Evolve Integumentry
A dark-skinned client has a gray-colored tongue and lips. Which complication does the nurse suspect?
Cyanosis The gray color of the tongue and lips is due to cyanosis. A yellow color to the oral mucous membranes is due to jaundice. If the affected area of the body side is swelling and darkening of the skin when compared to an unaffected area is visible, then it is due to skin bleeding. When the affected area is warm and the skin color is changed, it is inflammation.
Which description is associated with fissures?
Linear cracks in the epidermis that extend into the dermis Fissures are linear cracks in the epidermis that extend into the dermis. Ulcers may be described as deep erosions extending beneath the epidermis. Atrophy is the thinning of the surface of the skin with a loss of skin markings. Lichenifications are characterized by thick areas of epidermis with accentuated skin markings.
Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue?
Moisture-retentive dressing A moisture-retentive dressing is used to promote autolysis in the spontaneous separation of necrotic tissue in wound debridement. Continuous wet gauze is used in promoting dilution of viscous exudate and softening the dry scar. Topical enzyme preparation shows proteolytic action on thick, adherent eschar, causing the breakdown of denatured protein and a more rapid separation of necrotic tissue. In wet-to-dry damp saline-moistened gauze, necrotic debris is mechanically removed but with less trauma to healing tissue.
What is the function of the dermis?
Provides cells for wound healing The dermis is present between the epidermis and subcutaneous layers and has such functions as giving the skin its flexibility and strength and providing cells for wound healing. Subcutaneous tissue is the innermost layer of the skin that helps in retention of body heat and acts as a mechanical shock absorber. Epidermis is the outermost layer of skin that inhibits the proliferation of microorganisms.
While assessing the skin of a client, the nurse observes a lesion that has a wavy border. Which type of lesion is present in the client?
Serpiginous A lesion with a wavy border indicates a serpiginous lesion. A lesion that is ringlike with raised borders around a flat, clear center indicates an annular lesion. A circular lesion indicates a circinate lesion. A lesion that merges with another and appears confluent indicates a coalesced lesion.
What would the nurse state is a serious side effect of x-rays?
Desquamation X-ray is one of the radiologic diagnostic tests also used as therapy in some disease conditions. Desquamation is a serious side effect caused by x-rays. Vesicles, papules, and plaque-like lesions are serious effects caused by drug-induced photosensivity.
Which physical changes may cause longitudinal nail ridges?
Decreased Blood Flow Longitudinal ridges may be due to decreased blood flow to the nail beds. Decreased cell division in the skin may cause a delay in wound healing. Increased risk of fungal infections is due to decreased rate of growth. Increased risk of osteomalacia is due to a decrease in vitamin D levels.
Which physiologic activity is associated with the "proliferative phase" of normal wound healing?
Epithelial cells grow over the granulation tissue bed During the "proliferative phase" of normal wound healing, the epithelial cells grow over the granulation tissue bed. The white blood cells are migrated into the wound during the inflammatory phase. In the maturation phase, the scar tissues gradually become thinner and pale in color. The vasodilation with the increased capillary permeability may occur during the inflammatory phase.
A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia (CREST syndrome). Which clinical indicators should the nurse expect to identify upon assessment? Select all that apply.
Esophageal dysmotility Spiderlike hemangiomas Episodic blanching of the fingers
What is the source of an Integra graft?
Glycosaminoglycan bonded to silicone membrane Glycosaminoglycan bonded to silicone membrane is the source of an Integra artificial skin graft. Porcine skin is the source of a xenograft. Cadaveric skin is the source of an allograft. Porcine collagen bonded to silicone membrane is the source of a biobrane graft.
Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity?
Allergic contact dermatitis 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. Utricaria is an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis. A drug reaction may be caused by any drug such as penicillin that acts as antigen causing hypersensitivity reactions. Atopic dermatitis is a genetically influenced, chronic, relapsing disease associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.
Which drug can cause chemical burns?
Anthralin Anthralin is a strong irritant that has an action similar to tar. So this drug can cause chemical burns with topical use. Prednisone is a corticosteroid applied topically to treat psoriasis. Tazarotene and calcipotriene are teratogenic (cause birth defects)
A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up?
I will use an oatmeal-based lotion after each treatment While undergoing radiation therapy, lotions, powders, and ointments should not be applied to the area. The skin markings should not be removed, because they form the parameters for the delivery of radiation. To protect the irradiated skin, sunlight and heat should be avoided. Nonirritating clothing should be worn over the area to prevent trauma to the delicate irradiated skin.
Which statement by the nurse is true regarding dandruff?
It is a problem of excessive oil production Dandruff is associated with excessive oil production. Hirsutism may occur as a side effect of a drug therapy. Tenderness of the scalp is associated with lice and nits. Hirsutism is a manifestation of a hormonal imbalance
Which component of skin maintains optimal barrier function?
Keratin Keratin is a protein produced by keratinocytes that helps to maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.
Which predisposing condition may be present in a client with pitting edema?
Kidney Disease Kidney disease may be a predisposing condition associated with pitting edema. Shock may be associated with a decreased temperature. Hypothyroidism may be a predisposing condition of non-pitting edema, which occurs due to an endocrine imbalance. Severe dehydration may be associated with decreased elasticity of the dermis.
Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply.
Photoaging Wrinkling of skin The skin damage that happens from chronic exposure to ultraviolet rays are photoaging and skin wrinkling. Dryness, vascular lesions, and benign neoplasm are changes related to aging.
What is the color of a client's wound caused by skin tears?
Red A wound that is caused by skin tears is red in color. A wound caused by a full-thickness or third-degree burn is gray or black in color. Wounds with nonviable necrotic tissue that create an ideal situation for bacterial growth are yellow in color.
The nurse is caring for two clients with a below-the-knee amputation. The first client was in a motor vehicle collision. The second client had chronically decreased arterial perfusion. Which information has caused the nurse to conclude that the postoperative courses of these two clients may differ?
The second client's incision will take longer to heal Decreased arterial circulation in the second client will delay healing. The first client received an amputation without preoperative preparation for the loss of the limb and will most likely have greater difficulty adapting. Clients with chronic limb pain before surgery (e.g., the second client with chronically decreased arterial perfusion) are more likely to have phantom limb sensations. Both clients' responses may be influenced by their occupations, but there are no data to support this conclusion.
Which fungal infection does the client refer to as jock itch?
Tinea Cruris Tinea cruris is a fungal infection commonly referred to as jock itch. It clinically manifests with well-defined scaly plaque in the groin area. Tinea pedis is a fungal infection commonly referred to as athlete's foot. It is clinically manifested as interdigital scaling and maceration, scaly plantar surfaces, erythema, and blistering. Tinea corporis is a fungal infection commonly referred to as ringworm. It is clinically manifested as an erythematous annular, ringlike, scaly lesion with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.
