Chapter 56 & 57
A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
36%
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
36%
Which of the following is the preferred IV fluid for burn resuscitation?
LR
Which of the following skin substitutes is a nylon-silicone membrane coated with a protein?
biobrane
Which complication is common for victims of electrical burns?
cardiac dysrhythmias
A nurse is caring for a client experiencing an exacerbation of plaque psoriasis. The nurse assesses the area and documents a proliferation of which cell type?
epidermal
Which of the following is also known as "jock itch"?
tinea cruris
A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?
Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.
Which procedure done for skin cancer conserves the most amount of normal tissue?
Mohs
A nurse is admitting a client with toxic epidermal necrolysis. What is the nursing priority in preventing sepsis?
Preventing infection
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
irrigate the wounds with water
A client comes into the hospital with a Tegaderm dressing in place on the buttocks. The nurse documents this as being which type of dressing?
passive
Which condition is an autoimmune disease involving immunoglobulin G?
pemphigus
A client is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have?
psoriasis
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
pulmonary system
A dermatologist recommends an over-the-counter suspension to relieve pruritus. The nurse advises the patient that the lotion should be applied:
q3h
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:
replace lost fluids & electrolytes
While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply?
sterile
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?
full thickness (3)
Which of the following is to be expected soon after a major burn? Select all that apply.
hypotension, anxiety, tachycardia
A child tips a pot of boiling water onto his bare legs. The mother should:
immerse the child's legs in cool water
Which of the following information regarding the transmission of lice would the nurse identify as a myth?
lice can jump
Which of the following medications is used to reduce turnover time of the psoriatic epidermis?
methotrexate
The nurse is instructing the parents of a child with head lice. Which statement should the nurse include?
shampoo with piperonyl butoxide
To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?
tretinoin
Which of the following nonsedating antihistamines is appropriate for daytime pruritus?
allegra
Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body?
autograft
Which of the following uses the body's own digestive enzymes to break down necrotic tissues?
autolytic debridement
A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?
behind the ears
The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?
destruction of dermis & epidermis
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?
early appearance of the burn injury may change
A client has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. What intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
early enteral feeding
The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?
electrical burns follow an internal path
A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make?
encourages your body's natural processes to liquefy any damaged tissue
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:
epidermis & portion of deeper dermis
A day care worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears:
erythematous w/ raised papules
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?
escharotomy
Which is the primary reason for placing a client in a horizontal position while smothering flames are present?
fire and smoke away from the airway
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client
fluid resuscitation
Which factor aggravates the condition caused by acne vulgaris?
friction
Which type of burn injury requires skin grafting?
full thickness
Which term refers most precisely to a localized skin infection of a single hair follicle?
furuncle
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?
gastric ulcers
What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply.
hemodilution, sodium deficit, increased urinary output
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?
homografts
The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.
hourly urine output, daily weights, skin turgor
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
hypovolemia
The nurse is triaging a client over the phone who states having a contact dermatitis rash. Which treatment option of over-the-counter preparations does the nurse suggest for the client? Select all that apply.
idfk
When writing a plan of care for a client with psoriasis, the nurse would know that an appropriate nursing diagnosis for this client would be what?
impaired skin integrity dt scaly lesion
A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort?
instruct to pat not scratch
The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?
intravenous
The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition?
kaposi
A physician has ordered a wet-to-damp dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to:
keep moist
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
maintaining the clients fluid, electrolyte & acid-balance base
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:
melanoma
Which of the following is the analgesic of choice for burn pain?
morphine sulfate
A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested?
neck & chest
A patient is diagnosed with psoriasis after developing scales on the scalp, elbows, and behind the knees. The patient asks the nurse where this was "caught." What is the best response by the nurse?
overproduction of keratin
The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn?
preexisting conditions
A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?
private room
A nurse assesses a client with dry, rough, scaly skin without lesions on the legs. The client reports itching in the affected area. What skin assessment would the nurse document?
pruritus
A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?
risk for impaired gas exchange
The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?
roll the client in a blanket
Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of:
stasis
The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?
sulfadiazine, silver
Which of the following superficial fungal infections begins in the skin between the toes and spreads to the soles of the feet?
tinea pedis
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?
urinary output is 0.5 to 1 mL/kg/hr
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?
urine output of 20 mL per hour
Which of the following sedative medications is effective in treating pruritus?
allegra
The nurse is instructing the patient in how to apply a corticosteroid cream to lesions on the arm. What intervention can the nurse instruct the patient to do to increase the absorption of the medication?
apply an occlusive dressing over the site after application
A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?
are the burns associated with chemicals used in the plant?
The nurse is teaching a client about the correct use of topical concentrated corticosteroids. The nurse includes which statement(s)? Select all that apply.
avoid the face & prolonged use
The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings?
contact the PCP & prepare for an escharotomy
The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury?
hyperkalemia
A client with a history of diabetes mellitus has recently developed furunculosis. What is causing the client's condition?
infeciton
The nurse is developing a plan of care for a client with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome. Which action should the nurse include?
inspect oral cavity
A patient is scheduled for Mohs microscopic surgery for removal of a skin cancer lesion on his forehead. The nurse knows to prepare the patient by explaining that this type of surgery requires:
layer by layer removal of tumor
The nurse notes that the client's lower extremities are covered with very dry skin and that the horny layer of the skin has become thickened. The nurse notes the finding as
lichenification
The nurse and nursing assistant are moving a client who slid down in the chair. What does the nurse encourage the assistant to avoid shearing when moving the client to a higher position in the chair?
lift do not slide
A nurse in a healthcare provider's office teaches a client how to apply plastic film as an occlusive dressing to cover a medicated ointment applied to the arm. What important teaching point would be included by the nurse?
limit use to 12 hours
A patient is diagnosed with malignant melanoma that directly invades the adjacent dermis (vertical growth). The nurse knows that this type of melanoma has a poor prognosis. Which of the following is most likely the type of melanoma described in this scenario?
nodular melanoma
A young adult visits a health clinic for treatment of a severe case of eczema on his left leg. Which of the following is the preferred method for delivering medication in this scenario?
ointment
The nurse is caring for a patient with extensive bullous lesions on the trunk and back. Prior to initiating skin care, what is a priority for the nurse to do?
pain medication
The nurse is caring for a client 48 hours after their burn injury. Which treatment will the nurse anticipate to reduce the client's risk of mortality?
removal of burned tissueThe nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn?
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?
superficial
A client receives treatment for a dermatophyte infection of the toenail. How would the nurse document this condition in the chart?
tinea pedis
A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
to prevent evaporation of water from the hydrated epidermis
A client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to order:
topical agent
When a patient has been diagnosed with scabies, if the infection has spread, family members may complain of pruritus within which time frame?
1 month
The palm represents which percentage of a person's TBSA?
1%
A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as
18%
A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?
2400 mL
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?
27%
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
27%
With repeated reactions of contact dermatitis, which of the following can occur?
2nd bacterial infection
The patient is advised to apply a suspension-type lotion to a dermatosis site. The nurse should advise the patient to apply the lotion how often to be effective?
3 to 4 hr
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?
30 ml/hr
While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:
All family members need to be treated
The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?
As my wounds heal, my skin will be itchy; i can apply lotion if the scratching doesn't help
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?
BUN: 28 mg/dL
A patient is being evaluated for nodular cystic acne. What systemic pharmacologic agent may be prescribed for the treatment of this disorder?
accutane
Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client?
allograft
A client recently received lip and tongue piercings and subsequently developed a superinfection of candidiasis from the antibacterial mouthwash. What would the nurse recommend for this client?
antifungal
A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?
antiviral
A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. What is the appropriate teaching by the nurse to prevent skin damage?
apply sunscreen
Which medication classification may be used for contact dermatitis?
corticosteroids
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to
decrease catabolism
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote
decreased catabolism
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis?
deep partial thickness
Which assessment finding indicates an increased risk of skin cancer?
deep sunburn
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
hoarseness
Which sedative medication is effective for treating pruritus?
hydroxyzine
Which zone of burn injury sustains the most damage?
inner
The nurse is conducting a community education program on basal cell carcinoma (BCC). Which statement should the nurse make?
it begins as a small, waxy nodule w/ rolled translucent, pearly borders
The nurse is providing teaching to a client with acne who is using isotretinoin therapy. Which statement should the nurse make?
its teratogenic for humans
A nurse is assessing a client with a new skin disorder. Which questions would the nurse include when asking the client about the change in skin condition? Select all that apply.
when did it first begin, where did it first appear, where are the lesions located now, has it spread, have you tried to treat
A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should:
wrap elastic bandages distally to proximally on dependent areas
Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?
zone of stasis
Which antimicrobials is not commonly used to treat burns?
tetracycline
In a client with burns on the legs, which nursing intervention helps prevent contractures?
knee splints
Which term describes a fungal infection of the scalp?
tinea capitus
Which drug is an oral retinoid used to treat acne?
isotretinoin
A patient has a moisture-retentive dressing for the treatment of a sacral decubitus ulcer. How long should the nurse leave the dressing in place before replacing it?
12 to 24 hours
A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response?
Through applications of extreme cold, the tissue is destroyed
The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak?
college dorm
Which of the following is the primary lesion associated with acne, caused by sebum blockage in hair follicles?
comedones
What quick assessment technique should the nurse use to assess the percentage of burn injury?
compare clients palm to the size of the burn wound
Which of the following skin disorders is treated with intralesional therapy? Select all that apply.
cystic acne, keloids, psoriasis
The nurse is caring for a client who may have a lice infestation. The nurse is using a bright light focused on an area of the head to confirm the presence of lice. In which manner is it easiest to differentiate nits from dandruff?
difficult to remove
The nurse should assess all possible causes of pruritus for a patient complaining of generalized pruritus. What does the nurse understand can be another cause for this condition?
end stage kidney disease
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?
extensive full thickness burns
Specific potential complications are common to specific types of burns. Which burns can impair ventilation?
face, neck, & chest
A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. How would the nurse document the depth of burn injury this client has?
full thickness (3rd degree)
The classic lesions of impetigo manifest as
honey-yellow crusted lesions on an erythematous base.
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:
hyperkalemia
