ATI and workbook ch 42

Superficial thickness

A nurse in a providers office is collecting data from a client who has a severe sunburn which of the following classification. Should the nurse use to document this burn

Intravenous

A nurse is assisting with care of a client who sustained deep partial thickness and full thickness burn over 60% of their body 24 hours ago and is requesting pain medication. The nurse should ensure the medication is administered using which of the following routes to administer the medication.

Potassium hydroxide test

A nurse is caring for a client who has suspected fungal skin lesion which of the following diagnostic procedures. Should the nurse prepare the client to confirm diagnosis

Assigned the client to a private room Increased dietary protein i intake Restrict fresh flowers in the client's room

A nurse is contributing to the plan of care for an adult client who sustained severe burn injuries which of the following intervention should the nurse recommend for inclusion in the plan of care

Use a cotton tip applicator to obtain fluid from the lesion Place collected specimen tube immediately on ice

A nurse is in a clinic is preparing to assist with obtaining a skin specimen from a client who has a suspected herpes infection which of the following action should the nurse take

I should clean the site with sterile saline solution

A nurse is reinforcing discharge instructions with a client who had a skin biopsy with sutures, which of the following statements by the client indicates an understanding of the instructions

Apply the topical medication for up to two weeks after the lesions are gone

A nurse is reinforcing teaching with a client who has a new prescription for clotrimazole topical cream which of the following statement should the nurse include

Place the child in a bath with colloidal oatmeal.

A nurse is reinforcing teaching with the guardian of a child who has contact dermatitis which of the following information should the nurse include

Applying exclusive dressing after application Wear gloves after application lesions on the hands Avoid applying and skinfolds

A nurse is reviewing information about a prescription for corticosteroid cream with a client who has mild psoriasis which of the following instructions should the nurse include

Trauma

A physical wound or emotional shock

Melanin

Absorbs light and protects the tissue from ultraviolent light

Sweat glands

Act to excrete water and salt

Vitamins and minerals

Adequate intake of _______ is essential for healthy skin

Temporary

Allograft Xenograph

permanent

Autographed cultured epithelium

Dermis

Corium

Tissue loss Location of tear Size of tear What dressings are used?

Despite all precautions and patient teaching, Miss mary accidentally causes a small skin tear on her right forearm as she is reaching for an item on her food tray list for findings that should be included in the documentation of this new skin tear

Tropical climate Cold weather Exposure to chemicals and other irritants UV light exposure

Environmental factors that could be responsible for skin disorder include

Exacerbating

Frustrating, psychologically irritating making one lose

Sebum

Function to keep the hair and skin, soft and pliable inhibits bacterial growth on the surface of the skin and helps prevent water loss from the skin

Hair follicles

Hair, thin as we age because hair growth rate declines in the number of what decreases

Wheal

Itchy, raised skin area

Taking several medication Area isn't clean Sitting for too long Impaired mobility Rough handling

List five risk factors for skin tears

Protective clothing Staying hydrated Careful with patient Keep skin moist and dry Don't use adhesive dressings Keep area clean

List six measurements that could be used to prevent skin tears

senile lentigines, brown spots

Me at production changes, make the elderly more Susceptible to ______ and caused the appearance of_____

Fungal infections

Nail characteristics changed as we age and this makes the nails more susceptible to

Hair follicles

Produce hair

Fibroblasts

Produces new sales to heal the skin

Gland

Sebaceous sweat or ceruminous

Examining the entire body, including the back Assessing warts and moles that have become more uneven in color

Self assessment of the skin should take place every few months the patient should be

Appearance of skin adjacent to the lesions

Significant objective data in the assessment of a patient with a skin disorder include

Psoriasis

Skin disorder with patchy areas of silvery scales

Check to see if an informed consent has been signed Label any specimen properly and sent to the lab

The healthcare provider is preparing to examine the patient for a probable fungal infection, using a woods, lamp and culture maybe obtained what nursing care may be required

It seems like you're interested in doing your own research. Let me give you some additional resources.

The nurse advises the patient that tanning salon salons are not recommended. The patient states I have talked to a bunch of people who have been using tanning salon for years without any problem. What is the best response?

2500

The nurse is caring for a burn client whose calculated 24 hour IV fluid requirements are determined to be 5000 mL. What is the total volume that the nurse should infuse after the first eight hours of fluid resuscitation has infused?

Inhalation injury

The nurse is caring for a client who has sustained burns over 30% of total body surface area. The client's voice has become hoarse and a brassy cough as developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following.

Hyperkalemia Hyponatremia

The nurse is collecting data from a client who has sustained deep partial thickness and full thickness burns over 40% of the body 24 hours ago which of the following findings are common during this phase

Apply warm compresses to the affected area

The nurse is reinforcing discharge instructions with a client who has a bacterial infection of the skin which of the following instructions should the nurse include

Administer psoralen medication before treatment

The nurse is reinforcing teaching with a client about photo chemotherapy and UV light treatments. Who has a history psoriasis which of the following instructions should the nurse include

Skin stays tinted over several seconds

The nurse is reviewing the documentation of a patient skin assessment which piece of data causes the most immediate concern

Nerve receptors

Transmits feelings of heat, cold pain, touch, and pressure

We're protective gear and clothes Avoid sunlight Reapply sunscreen every two hours Apply sunscreen, 15 to 30 minutes before exposure

What are four ways to protect yourself against damage caused by UV rays of the sun?

Oatmeal

When itching is a problem the patient may be instructed to take which type of bath

Gently cleanse the skin tear with normal saline

While receiving Miss mary's discharge summary from the hospital, you see that a category one skin care was identified using the pain martin classification system which intervention is most appropriate for this wound

Identify predisposing factors

Why is A thorough medication history is important in diagnosing skin disorder