. Cover the burns with a cleint dry cloth as directed by a burn center

The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include interventions in the plan of care for the client?Select all that apply.

1. Applying prescribed topical antibiotic 2. Administering prescribed corticosteroid 3. Applying Domeboro solution to the affect skin - Pemphigus is a chronic autoimmune condition in which bullae (blisters) develop on the face, back, chest, groin, and umbilicus. The blisters rupture easily, releasing a foul-smelling drainage. Potassium permanganate baths, Domeboro solution, and oatmeal products with oil may be prescribed to soothe the affected areas, reduce odor, and decrease the risk of infection. Treatments may include corticosteroids, other immunosuppressants, and oral or topical antibiotics. Acyclovir is an antiviral medications used to treat chickenpox or shingles. Amphotericin B is an antifungal used to treat fungal infections.

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. (3)

1. Do not remove any of the markings for radiation treatment. 2. Use the hand to wash the affected area rather than a washcloth. 3. Shower or wash the area once a day using warm water and mild soap.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nruse understands that which characteristics describe this type of a lesion? Select all that apply. ***

1. It is highly metastatic 2. Lesion is a nevus that has changed in color

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. (3)

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

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. ***

1. Lesion has a waxy border 2. An irregularly shaped lesion

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. Use moisturizers and sunscreens. 2. Wash new clothing before it is worn. 3. Use mild detergent and rinse clothes twice. 4. Maintain room temperature at 68° F to 75° F. 5. Wear open-weave fabrics and loose clothing. - Humidity should be kept at 45% to 55%

The health education nurse provides instructions to a group of clients regarding measures that will assist preventing skin cancer. Which instructions should the nurse provide? Select all that apply.

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

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected, Which should the nurse anticipate as being prescribed for the client? ***

100% oxygen via a tight-fitting, nonrebreather face mask

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior hald of the head) and the upper hald of the naterior torso, and there were circumferential burns to the lower hald of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury. Fill in the blank ***

36%

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy?

Covering the application with a warm, moist dressing and an occlusive outer wrap - The nurse can enhance penetration of topical corticosteroid therapy to the client with psoriasis by applying warm moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or a similar item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic side effects. The remaining options are not measures that will enhance the effectiveness of therapy.

The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment?

Culture of the lesion - Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the cause of chickenpox. A viral culture of the lesion provides the definitive diagnosis. A patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies. A biopsy will determine tissue type. During a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable. - There is a blood test available to detect Lyme disease; however, it is not reliable if performed before 4 to 6 weeks following the tick bite.

The nurse prepares to assist in instructing a client about Lyme disease. Which should the nurse include in the instructions?

It is caused by a tick carried by deer. - Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

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? ***

Positive culture results - With the class presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections 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?

Stage II - A stage II pressure injury is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, shallow crater, or a blister. A stage I pressure injury is a reddened area that doesn't blanch but has intact skin. Stages III and IV pressure injuries are full thickness, or full thickness with necrosis or damage to muscle, bone, or supportive tissue, respectively.

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? ***

Urine output

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?

Use the edge of a sterile surgical tool to scrape out the stinger. -Using the edge of a sterile surgical tool to scrape out the stinger will not likely squeeze any bee venom into the tissue. Tweezers likely would squeeze additional venom into the tissues. Applying warm compresses likely would cause additional absorption because of vasodilation. An occlusive dressing would not prevent tissue absorption and would not assist in removal of the stinger.

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?

Venous circulation is being impaired. - The blue color is a sign of venous engorgement resulting from venous stasis, which increases local tissue hypoxia and can lead to necrosis of the area affected. This is not a normal expectation. Heat application would cause more damage to the tissue.

The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment should the nurse anticipate being prescribed for the client?

Warm compresses to the affected area - Warm compresses may be used to decrease discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics are initiated. Heat lamps can cause more disruption to tissue that is already inflamed. Continuous cold and hot compresses are not the best measures.

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? ***

Wear a gown and gloves