Exam 3 Integumentary
A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. What is the best response by the nurse?
"May I take a look at it?"
Which phase of wound healing involves adherence of blood platelets to the walls of an injured vessel?
Hemostasis
The nurse explains to a patient that the virus that causes chickenpox also can cause what?
Herpes zoster
Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply.
Burns Osteomyelitis Diabetic ulcers
A client is hospitalized with pressure ulcers. Which task could be delegated to an unlicensed nursing professional (UNP)? Select all that apply.
Empty wound drainage containers. Report changes in wound appearance
The nurse is providing care to an African-American patient who is recovering from a burn wound. Which statement by the patient indicates correct understanding of the information provided related to healing?
"I should expect hyperpigmentation of the skin upon healing."
A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be prevented. What is the nurse's response?
"Scratching results in skin breaks that can lead to infection."
A leader should have time-management skills. Arrange the principles of time management in order.
1. Goal setting 2. Time analysis 3. Priority setting 4. Interruption control 5. Evaluation
A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at what angle?
30 degrees
A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath?
98° to 100° F
A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection because it resulted from what?
A procedure performed at the hospital
The nurse is caring for a client with a closed soft tissue injury. How will the nurse describe this injury?
As a contusion
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing?
Ascorbic acid (Ascorbicap)
During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to do what?
Assess the person's breathing
Which wound care is given by the nurse to a client with severe burn injuries during the acute phase?
Assess the wound daily and adjust the dressing
Which description could be related to zosteriform-type lesions?
Band-like distribution
Which foods rich in vitamin C act as dietary supplement for wound healing? Select all that apply.
Broccoli Cabbage Strawberries
A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?
Capillarity
When a client who has had a mastectomy returns from surgery, a dressing and a portable wound drainage system to the axillary area are in place. The nurse notes an excessive amount of serosanguineous drainage on the mastectomy dressing. What is the nurse's next action?
Checking the function of the drainage system
A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time?
Client with epilepsy
Which topical drugs are typically used to treat a client with acne vulgaris? Select all that apply.
Clindamycin Erythromycin
While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention?
Compress the container before closing the port
The nurse suspects fluid volume deficiency in a client who complains of weight loss and skin dryness. Which other finding might confirm the nurse's suspicion?
Darkened urine
A 23-year-old client has white hair. Which change in the hair is responsible for this condition?
Decreased melanocytes
What would the nurse state is a serious side effect of x-rays?
Desquamation
A nurse is assessing the skin of a client with a cortisol deficiency. Which integumentary assessment finding will most likely be observed in this client?
Diminished axillary hair
In talking with a client, the nurse learns that the client spends more than an hour at a time trimming and combing her hair five times a day. Which nursing intervention would be most beneficial?
Discussing the triggers that provoke this behavior
A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). What recommendations are essential for the nurse to include? Select all that apply.
Eat foods high in vitamin C. Take your temperature daily. Balance periods of rest and activity.
A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take?
Elevate the affected leg above the level of the heart
The nurse is preparing a care plan for a client with fatigue, angina, anxiety, and pale, cool skin. Which nursing intervention will help reduce fatigue in this client?
Encouraging diversionary activities
Which intervention is beneficial when vascular changes impair circulation to the wound site?
Encouraging the client to eat foods rich in protein, zinc, and vitamins A and C
The nurse is providing care for a client that is on bed rest. How can the nurse prevent skin breakdown for this client?
Encouraging the client to move around as much as possible
A client is admitted for malignant melanoma that was discovered during a routine eye examination. For which preferred treatment does the nurse expect the client to be scheduled?
Enucleation
Which drugs used for the treatment of plaque psoriasis will the nurse administer subcutaneously? Select all that apply
Etanercept Adalimumab Ustekinumab
Which skills would be essential for an effective nurse manager to develop and improve collaboration with others? Select all that apply.
Flexibility Ability to listen to others Ability to share information and ideas
In preparation for discharge, the nurse reviews wound care for a client recovering from a total hip replacement. The nurse identifies that the client understands the instructions when the client makes which statement?
I will inspect the incision for healing when I change the dressing."
An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which standard of the nursing practice as defined by the American Nurses Association does the nurse follow?
Implementation
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
A direct care nurse has great skill in teaching clients different self-care activities and is sought out by colleagues to teach their clients. Which power does the nurse possess?
Information power
The nursing staff complains about confusion at the work place due to the nurse leader's habit of avoiding responsibility and asking the staff to self-schedule client care assignments. Which type of leadership does the leader exhibit?
Laissez-faire leadership
A client is admitted to the hospital for surgery for a total abdominoperineal resection. What position should the nurse encourage the client to maintain when in bed to promote perineal wound healing after surgery?
Left or right side-lying
Which statement is true regarding wound healing?
Leukocytes begin to engulf bacteria, fungi, and virus
A client with a gunshot wound has severe hemiplegia associated with abnormal body posturing and fixed and dilated pupils. What is the nursing priority in this condition?
Monitoring respiratory rate
During a physical assessment, the nurse notes cutaneous fibromas and Lisch nodules (yellow elevations) on a client's irises. What genetic condition might this client have?
Neurofibromatosis
Within the first 2.5 hours after a radical neck dissection, 40 mL of medium red, bloody fluid is collected in the portable wound drainage system. What should the nurse do first?
Obtain the vital signs
Which complication may be caused by sepsis in burns?
Paralytic ileus
A toddler-age child presents in the emergency department (ED) with an infected wound. The child's mother states, "I don't have time to take care of this." A review of the child's medical record indicates that each appointment related to the wound was cancelled. Which should the nurse suspect based on the current data?
Physical neglect
After changing a dressing that was used to cover a draining wound on a client with Vancomycin Resistant Enterococcus (VRE), the nurse should take which step to ensure proper disposal of soiled dressing?
Place the dressing in a red bag/hazardous materials bag
While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent the development of pneumonia. Which other complication can be prevented through this nursing intervention?
Pressure ulcers
A nurse places a client with severe burns on a circulating air bed. What is the primary reason why the nurse implements this action?
Prevent pressure on peripheral blood vessels
A client who is being provided palliative care for melanoma complains of severe pain at the lesion sites on his lower leg. Which action by the nurse is most appropriate in this situation?
Providing a back rub
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments?
Quality of respirations and presence of pulses
After a basal cell carcinoma is removed by fulguration, a client is given a topical steroid to apply to the surgical site. The nurse evaluates that the teaching regarding steroids and skin lesions is effective when the client states that the primary purpose of the medication is to do what?
Reduce inflammation at the surgical site
Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first intervention?
Safely remove the victim from the immediate vicinity
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 Pruritic lesions Reddened papules
While completing an assessment, the nurse finds that a client has decreased thickness and excessive dryness of the epidermis. Which clinical finding is associated with this skin assessment?
Skin fragility
A nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the primary concern of the nurse when caring for this client?
Skin integrity
A health care provider tells a client that vitamin E and beta-carotene are important for healthier skin. Which foods should the nurse recommend that are excellent sources of both of these substances?
Spinach and mangoes
Which is the priority nursing action when providing care to a client with a penetrating abdominal wound?
Stabilizing the impaled object
A nurse is assessing a newly admitted client with the pressure ulcer indicated in the picture. Which pressure ulcer stage should the nurse document on the admission history and physical?
Stage II
A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly?
Strawberries
Which statement is true with respect to the secondary intention in the process of wound healing?
The wound may develop purulent exudate when a tissue dies
Which fungal infection in a client is commonly referred to as athlete's foot?
Tinea pedis
A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing what phenomenon?
Tolerance
A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching?
Using a back-and-forth motion while cleaning the wound
A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing?
Vitamin C is required for collagen production by fibroblasts.
A client had a colostomy surgery and is learning how to care for the skin around the stoma. What information from the teaching plan should the nurse reinforce with this client?
Wash the area gently with soap and water before applying an appliance
A client has a basal cell epithelioma that is scheduled to be removed. The client expresses concerns that the cancer has spread. What is the best response by the nurse?
"Basal cell tumors usually do not spread."
A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching?
"I should not worry about what the client eats."
The registered nurse is teaching the student nurse about precautions to take when treating a client with open burn wounds. Which statement made by the student nurse indicates the need for further teaching?
"I should use non-sterile gloves when applying ointments."
A client is diagnosed with psoriasis and the nurse is providing health teaching concerning skin care at home. What recommendation does the nurse include in the teaching?
Apply moisturizing lotion several times a day
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?
Cover the wound with a sterile towel moistened with normal saline
An adolescent is taken to the emergency department after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The adolescent reports that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation?
Data collection by the nurse was incomplete, and as a result the treatment was insufficient
While assessing the skin of an older adult, the nurse observes that the skin has a dry and uneven color. Which change is responsible for this condition?
Decreased activity of sebaceous glands
What is the primary focus of nursing care for a client admitted with tetanus caused by a puncture wound?
Decreasing external stimuli
A client is admitted to the hospital for the medical management of burns over 18% of the body's surface. What should the nurse teach the client to help manage pain during dressing changes?
Deep breathing exercises
Which integumentary manifestation can be noticed in a client with CD4+ count of 180/mm3/(200/uL)?
Delayed wound healing
Which type of home health care agency is most likely to be owned by corporate chains and be profit oriented?
Proprietary agency
Which type of continuing care should a client expect if discharged home with a drug infusion device to continue treatment for a leg wound?
Home care
The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound?
Red
Five days after a client has abdominal surgery a nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?
Serosanguineous drainage
When changing a postoperative client's dressing, the nurse is careful not to introduce microorganisms into the incision. What type of asepsis includes this principle?
Surgical asepsis
What is the priority nursing intervention for an older client with diabetes mellitus who presents with a large leg ulcer?
Teaching how to transfer from a bed to chair in the least painful manner
A nurse observes regular patterns that look like they were made by a belt buckle, wire hanger, and chain on a child's skin. What behavioral change might the nurse also expect from the child?
The child expresses fear of going home.
Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult?
The nurse should keep the client adequately hydrated.
When should the nurse use hypoallergenic tape or Montgomery straps as the best practice in postoperative skin care?
When protecting the fragile skin of the older client
A nurse is administering an intradermal skin test injection to a client. What is the next action the nurse needs to do after the medication has been injected?
Withdraw the needle and place a piece of gauze over the injection site
Which statement is true regarding the reconstruction phase of wound healing?
Wound dehiscence mostly occurs in the reconstruction phase.
A nurse is assessing a wound that is healing by secondary intention. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?
Yellow
The nurse introduces herself to the client and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying?
Confidence
A client with burns over 35% of the body complains of chilling. What should the nurse do to promote client comfort?
Limit room drafts
In which delegation right is it essential for the assistive personnel to be comfortable asking questions and seeking assistance?
Right supervision
A nurse is caring for a client with chronic occlusive arterial disease. Which precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions?
Trauma from mechanical, chemical, or thermal sources
The nurse stops at an accident scene to administer emergency care for a person who has sustained partial- and full-thickness burns to the chest, right arm, and upper legs as the result of a car fire. What should the nurse do first when caring for this person?
Wrap the person in a clean, dry sheet
A client is admitted for treatment of partial- and full-thickness burns of the entire right lower leg extremity and the anterior portion of the right upper arm. A nurse performs an immediate appraisal of the percentage of body surface area burned using the rule of nines. What percentage of body surface area does the nurse determine is affected? Record the answer to one decimal place. _______%
22.5
The victim of an automobile accident has been brought in to the emergency department with a few skin cuts. The client identifies himself as belonging to a strict religious group and refuses to take pain medication or to get sutures for the wound. Which ethical principle is the nurse following by not insisting the client get the treatment the emergency department personnel feel is necessary?
Autonomy
A client reports purplish bruises on the skin. The laboratory report shows the platelet count as 100,000 and the condition is diagnosed as autoimmune disorder. Which therapy would be most appropriate for this client?
Plasmapheresis
