EAQ - Med-Surg - Integumentary

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. Which is the nurse's best response?

"This type of schedule gives noncancerous cells time to recover."

The nurse is providing care for a client diagnosed with invasive pancreatic cancer. The client has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action should the nurse take postoperatively?

Cleanse the area around the insertion site to prevent skin breakdown

Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins?

Contact dermatitis Rationale: In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins.

A nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond?

Explain that the incision should not be immersed in water until it has healed

Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor?

Pseudomonas

Which gastrointestinal (GI) change may be found in the client with burn injuries?

Abdominal distention

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity?

Allergic contact dermatitis Rationale: Allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens.

When reestablishing a Jackson-Pratt drain after emptying its contents, the nurse squeezes the collection container and recaps the drain. What is the rationale for the nurse's action?

To restore suction Rationale: Closed suction drains such as Hemovac and Jackson-Pratt suction by means of compression and reexpansion of the system.

A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care?

Use a consistent approach to care and encourage participation

Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue?

Moisture-retentive dressing

A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply.

Scaly lesions Reddend papules

What is the color of a client's wound caused by skin tears?

Red

Which surgery is used to treat excessive wrinkling or sagging of facial skin?

Rhytidectomy

What is a clinical manifestation of hypernatremia in burns?

Seizures

Which drug can cause chemical burns?

Anthralin Rationale: Anthralin is a strong irritant that has an action similar to tar. So this drug can cause chemical burns with topical use.

Which type of laser is used in the treatment of vascular and other pigmented lesions?

Argon

Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply.

Impetigo Erysipelas

A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan?

"Avoid applying lotions and powders over the area."

A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan?

"Clean the mouth with a soft toothbrush or a gentle spray."

A client is found to have groups of isolated erythematous pustules on the scalp. Which statement made by the client is associated with the skin infection present in the client?

"I have no discomfort." Rationale: The presence of isolated erythematous pustules in groups on the scalp indicates folliculitis. A client with folliculitis may not feel any discomfort. A client with cellulitis has a fever. A client with herpes simplex infection feels itching, stinging, or pain. A client with candidiasis may have cracks at the corner of the mouth.

A registered nurse teaches a client about the self-care measures to be taken to prevent dry skin. Which statement made by the client indicates the nurse needs to follow up?

"I will use deodorant soap in place of alkaline soap."

Which complications does the nurse anticipate in the client who has blue-colored nail beds?

Cardiopulmonary disease

Which description describes a coalesced type of skin lesion configuration?

Lesions merge together and appear confluent.

Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply.

Photoaging Wrinkling of the skin

What is the function of the dermis?

Provides cells for wound healing

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?

Skin integrity

The registered nurse is teaching a student nurse about delegating tasks to the unlicensed assistive personnel (UAP) while caring for a client with a skin disease. Which delegation statement made by the student nurse requires a need for further teaching?

"I will advise the UAP to reinforce the client teaching." Rationale: Reinforcement of client teaching is a task to be performed by licensed practical nurses and licensed vocational nurses. This task should not be delegated to the UAP.

Which infection is caused due to fungus?

Dermatophytosis

Which topical immunomodulator is used to treat a client with atopic dermatitis?

Tacrolimus Rationale: Tacrolimus is used to treat atopic dermatitis. Mupirocin is used to treat impetigo. Clindamycin and erythromycin are used to treat acne vulgaris.

What should the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn?

The risk of septicemia and its potential complications from treatment

The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing?

The scar is firm and inelastic on palpation.

Which fungal infection in a client is commonly referred to as athlete's foot?

Tinea pedis

A client who had a history of chicken pox arrived at the hospital complaining of itching and deep pain on the skin. Which assessment finding made by the nurse helps to confirm the diagnosis?

Appearance of multiple lesions in a segmental distribution on the skin Rationale: The client who had a history of chicken pox may have a chance of getting herpes zoster. Multiple lesions in a segmental distribution on the skin may be a viral infection such as herpes zoster.

The nurse is examining the nails of four different clients. Which client does the nurse suspect as having an iron deficiency?

Client B has iron deficiency. Rationale: The shape of the nail is koilonychias, characterized by flattening of the nail plate with an increased smoothness of the nail surface.

Which integumentary change is associated with delayed wound healing in a client?

Decreased cell division

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which classification should the nurse use to describe these burns?

Deep partial-thickness Rationale: In deep partial-thickness burns, upper layers of the dermis, and injury to deeper portions of the dermis occur.

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly proportional

Which skin infection would cause facial paralysis?

Herpes zoster Rationale: Facial paralysis is the clinical sign of Bell's palsy, a complication of the herpes zoster infection. This is seen when the trigeminal nerve is infected by the varicella-zoster virus.

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?

In the preoperative period Rationale: Teaching for the postoperative period should begin as soon as the decision for surgery is made; knowledge of what to expect decreases anxiety and may improve adherence to the treatment regimen.

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?

Inadequate gas exchange caused by smoke inhalation

Which functions does the nurse associate with the epidermis?

Inhibits proliferation of microorganisms Allows the photoconversion of 7-dehydrocholesterol to vitamin D

Which characteristic does the nurse associate with a punch biopsy?

It is performed using a circular cutting instrument 2 to 6 mm in diameter.

What are the functions of a client's subcutaneous layer of skin?

It provides insulation. It acts as an energy reservoir. It acts as a mechanical shock absorber.

A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema should the nurse initially assess?

Tissue ischemia Rationale: Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia, and should be assessed first.

What are the roles of an unlicensed assistive personnel in skin care?

To assist the client in bathing To apply wet dressings to the skin To report changes in the skin appearance

A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client?

his limits muscle contractions that may force causative organisms into the bloodstream.