Integument System

Which statement made by the mother of a child suffering from eczema alerts the nurse to the need for further teaching?

"I will use baby wipes to clean the affected areas between baths."

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An unlicensed assistive personnel who has never had chickenpox.

The LPN is caring for a client with severe burn injury and is preparing to initiate with the RN the IV fluids for fluid resuscitation. The LPN is aware that the most appropriate IV fluid solution for severe burn injury fluid resuscitation would be?

Lactated Ringers Solution

A client presents to the primary care clinic reporting frequent scratching and itching of the skin that is worse at night. The nurse should gather additional data that would consistent with which of the following skin disorders?

Scabies

Which finding noted by the school nurse while conducting pediculosis capitis (head lice) indicates the need for treatment?

Silver/white sacs attached to the hair shafts in the occipital area.

The nurse is providing care to a child diagnosed with impetigo. The child's parents ask what caused this to occur. Which organism does the nurse include when educating the parents about impetigo?

Staphylococcus Aureus

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 the fluid resuscitation?

Urine output

The nurse works in an extended-care facility and is assisting in the development of a policy and procedure addressing foot care of the residents. Which intervention does the nurse identify as needing to be reconsidered in regard to routine foot care?

Use a pumice stone to remove dry skin from heels or callused areas.

When providing education for new parents on the prevention of diaper rash the nurse should be sure to cover which of the following topics?

Using skin protective ointment may prevent your baby from getting diaper rash; you do not have to wait for your baby to get a diaper rash to use it.

The nurse is assisting with a patient who has a suspected diagnosis of Tinea Captitis (ringworm) . For which diagnostic test does the nurse prepare the patient?

Wood's light examination

A toddler pulled a pot of boiling water off of the stove and suffered partial and full-thickness burns to the chest. The child is now in the recovery-management phase of burn treatment. Which common complication should the nurse assess this client for based on the current data?

Wound infection

The nurse is providing care for a patient who is receiving fluid replacement after being burned on 37 percent of the body. Nursing assessment reveals a blood pressure of 80/60 Hg. Pulse of 120 bpm. Urine output of 10 mL over the past hour. After reporting these findings, which order does the nurse suspect to be prescribed for this patient?

Increase the amount of IV fluid administered per hour.

The nurse in a healthcare providers office is reassessing a patient's skin and making a comparison with the information from the patient's last visit. For which reason does the nurse focus on any changes noted in the patient's skin?

The skin is a good communicator regarding the patient's health

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

100% oxygen via a tight fitting nonrebreather face mask

Thhe nurse is caring for a client who received extensive burn injuries across anterior chest and one entire leg. Rules of nines formula indicates 36% of total body surface area burned. The nurse is assisting with the fluid resuscitation calculation. The client weighs 110 lbs. What amount of fluid should be infused within the first 8 hours?

3600 mL

The nurse is providing care for a patient with a large skin abrasion to the outer thigh. The HCP has ordered a daily dressing change without disturbance of the healing crusts that have formed in the area. Which dressing material will the nurse select?

A nonadherant dressing for cover and gauze for wrapping.

The nurse notes that a client has an elevated lesion that contains clear fluid and measures >1 cm in diameter. This finding is best documented by the nurse as which of the following?

Bulla

When caring for a client with a burn in the emergent stage, which of the following has lowest priority as part of an accurate burn assessment?

Gender

A client with herpes simplex virus 1 makes the remark that she hopes she never gets another lesion on her lip "like this one". What is the nurse's best response?

Herpes Simplex Virus 1 can be reactivated at any time.

The client presents with a pruritic rash. The nurse would ask the client questions about which of the following to help differentiate the cause?

Location of the rash

The nurse is caring for a child with severe pruritis knows that which of the following findings are not consistent with a scabies diagnosis?

Mild regional swollen lymph nodes

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which should the nurse expect to find when checking the client's sacral area?

Partial thickness skin loss of the epidermis

A client presents with silvery plaques on both elbows that are not itchy, but bleed when the scales are removed. The nurse concludes that the client most likely has which of the following conditions?

Psoriasis

The nurse is providing care for a patient with limited mobility. The nurse notes that the head of the patient's bed is frequently at 45 degrees of elevation and the patient is slouched in the bed. Which area of the patient needs to be inspected carefully?

The coccyx and the buttocks

The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst Stocking) during the rehabilitative stage can prevent which complication?

Hypertrophic scarring

Nurses can be very influential in the decision making process for teens. Which of the following should the nurse include in her teaching for a teen asking about getting a tattoo?

Implications to consider for future employment opportunities and Information on infectious diseases associated with tattooing performed without sterile technique and sterile equipment.

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client becomes restless, and his color is becoming dusky. The nurse should interpret this data as indicating which?

The burn has probably caused laryngeal edema which has occluded the airway

The nurse is assisting with the care of an older adult patient who is hospitalized for second-degree burns of the legs and feet acquired when a deep fryer tipped over. Which factor has the least impact on the condition and recovery of the patient?

The patient wearing light-weight cotton pajamas

A client diagnosed with Herpes Simplex Virus type 1 is being seen at the clinic for a returned outbreak. The LPN would anticipate which medication as part of the treatment plan?

Acyclovir

Which is the priority nursing intervention for a 4-year-old patient brought to the emergency department (ED) for treatment of frostbite?

Administering analgesics

During the assessment of a child, the nurse notices the presence of vesicles that are oozing honey-colored fluid on the child's legs. Which condition would the nurse suspect?

Impetigo