Integumentary Disorders

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may

dislodge the autografts.

A daycare worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears

erythematous with raised papules.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by

first intention.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

hoarseness of the voice

The nurse should assess a client who is in the emergency phase of burn management for which finding?

hyperkalemia

A client with Stevens-Johnson syndrome exhibits the following clinical manifestations. Which assessment finding requires priority action by the nurse?

oral temperature of 102.2°F (39°C)

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should assess the client for which adverse reaction?

ototoxicity

The nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client's medical record, the nurse would suspect which medication to be a probable cause of this disorder?

phenytoin

A client is to receive biologic burn grafts. What should the nurse tell the client's family is the advantage of using biologic burn grafts such as porcine (pigskin) grafts?

promote the growth of epithelial tissue.

A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective?

urine output at 0.5 mL/kg/hour

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

urine output of 20 ml/hour

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath?

Administer an analgesic agent.

A client is experiencing intertrigo caused by friction between the inner thighs. Which action should the nurse take to help this client?

Apply lubricating lotion over the affected areas.

A client has several patches of vesicles over both arms. Which care should the nurse provide to this client?

Cover the draining areas with sterile gauze.

The nurse is planning care for an older adult with a pressure injury (see figure). What should the nurse do? Select all that apply.

Cover the injury with protective dressing. Reposition the client every 2 hours. Request an alternating-pressure mattress.

A client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN?

Ensure adequate caloric and protein intake.

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care?

Place the client on a pressure redistribution bed.

The nurse is bathing a client and discovers a pressure injury on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first?

Position the client off of the injury.

Which action should the nurse take when providing emergency care at the accident site for a victim with a heat burn?

Pour cool water over the burned area.

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

What is the primary goal of nursing care during the emergent phase after a burn injury?

Replace lost fluids.

A client with a partial thickness burn injury has had Biobrane applied 2 weeks ago. The Biobrane is now separating from the wound. What nursing intervention is appropriate?

Trim away the Biobrane that has separated from the wound.

Which information should the nurse include when providing discharge instructions to a client with psoriasis?

Trim fingernails regularly.

The nurse is assisting a client who has dentures with oral hygiene. To prevent stomatitis, the nurse should assist the client to take which action?

Use a soft toothbrush or gauze pad to provide oral hygiene.

A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. All options must be used.

Wash hands thoroughly. Put on latex gloves. Slowly remove the soiled dressing. Assess the drainage in the dressing.

When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers?

a client who has a decreased serum albumin level

The nurse is collaborating with the surgeon to manage pain for a client with full-thickness burns over 35% of the body. Which approach to pain management will be most effective? The most appropriate plan will include:

administering intravenous opioid analgesics.

The nurse is working as charge nurse on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention?

administering oral tetracycline with milk to a client with cellulitis

The health care team is developing a care plan for a client who has burns on 30% of their body. When should the team initiate rehabilitation plans for this client?

after the client's circulatory status has been stabilized

Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection?

amount of subcutaneous tissue

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at an adult child's home with six other people. During the client's visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is

"All family members need to be treated."

A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."

Which question is most important for a nurse to ask when taking a history from a client diagnosed with tinea corporis?

"Do you have any pets?"

Which is the best nursing response to make when a client asks why there are small lumps under the suture line of the incision three weeks after abdominal surgery?

"Those lumps are caused by new tissue growing at different rates."

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

A client with psoriasis is scheduled for ultraviolet B (UVB) phototherapy. Which statement by the client indicates a correct understanding of this form of treatment?

"Phototherapy can slow down the production of skin cells."

A client is admitted with pneumonia and shingles with draining lesions over the right anterior and posterior chest wall. Of the nurses scheduled for the shift, which nurse(s) may be assigned to care for this client? Select all that apply.

-43-year-old nurse who had a preexposure varicella vaccination -48-year-old nurse who had shingles 1 year ago -24-year-old nurse who has never had the pneumococcal vaccine

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.

-Reposition the client every 2 hours. -Perform range-of-motion exercises -Encourage the client to eat a well-balanced diet.

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care?

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias.

A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate?

Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.

A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that the client's children work and no one has time to assist the client with self-care activities. Which action should the nurse take?

Contact the nursing supervisor.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assistant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first?

Document the findings.

The nurse is preparing information for a community health fair. Which information should the nurse include to promote healthy skin?

Drink an adequate amount of water.

A client is receiving fluid replacement with lactated Ringer's solution after 40% of the body was burned 10 hours ago. The assessment reveals a temperature of 97.1°F (36.2°C), heart rate of 122 bpm, blood pressure of 84/42 mm Hg, central venous pressure (CVP) of 2 mm Hg, and urine output of 25 mL for the last 2 hours. The intravenous (IV) rate is currently at 375 mL per hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse should request which prescription from the health care provider?

IV rate increase

A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

behind the ears

The nurse is assessing a client who experienced second- and third-degree burns of the arms and hands from a kitchen grease fire. After determining that the client did not experience an inhalation injury, which assessment should be completed next?

blood pressure and heart rate

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy?

client with a compromised skin graft

A school-age client is experiencing severe itching in both hands that is worse at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. Which nursing diagnosis should the nurse use to plan care for this client?

impaired skin integrity

A client in the acute phase of burn injury rates their pain as 9 on a scale of 0 to 10. Which pain medication would be most effective to decrease the client's perception of the pain?

intravenous opioids

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects

melanoma.

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant s. aureus (VRSA). Which nursing actions can be delegated to a licensed practical/vocational nurse (LPN/VN)?

obtaining a wound culture during a dressing change

A client is brought to the emergency department having been involved in a fire while putting lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be dry and pale white with some areas that are brown and leathery. Which type of burns does the nurse determine are present?

third degree (full thickness)

A client is diagnosed with contact dermatitis. Which medication should the nurse expect to be prescribed to treat this disorder?

topical corticosteroid

The rate at which IV fluids are infused is based on the burn client's:

total body weight and BSA burned.

The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home?

use of smoke detectors

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?

"I'll eat plenty of fruits and vegetables."

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education?

"On the morning of the surgery, I can shave my surgical area at home to save time."

The client phones the outpatient surgery center following skin biopsy on the left shoulder. The client states that the site continues to drain pinkish drainage and is uncomfortable. Which triage questions are appropriate to evaluate the client's concern? Select all that apply.

"On which day did you have the biopsy completed?" "Can you describe the drainage that you see." "What is your pain level on a 0-10 pain scale?" "How are you cleaning the area?"

A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment, the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist (ET). When gathering supplies for a stage II ulcer, what characteristics would the ET anticipate? Select all that apply.

-The ulcer is superficial, like a blister. -Partial-thickness skin loss of the epidermis is evident.

An autograft is taken from a client's left leg. The nurse should care for the donor site by taking which action?

keeping the site clean and dry

A nurse assesses wound evisceration in a client that had abdominal surgery. In what position should the nurse place the client?

knees flexed, supine

The nurse is reviewing the intraoperative record of a client. Which information would alert the nurse to the greatest possibility of a potential for skin breakdown?

length of surgery

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

mafenide

A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy?

maintaining the client's fluid and electrolyte balance

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority?

replacing fluid and electrolytes

A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take?

Assess oxygen saturation using pulse oximetry.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water.

A high school student is brought to the nurse by the chemistry instructor after a classmate accidentally spilled a toxic chemical on the student's hands. Which action should the school nurse prioritize in this situation?

Run water at low pressure over the hands to remove the chemical.

A 29-year-old client is concerned about their personal risk factors for malignant melanoma. They are upset because their 49-year-old sibling was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse should tell the client which information?

Some melanomas have a familial component, and the client should seek medical advice.

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?

The dressing should keep the wound moist.

A client is asking the nurse about receiving the current shingles vaccine (Shingrix). Which factor indicates the client should receive the vaccine?

is over 50 years of age.

When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure injuries, the nurse should emphasize that most tissue injuries related to shearing can be prevented by which action?

proper positioning and moving of the client

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

ring or donut

When instructing a client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch?

roast beef sandwich, milkshake, and cottage cheese

A client received burns to the entire back and left arm. Using the Rule of Nines, the nurse can calculate that the client has sustained burns on what percentage of the body?

27%

A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure?

"Apply sunscreen even on overcast days."

A client presents to the emergency department with a foot lesion. When documenting the foot lesion in the medical record, which medical terms would a nurse use to classify the pictured lesion? Select all that apply.

-linear -fissure

The nurse is using home telehealth monitoring to manage care for an 80-year-old client who is homebound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. During this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) with the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit with the previous visit, the nurse should do what next?

Contact the health care provider to request a hydrocolloid dressing.

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan?

Use a topical skin moisturizer daily.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

scale

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?

small, waxy nodule with pearly borders

A nurse is performing an admission assessment on a client entering a long-term care facility. The nurse notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

stage II pressure injury

The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. Which position would be most appropriate for preventing contractures?

supine

Sudoriferous glands secrete which type of substance?

sweat

The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot, followed by an infection. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse?

take the antibiotics until the redness goes away and my foot feels better."

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate?

urine output

A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure injuries on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. Over the past few weeks, the client has been spending less time in the wheelchair. During the appointment, the nurse notes that the client is not using a cushion and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen?

Ask the client to explain the treatment regimen.

The nurse is reviewing risk factors for malignant melanoma with a group of individuals in a community setting. Which risk factors should the nurse include in the instructions? Select all that apply.

-freckles -light-colored eyes -history of severe sunburn -presence of large moles

The nurse is caring for a resident in a long-term care facility who has venous stasis ulcers and is being treated with an Unna boot. Which of the nursing activities is best for the nurse to delegate to a unlicensed assistive personnel (UAP)?

Assist the client in cleaning around the Unna boot.

The nurse is planning care for a group of clients who are at risk for the development of pressure ulcers. What should the nurse do first?

Identify at-risk clients on admission to the health care facility.

At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress note and begins planning client care based on which nursing diagnosis?

fear related to potential diagnosis of malignant melanoma