Chapters 53-55

The nurse is providing teaching for a client in the blistering phase of herpes. Which of the following indicates a need for further teaching?

"I can drink out of the same glass as my spouse."

The nurse is teaching a client about preventing skin cancer. Which statement made by the client indicates an understanding of the teaching?

"I need to cancel my tanning membership."

The nurse is providing teaching for a client with acne vulgaris. Which of the following statements made by the client indicates an understanding of the teaching?

"I need to change my pillowcase often."

What are nursing interventions for itching due to dermatitis?

1. Pressure with a clean cloth 2. Antihistamines 3. Humidification

The nurse is caring for a client with burns. Which of the following interventions should the nurse implement during the emergent stage?

1. Remove clothing 2. Cool the wound with tepid water

The nurse is assigned to care for a client with herpes zoster. Based on the understanding of the calls of the disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

Positive culture results

What are the best interventions to prevent contractures?

1. Exercises 2. Pressure garments 3. Splints

What factors are considered when classifying a burn wound?

1. Extent 2. Depth 3. Body area

The nurse is assessing for an increase in melanin production in a pregnant client. Which of the following locations would the nurse expect to assess?

1. Areolae 2. Nipples 3. Face

At which of the following locations are pressure injuries commonly seen?

1. Sacrum 2. Heels 3. Scapulae 4. Greater trochanter

A nurse is Collecting data from a client who 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?

1. Temperature of 97°F 2. Hyperkalemia 3. Hyponatremia

What term would the nurse use to document a large (>1 centimeter) fluid-filled lesion?

Bulla

A 55-year-old woman is burned with hot water over her anterior trunk and her right anterior thigh. Using the Rule of Nines, what is the approximate percentage of burn?

23%

A nurse is reinforcing teaching with a client on the use of calcipotriene Topical medication for the treatment of psoriasis. Which of the following laboratory values should the nurse monitor?

Calcium

The nurse is about to perform a dressing change for a client with a pressure injury. When should the nurse administer the ordered analgesic?

30 minutes before performing the dressing change

The nurse is caring for a client receiving balneotherapy. Which of the following interventions should the nurse implement?

Advise the client to wear loose clothes after the bath

When is the best time for the nurse to apply prescribed ointment to a patient with an inflamed skin rash?

After the patient bathes

A nurse is caring for a client who has contact dermatitis and has a new prescription for diphenhydramine. Which of the following adverse effects should the nurse monitor?

Anorexia

The nurse is caring for a client with scabies. Which of the following interventions should the nurse implement?

Apply permethrin as ordered

For which type of burn should you overestimate the percentage of injury on initial evaluation?

Electrical

The nurse is caring for a client with a circumferential burn. Which intervention should the nurse implement?

Elevate affected extremities

Debridement is essential when which of the following is present?

Eschar

A nurse is caring for a client who has a stain burns over 35% of total body surface area. The client voice has become horse, a brassy cough has developed, in the client is drooling. The nurse should identify these findings as indications that the client has which of the following?

Inhalation injury

The nurse is assessing a client who was involved in a fire. Which of the following takes priority?

Inhalation injury

A nurse is assisting with the care of a client who Sistine deep partial thickness and full thickness burns over 60% of the 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?

Intravenous

What equipment is most important to have readily available when a patient is undergoing skin testing for allergies?

Resuscitation equipment

The nurse is performing a skin assessment. What is the best location to assess for jaundice?

Sclera

The nurse in specs the skin of a client who is suspected of having psoriasis. Which finding would the nurse note of this disorder is present?

Silvery white scaly lesions

Which of the following are age-related changes of the integumentary system?

Skin becomes thin

The nurse is assessing a client's pressure injury and notes wound exudate of creamy yellow pus. This finding can be indicative of which of the following?

Staphylococcus

The nurse is assessing a client with burns. For which of the following findings should the nurse notify the health-care provider?

Stridor

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 used to document this burn?

Superficial thickness

The nurse is caring for a client with chemical burns. Which of the following interventions should the nurse implement?

Tepid water lavage for 20 minutes

Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 cm?

Vesicle

A patient is admitted to the emergency department with flame burns to the entire chest, abdomen, back, and upper. Using the rule of nines, what approximate percentage of burns should the nurse document?

54%

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 fluid resuscitation?

Urine output

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse?

WBC of 3,000 mm3

Which of the following is the most common type of cancer in the United States?

skin

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates the occurrence of a systemic effect?

Hyperventilation

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

Tinnitus

A nurse is reinforcing discharge instructions to a client who had a skin biopsy with sutures. The nurse should identify that which of the following client statements indicates an understanding?

" I should apply the antibiotic ointment to the area"

A patient develops pressure injuries on the sacrum and buttocks despite being turned and repositioned regularly. Which factors may have contributed to the patient's skin breakdown?

1. The patient commonly slides down in the chair 2. The patient sits in the chair most of the day 3. The patient is often diaphoretic 4. The patient is incontinent of urine and stool

What are effects of aging on the integumentary system?

1. Wrinkles develop 2. Skin becomes thinner 3. Hair follicles become inactive. 4. Subcutaneous fat decreases

The nurse is caring for a client with psoriasis. Which of the following are factors that may aggravate the condition?

1. smoking 2. alcohol 3. hormonal changes

The client arrives to the emergency department after a burn injury that occurred in their home basement in and inhalation injury is suspected. Which would the nurse anticipate as being prescribed for the client?

100% oxygen via a tight fitting non-rebreather facemask

The nurse is caring for a group of clients. Which client should the nurse see first?

A client with burns who has developed stridor

The nurse is caring for a group of clients. Which client is at high risk for impaired healing of a pressure injury?

A client with quadriplegia

The nurse is caring for a group of clients. Which client is at highest risk for developing skin cancer?

A fair-skinned client who tans weekly whose father had skin cancer

Vesicle

A small, blister-like raised area of the skin that contains serous fluid, up to one cm in diameter. Examples poison Ivy, shingles, chickenpox

The nurse is teaching client about avoiding malignant skin lesions. Which of the following should the nurse include in the teaching?

Avoid overexposure to the sun

What information is most important for the nurse to teach patients about avoiding malignant skin lesions?

Avoid overexposure to ultraviolet rays

The nurse is assessing a client's wound. Which tissue color should be of most concern to the nurse?

Black

A patient is brought to the emergency department after a house fire. The patient has extensive trunk and lower extremity burns and is diagnosed with a deep partial-thickness burn. What assessment findings does the nurse expect?

Blistered, pinkish-white, painful lesions

The nurse is caring for a client with cellulitis. Which of the following warrants a telephone call to the health-care provider?

Blood pressure 80/42

The nurse is caring for a client with superficial partial-thickness burns. Which clinical finding should the nurse expect to find?

Bright red to pink skin

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

Elevation above the level of the heart

The nurse is teaching a 75-year-old client about immunizations. Which of the following should the nurse include in the teaching?

Encourage the client to receive the shingles vaccination.

Which of the following burn locations would lead the nurse to assess for inhalation injury?

Face

Macule

Flat, nonpalpable change in skin color, with different sizes, shapes, color; usually smaller than 1 cm. Examples rubella, scarlet fever or freckles

Which type of burn involves the muscle and bone?

Full thickness

Which of the following actions is appropriate initial treatment of a chemical burn?

Lavage with water

Which protein gives skin its characteristic color?

Melanin

The nurse is reviewing orders for a client with psoriasis. Which medication should the nurse question?

Nadolol

The nurse is assessing the skin of a Caucasian client. In which location will the nurse assess for cyanosis?

Nailbeds

The nurse is assessing pulses on a burn victim and notes a diminished pedal pulse. Which action should the nurse take?

Notify the health-care provider.

The evening nurse reviews the nursing documentation in the clients chart in notes that the day Nurse has documented that the client had a stage two pressure injury in the sacral area. What would the nurse expect to find when checking the client sacral area?

Partial thickness skin loss of the epidermis

The nurse is caring for a client with contact dermatitis. Which of the following is the most likely cause?

Perfume

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

Place the child in a bath with colloidal oatmeal

The nurse is caring for a client with dermatitis. Which interventions will the nurse implement?

Provide skin care at bedtime.

The nurse is caring for a client with silvery scales on the knees and elbows. The nurse suspects the client has which of the following conditions?

Psoriasis

The nurse is caring for a client with impetigo. Which of the following clinical manifestations can the nurse expect to find?

Honey-colored crusting

The nurse is caring for a client with cellulitis of the right lower leg. Which of the following clinical manifestations can the nurse expect to find?

Redness

Which nursing intervention is essential to protecting the patient's skin integrity when applying occlusive dressings?

Remove the dressing for 12 of every 24 hours

The nurse is performing a dressing change for a client with a pressure injury. Which of the following requires correction by the charge nurse?

The nurse applies clean gloves to irrigate the wound and apply a new dressing.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?

"The medication is likely to cause stinging initially."

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?

1. Limit visitors in the clients room 2. Increase protein intake 3. Restrict fresh flowers in the room

The nurse notes a pressure injury on a newly admitted patient's ischial tuberosity, with a thick, tough black center. Which intervention is most appropriate first?

Talk to the health care provider about debridement

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

The burn has probably caused laryngial edema, which has included the airway

The nurse is providing teaching for a client with tinea pedis. Which of the following statements made by the client indicates a need for further teaching?

"I will be sure to keep my feet moist."

The nurse is providing teaching for a client with dermatitis. Which of the following statements made by the client indicates an understanding of the teaching?

"I will lubricate my skin with unscented cream."

What are risk factors for pressure ulcers?

1. Immobility 2. Impaired sensory perception 3. Elderly 4. Very thin or obese

Which nursing interventions are essential to achieve maximum benefit for the patient receiving balneotherapy for widespread dermatitis?

1. Keep the patient in the water for 15 to 30 minutes 2. Keep the tub room warm 3. Use gentle or emollient soaps

A client arrives at the emergency department and has experience frostbite to the right hand. What would the nurse expect to find when inspecting the clients right hand?

A white color of the skin which is in sensitive to touch

A nurse is caring for a client who has herpes zoster. Which of the following medication should the nurse expect to administer for the treatment?

Acyclovir

A nurse is reinforcing teaching with a client on home care after a culture for a bacterial infection of cellulitis. Which of the following information should the nurse include?

Apply warm compresses to the affected area

The nurse is caring for a client with partial-thickness burns expects which findings upon assessment?

Areas of painful, fluid-filled blisters

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

1. Apply an exclusive dressing after application 2. Wear gloves after application to lesions on the hands 3. Avoid applying in skin folds

The nurse notes scratch marks on a patient with psoriasis. What interventions can the nurse teach the patient that will decrease itching and protect the skin?

1. Apply pressure to the itchy area with a clean cloth 2. Encourage use of gloves at night 3. Bathe daily in a hot soapy bath 4. Use a room humidifier