Integumentary Disorders
The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore?
mobility status
Sudoriferous glands secrete which type of substance?
sweat
The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has:
reduced sensation of pressure.
A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should
wrap elastic bandages distally to proximally on dependent areas.
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 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 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.
The nurse is caring for an immune-compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems?
Avoid sharing combs and brushes.
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.
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.
The nurse is working as charge 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
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
A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?
contact
While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for:
gastrointestinal ulceration.
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
hoarseness of the voice
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
A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception?
Tattoos are easily removed with laser surgery.
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.
A nurse is planning an educational program about cancer prevention and detection. Which group would benefit most from education regarding potential risk factors for melanoma?
parents with children
The rate at which IV fluids are infused is based on the burn client's:
total body weight and BSA burned.
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 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 reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?
"If I notice tingling in my lips or mouth, gargling may help the symptoms."
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.
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 assitant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first?
Document the findings.
A client has severe cellulitis of the perineum. Orders are entered by the healthcare provider. Which order should take priority?
Obtain baseline complete blood count (CBC) and renal and liver function tests.
A suspected outbreak of anthrax has been transmitted by skin exposure. A client is admitted to the emergency department with lesions on the hands. The health care provider prescribes antibiotics and sends the client home. What should the nurse instruct the client to do? Select all that apply.
Take the prescribed antibiotics for 60 days. Expect the skin lesions to clear up within 1 to 2 weeks.
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
a urine output consistently above 40 ml/hour (40 mL/hour)
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
A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should
isolate the client's bed linens until the client is no longer infectious.
A nurse assesses wound evicsceration in a client that had abdominal surgery. In what position should the nurse place the client?
knees flexed, supine
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?
lactated Ringer's solution
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 the 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
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation?
serum creatinine level of 2.5 mg/dL (221 µmol/L)
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
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record?
stage II pressure ulcer
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
Which type of mouth care is most appropriate when the nurse is caring for a client with dentures who has severe stomatitis?
using a soft toothbrush to provide oral hygiene
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 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%
The nurse is performing wound care on a client with an open fracture. What is the nurse's priority action to clean the wound?
Irrigate the wound with normal saline.
The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next?
Reposition the client off the reddened skin and reassess in a few hours.
The nurse should assess a client who is in the emergent phase of burn management for:
hyperkalemia
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 male client with hair on the chest is prescribed dexamethasone cream for a rash over the midthoracic region. Which approach should the nurse use to apply this topical medication?
in long, even, outward, and downward strokes in the direction of hair growth
When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by:
proper positioning and moving of the client.
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 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."
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 has burns on both hands and upper arms. Which nursing actions will be most helpful in preventing contractures? Select all that apply.
Keep the hands elevated. Apply splints as prescribed. Collaborate with the physical therapist.
An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action?
Apply direct pressure to the finger with a clean, dry cloth.
A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. During the past few weeks, the client has been spending less time in the wheelchair and, when in the wheelchair, uses a cushion. 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.
A client with right-sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?
Turn the client regularly.
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.
