Adult Health: Integumentary

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%. 👩‍🔬Rationale: According to the rule of nines, the entire right leg equals 18%, and the anterior thorax equals 18%. This totals 36%.

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the 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, 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%. 👩‍🔬Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This totals 36%.

The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply.

✅ Wound from repair of a perforated appendix. ✅Gunshot wound that punctured the small intestine. ✅Traumatic wound to the abdomen and intentionally left open for several days. ✅Wound related to debridement of a chronic pressure injury resulting in a cavity-like defect. 👩‍🔬Rationale: Surgical incisions that enter a non-sterile body cavity or traumatic wounds that occur under unclean conditions place the client at risk for wound infection. A perforated appendix, puncture of the intestine, an open wound, and a wound requiring debridement increase the risk for wound infection. A simple surgical wound and a sterile wound are at less risk for becoming infected.

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 indicates the need for further teaching?

✅"I need to avoid sun exposure before 10:00 am and after 4:00 pm." 👩‍🔬Rationale: The client should be instructed to avoid sun exposure between the hours of approximately 10:00 am and 4:00 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

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?

✅"I need to stop taking my antihistamine 2 days before I come to the clinic for the test." 👩‍🔬Rationale: Client preparation for a patch test includes informing the client to discontinue the administration of systemic corticosteroids or antihistamines for at least 48 hours before the test. Topical corticosteroid therapy may be continued as long as the agent is not applied on the area to be tested. To prevent suppression of the inflammatory response to an allergen, these medications must be discontinued. There are no dietary restrictions, and the client is not instructed to shower on the morning of the test using povidone-iodine, which is very irritating to already irritated skin.

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? "I need to bathe using a mild soap and to rinse thoroughly." "I need to avoid direct sunlight on the newly healed skin area." "I should never wear warm clothing over the newly healed skin area." "I need to avoid the use of lanolin products to the newly healed skin area."

✅"I should never wear warm clothing over the newly healed skin area." 👩‍🔬Rationale: 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 need to avoid using astringents on my skin." "I should drink 8 to 10 glasses of water a day." "I should use a dehumidifier, especially during the winter months." "I should limit myself to one shower per day and apply an emollient to my skin after the shower."

✅"I should use a dehumidifier, especially during the winter months." 👩‍🔬Rationale: 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.

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 leave it open to the air." "I will apply the ointment twice a day and leave it open to the air." "I will apply the ointment once a day and cover it with a sterile dressing." "I will apply the ointment at bedtime and in the morning and cover it with a sterile dressing."

✅"I will apply the ointment once a day and cover it with a sterile dressing." 👩‍🔬Rationale: Collagenase is used to promote debridement of dermal lesions and severe burns. It is usually applied once daily and covered 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 use the antibiotic ointment as prescribed." "I will return in 7 days to have the sutures removed." "I will remove the dressing when I get home and wash the site with tap water." "I will call the health care provider (HCP) if I see any drainage from the wound."

✅"I will remove the dressing when I get home and wash the site with tap water." 👩‍🔬Rationale: 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.

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." 👩‍🔬Rationale: 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.

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." 👩‍🔬Rationale: 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." 👩‍🔬Rationale: It is necessary to separate the client's laundry from other household members' clothing. Thorough handwashing, separating laundry, and separate washing of the client's dishes are required because the infection is contagious as long as skin lesions are present. Antibiotics are administered and should be continued as prescribed.

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 asks the nurse what to do. The nurse makes which statement to the client?

✅"Take a shower immediately, and lather and rinse several times." 👩‍🔬Rationale: 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." 👩‍🔬Rationale: 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." 👩‍🔬Rationale: 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.

Using the rule of nines, calculate the burn percentage for the client. Which matches your calculations? Refer to the figure; the burned area is the darkly shaded area. Fill in the blank. Refer to figure. 17 19 21 23

✅19% 👩‍🔬Rationale: The rule of nines is a quick method for early assessment of burn surface area. The head and neck are equal to 9%; each arm is equal to 9%; each leg is equal to 18%; the entire trunk is equal to 36%; and the genitalia are equal to 1%.

An adult client trapped in a burning house 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, the nurse determines the extent of the burn injury to be which percentage? 22.5% 31.5% 36% 40.5%

✅22.5% 👩‍🔬Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the upper half of the posterior trunk equals 9%, and the back of both arms equals 9%, totaling 22.5%.

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

✅A client who is underweight ✅A client diagnosed with heart failure ✅A client diagnosed with spinal cord injury 👩‍🔬Rationale: 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 not put the client at risk for skin breakdown.

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 incontinent of urine and feces A client with chronic nutritional deficiencies A client with a lowered mental awareness status A client who is unable to move about and is confined to bed

✅A client with a lowered mental awareness status 👩‍🔬Rationale: Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and a lowered mental awareness can contribute to the development of skin breakdown. However, the least likely risk as presented in the options is the lowered mental awareness status. Options 1, 2, and 4 identify physiological conditions, which are the highest risk priorities.

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 👩‍🔬Rationale: The 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 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?

✅Administer an opioid analgesic last taken 6 hours ago. 👩‍🔬Rationale: The client should receive pain medication approximately 30 minutes before a burn dressing change. This will help the client tolerate a painful procedure. The client does not need to be NPO for this procedure. Dressing supplies are not sent with the client because they are available in the hydrotherapy area. A robe and slippers are given to the client for transport but are not indicated 30 minutes ahead of time.

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.

✅Administering pain medications as prescribed ✅Monitoring the donor site and the graft site for signs of infection 👩‍🔬Rationale: Donor sites may be covered by a film dressing to hasten healing and decrease pain; they are not left open to air. The donor site is often more painful than the graft site and pain medications are prescribed. The sites are monitored for infection. The graft area is immobilized for 3 to 7 days, not just 24 hours, to permit attachment of the graft to the wound base. Pressure dressings are worn as soon as grafts heal but not right after the procedure.

After 7 days of wound care, a client who has a well-granulated pressure injury reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings?

✅Ambulation three times daily. 👩‍🔬Rationale: The effects of exercise include client reports of feeling better generally because the benefits of exercise are wide ranging. Ambulation can enhance tissue oxygenation and other cardiovascular, pulmonary, metabolic, integumentary, neuromuscular, and conditioning benefits. Thus, the wide-ranging benefits of exercise are more likely to promote an overall sense of feeling better versus benefiting from pain control, less discomfort, or a well-granulated wound. The benefits of pain management, comfort measures, and dressing changes are more limited (options 1, 2, and 3).

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. 👩‍🔬Rationale: 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 greatest risk for development of an integumentary disorder?

✅An outdoor construction worker 👩‍🔬Rationale: 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.

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?

✅Appearance 👩‍🔬Rationale: The client with a burn injury experiences structural and functional changes of the integumentary system as a result of this injury. The client's statement indicates a problem with appearance.

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 👩‍🔬Rationale: 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 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?

✅Apply cold compresses to the affected area. 👩‍🔬Rationale: Warm compresses such as moist heat may be used to decrease discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics are initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Cold compresses are not a component of the treatment measures.

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.

✅Apply cool water to the area. ✅Wrap burned fingers separately to prevent sticking together. ✅Cover the burns with a clean dry cloth as directed by a burn center. 👩‍🔬Rationale: Cool water is applied until the burned area is cool. Butter, lotions, ice, medications, or absorbent materials are never applied. The nearest burn center is contacted for instructions before applying any dressing. The rescuer may be advised to cover burns with a clean, dry dressing or cloth. Burned fingers and toes are wrapped separately to prevent sticking together.

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.

✅Apply sunscreen liberally 15 to 30 minutes before sun exposure. ✅Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. ✅It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm. 👩‍🔬Rationale: It is best to avoid exposure to the sun during the daytime when its rays are most hazardous. Sunscreen is applied liberally 15 to 30 minutes before sun exposure. A sun protection factor (SPF) of at least 30, as well as ultraviolet A (UVA) and ultraviolet B (UVB) protection, should always be used. One can become sunburned on a cloudy or overcast day so sunscreen is needed. Light, loosely woven clothing will not give adequate protection from the sun's rays.

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.

✅Applying prescribed topical antibiotic. ✅Administering prescribed corticosteroid. ✅Applying Domeboro solution to the affected skin. 👩‍🔬Rationale: 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.

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? Allograft Autograft Xenograft Biosynthetic

✅Autograft. 👩‍🔬Rationale: 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 is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse should include on the poster instructions to avoid which activities?

✅Being in the sun for prolonged periods during the daytime hours to ensure absorption of vitamin D 👩‍🔬Rationale: The client should be instructed to avoid sun exposure during the daytime hours when the sun is strongest. Sunscreen, a hat, opaque clothing, and sunglasses should be worn when spending time outdoors. The client should examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

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?

✅Bull's-Eye Rash 👩‍🔬Rationale: The classic characteristic of Lyme disease is a small bite with a bull's-eye rash, although not all individuals who sustain a bite develop this rash. A painful rash around a necrotic lesion is indicative of a brown recluse spider bite. Papules, vesicles, and oval lesions are not characteristics of Lyme disease.

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?

✅Butterfly rash 👩‍🔬Rationale: The two main classifications of lupus are discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE). The major skin manifestation of DLE and SLE is a dry, scaly, raised rash on the face called the butterfly rash. This rash may also appear on other sun-exposed areas. The rash is initially nonscarring and may increase in a lupus flare and disappear when the disease is in remission. A harmless rash, pityriasis rosea usually begins as a single scaly, pink patch with a raised border. Days to weeks later, it starts to itch and spread. The rash may look like Christmas trees spread across your body. Doctors don't know for sure what causes it, but they don't think it's contagious. It often goes away in 6 to 8 weeks without treatment. Pityriasis rosea most often shows up between the ages of 10 and 35. There are no known rashes called spider or lilac bush.

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?

✅Can stain the skin and hair. 👩‍🔬Rationale: Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It frequently can stain the skin and hair, and clients should be taught about this aspect of the medication. It has an unpleasant odor and can cause phototoxicity. It does not carry a risk for systemic effects.

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.

✅Change the bandage daily until site is healed. ✅Apply topical antibiotic ointment as prescribed. 👩‍🔬Rationale: After the procedure, the client is given instructions for the care of the biopsy site. Usually the bandage is changed daily. The site may or may not be treated with a topical antibiotic solution or ointment. Biopsy sites for a punch biopsy will not have any sutures. Oxycodone would not be prescribed for pain; acetaminophen or ibuprofen would be adequate to relieve any pain after the procedure.

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 👩‍🔬Rationale: 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.

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? Spaghetti, bread, cola Salad, watermelon, tea Baked potatoes, Jell-O, water Chicken breast, broccoli, strawberries, milk

✅Chicken breast, broccoli, strawberries, milk 👩‍🔬Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Options 1, 2, and 3 do not provide protein or vitamin C.

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.

✅Clean with mild soap and water. ✅Encourage adequate nutritional intake. ✅Apply a dressing that allows oxygen to pass through. 👩‍🔬Rationale: In general, stages I and II pressure injuries should be cleaned with mild soap and water or normal saline. Adequate nutrients are essential to maintain or restore skin integrity. All wound covers should allow oxygen to pass through. Any kind of massage around or on a reddened area of skin can damage fragile capillaries. In addition, rubber rings should not be used to elevate heels or sacral areas. Rings cause a concentrated area of pressure that places the client at a higher risk for developing pressure ulcers.

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? _Rubbing the application into the skin _Placing the area under a heat lamp for 20 minutes _Applying a dry sterile dressing over the affected area _Covering the application with a warm, moist dressing and an occlusive outer wrap

✅Covering the application with a warm, moist dressing and an occlusive outer wrap. 👩‍🔬Rationale: 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 👩‍🔬Rationale: 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.

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. 👩‍🔬Rationale: 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.

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.

✅Do not remove any of the markings for radiation treatment. ✅Use the hand to wash the affected area rather than a washcloth. ✅Shower or wash the area once a day using warm water and mild soap. 👩‍🔬Rationale: Skin care during radiation therapy includes not removing markings, showering or washing the area once a day using warm water and mild soap, and using the hand to wash the affected area rather than a washcloth. The skin should not be subjected to cold and lotions should not be used unless recommended by the radiologist.

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?

✅Elevated hematocrit levels. 👩‍🔬Rationale: The emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the emergent phase, the hematocrit rises above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury but generally return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, reducing renal perfusion and glomerular filtration. This leads to a decreased urine output. Pulse rates are typically higher than normal; the blood pressure is normal or slightly elevated unless hypovolemia is severe.

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?

✅Elevating and immobilizing the affected leg. 👩‍🔬Rationale: 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 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 👩‍🔬Rationale: 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. 👩‍🔬Rationale: 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 is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply.

✅Inflammatory or (lag) phase ✅Maturation or (remodeling) phase ✅Proliferative or (connective tissue repair) phase 👩‍🔬Rationale: Wound healing occurs in three phases: the inflammatory (lag) phase, the proliferative (connective tissue repair) phase, and the maturation (remodeling) phase. The length of each phase depends on the type of injury; the client's overall health status; and whether the wound is healing by first, second, or third intention. A wound without tissue loss, such as a clean laceration or a surgical incision, can be closed with sutures or staples. The wound edges are brought together with the skin layers lined up in correct anatomic position. This type of wound heals by first intention because closing the wound eliminates dead space and shortens the three phases of tissue repair. Inflammation resolves quickly, and connective tissue repair is minimal, resulting in less remodeling and a thin scar. Deeper tissue injuries or wounds with tissue loss, such as a chronic pressure ulcer or venous stasis ulcer, result in a cavity-like defect that requires gradual filling in of the dead space with connective tissue. This healing occurs by second intention and prolongs the repair process.

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. 👩‍🔬Rationale: 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. 👩‍🔬Rationale: 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.

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 nurse understands that which characteristics describe this type of a lesion? Select all that apply.

✅It is highly metastatic. ✅Lesion is a nevus that has changed in color. 👩‍🔬Rationale: Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis.

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?

✅It provides better cosmetic results. 👩‍🔬Rationale: For very deep burns and burns of the face, neck, or hands, a full-thickness graft may be preferred. A full-thickness graft includes skin and subcutaneous tissue and provides better cosmetic results. Split-thickness grafts can be stretched to cover more area and allows for wound exudate to be absorbed by a dressing. Both thick-thickness and split-thickness grafts have to be immobilized for 3 to 7 days.

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.

✅Knees ✅Elbows ✅Base of Spine 👩‍🔬Rationale: The plaques most often appear on the skin of the elbows, knees, and base of the spine of a client with psoriasis. The plaques do not often appear on the face or the abdomen.

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.

✅Lesion has a waxy border ✅An irregularly shaped lesion 👩‍🔬Rationale: 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. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

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.

✅Lesions are very contagious when they are fluid-filled blisters. ✅Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved. ✅To reduce the risk of transmitting the virus to others, clients with lesions are separated from other clients until lesions have crusted. 👩‍🔬Rationale: Herpes zoster, or shingles, is a disease of immunosuppression, occurring most often and with greater severity in older people or in anyone who is immunosuppressed for any reason. The disorder can be accompanied by fever and malaise, often progressing to visceral involvement. It is contagious to people who have not previously had chickenpox and have not been vaccinated against the disease. Transmission-based precautions are essential when caring for clients with this condition. Multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve. Eruptions usually occur after several days of discomfort, which may vary from minor irritation and itching to severe, deep pain.

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? Recheck the vital signs in 1 hour. Monitor the client for signs of infection. Change the parenteral nutrition solution and IV tubing. Determine when the client was last medicated for pain.

✅Monitor the client for signs of infection. 👩‍🔬Rationale: 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 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.

✅Nails for shape, contour, color, thickness and cleanliness ✅Skin for color, integrity, scars, lesions, and signs of breakdown ✅Facial and body hair for distribution, color, quantity and hygiene ✅Skin temperature, texture, moisture, thickness, turgor, and mobility 👩‍🔬Rationale: Inspection includes assessing nails for shape and contour, color, thickness and cleanliness; skin for color, integrity, scars, lesions, and signs of breakdown; facial and body hair distribution, color, quantity and hygiene; and skin temperature, texture, moisture, thickness, turgor, and mobility.

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. 👩‍🔬Rationale: 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 👩‍🔬Rationale: 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 👩‍🔬Rationale: 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.

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.

✅Palpation. ✅Induration. 👩‍🔬Rationale: The darker a person's skin, the more difficult it is to assess for changes in color. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation for warmth and induration rather than observation. Visualization is often not helpful because of skin color; percussion and auscultation are not the appropriate assessment skills for skin rash.

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?

✅Partial-thickness skin loss of the epidermis. 👩‍🔬Rationale: 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 and tunneling develops during stage 4.

A client with jaundice is complaining of pruritus. Which strategy should the nurse institute to help control the problem and prevent injury?

✅Pat the skin dry after bathing. 👩‍🔬Rationale: The nurse should pat the client's skin dry after bathing or showering. Rubbing should be avoided because it may lead to further skin injury. The client should be bathed with tepid water rather than hot water. A cool environment should be maintained because a warm environment may promote further drying and increased sweating, which should be avoided. Emollient creams and lotions can be applied regularly to alleviate dryness.

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 👩‍🔬Rationale: With the classic 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 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 👩‍🔬Rationale: 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. 👩‍🔬Rationale: 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. 👩‍🔬Rationale: Psoriatic patches are covered with silvery white scales. There is no patchy hair loss or round, red macules with scales. The skin is dry and there is no presence of wheal patches scattered about the trunk.

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 I Stage II Stage III Stage IV

✅Stage Ⅱ 👩‍🔬Rationale: A stage II pressure injury is characterized by non-intact 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 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.

✅The allergen will be placed on the skin and covered with an airtight dressing. ✅A negative reaction occurs when there is no erythema, swelling, or complaint of itching. 👩‍🔬Rationale: A patch test is done to identify an allergen-causing dermatitis. The patch test is similar to the scratch test except the allergen is simply placed on the surface of the skin and covered with an airtight dressing (patch). For both of these tests, a negative reaction occurs when there is no erythema, swelling, or complaint of itching. Patch tests are sometimes evaluated at a later time rather than the next day. A scratch test (also called a prick or puncture test) involves dropping extracts of allergens into scratches made on the skin. Intradermal injection of allergens is used to detect allergies to insect venom or penicillin.

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

✅The return of distal pulses 👩‍🔬Rationale: Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema.

The nurse documents that the client has a stage 2 pressure injury on the decubitus area. Which describes a stage 2 pressure injury?

✅The ulcer is superficial and characterizes an abrasion. 👩‍🔬Rationale: In a stage 1 pressure injury, the skin is intact; the area is red and does not blanch with external pressure. In a stage 2 pressure injury, the skin is not intact; the ulcer is superficial and may be characterized as an abrasion, blister, or shallow crater. In stage 3, skin loss is full thickness, and the skin has a deep crater-like appearance. In stage 4, skin loss is full thickness with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.

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.

✅Use moisturizers and sunscreens. ✅Wash new clothing before it is worn. ✅Use mild detergent and rinse clothes twice. ✅Maintain room temperature at 68° F to 75° F. ✅Wear open-weave fabrics and loose clothing. 👩‍🔬Rationale: Measures that decrease itching and moisturize the skin help maintain skin integrity. Encourage the client to maintain the room temperature at 68° F to 75° F. New clothing should be washed before it is worn. Mild detergent should be used for laundry and clothes should be rinsed twice. Recommend open-weave fabrics and loose clothing. Advise the use of moisturizers and sunscreens. The humidity should be kept at 45% to 55%.

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.

✅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. 👩‍🔬Rationale: The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 am to 4 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

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 tweezers to remove the insect stinger. Apply an occlusive dressing over the stinger. Apply a warm compress to relieve the discomfort. Use the edge of a sterile surgical tool to scrape out the stinger.

✅Use the edge of a sterile surgical tool to scrape out the stinger. 👩‍🔬Rationale: 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? This is a normal expectation. Heat should be applied to the area. Venous circulation is being impaired. The client is exhibiting generalized hypoxia.

✅Venous circulation is being impaired. 👩‍🔬Rationale: 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. There is no evidence to support option 4.

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? Cold compresses to the affected area Warm compresses to the affected area Alternating hot and cold compresses continuously Intermittent heat-lamp treatments four times per day

✅Warm compresses to the affected area. 👩‍🔬Rationale: 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 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? A rash Dermatitis Reddened skin Weeping of the skin

✅Weeping of the skin. 👩‍🔬Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. Reddened skin, a rash, and dermatitis may occur with external radiation but are not described as moist desquamation.

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. 👩‍🔬Rationale: 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.

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the health care provider's prescription sheet expecting which to be prescribed? Select all that apply.

✅Wound culture ✅Antibiotic therapy ✅Warm compresses 👩‍🔬Rationale: Warm compresses may be used to decrease the discomfort, erythema, and edema that accompany cellulitis. Definitive treatment also includes antibiotic therapy after appropriate cultures have been done. Other supportive measures also are used to manage symptoms such as fatigue, fever, chills, headache, or myalgia. Heat lamps are not used because of the risk of burns and because moist heat is most useful in treating this disorder.