Integumentary Disorders Study Guide
The nurse is caring for a female client who is planning to start isotretinoin in 3 months. What should the nurse be sure to include in the instructions for the administration of this medication? a. now is the time to begin contraceptive precautions b. now is a good time to get pregnant, if she is planning to have a baby c. isotretinoin can cause women to become infertile d. isotretinoin can cause women to become infertile
a
the nurse is preparing to perform wound care for a client. what action should the nurse prioritize before changing the dressing? a. put on gloves b. wash hands thoroughly c. slowly remove the soiled dressing d. observe the dressing for the amount, type, and odor of drainage
b
a nurse is caring for a client who was admitted to the burn unit after suffering burns from a house fire. during the acute phase of a burn, the nurse should collect data on which topic? a. lifestyle b. alcohol use c. tobacco use d. circulatory status
d
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? a. Scale b. Crust c. Ulcer d. Scar
a
A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may: a. dislodge the autografts b. increase edema in the arms c. increase the amount of scarring d. decrease circulation to the fingers
a
A nurse in the emergency department is caring for a client with burns on the upper torso. what is the priority nursing action? a. monitor respiratory status b. have the client rate the pain c. cover the burns with an occlusive dressing d. administer an IV antibiotic
a
A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client? a. Charge nurse b. Physician c. Wound care nurse d. Risk management
c
The nurse is caring for an older adult client who is unable to reposition in bed independently. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? a. Turn and reposition the client once every 8 hours. b. Massage moisturizing lotion into hips and coccyx twice daily. c. Post a schedule for repositioning the client at the bedside. d. Slide the client, rather than lifting, when turning.
c
a postoperative client has just been admitted to a unit from the post anesthesia care unit. when should the nurse change the dressing for the first time? a. 2 hours after admission b. when it becomes saturated c. based on written orders for dressing changes d. after the surgeon changes the first dressing and provides the written orders
d
a registered nurse (RN) is working with the license practical nurse (LPN) to care for a group of clients in a nursing home. how should the RN expect the LPN to communicate changes in the clients' wound status? a. the LPN speaks directly to the physician b. the LPN informs the RN when wound heals c. the LPN informs the RN only if a wound worsens d. the RN communicates daily with the LPN about the condition of each resident
d
the nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with VRSA. which nursing actions can be delegated to an LPN/LVN? a. teaching the client about the care of the leg ulcer b. planning the client's diet to improve protein intake c. assessing the risk of further skin breakdown d. obtaining a wound culture during a dressing change
d
the nurse is gathering data on a child suspected of being a victim of abuse. what observation by the nurse would lead to this suspicion? a. multiple contusion of the shins b. contusions of the back and buttocks c. contusions at the same stages of healing d. large contusion and hematoma of the forehead
b
Which action should a nurse take first when admitting a client with herpes zoster infection? a. Institute isolation precautions according to facility policy. b. Instruct the client to wear light clothing. c. Advise the client not to scratch the lesions. d. Provide a tepid bath.
a
a child has a desquamative rash of the hands and feet. which additional finding should the nurse expect to observe with this rash? a. peeling skin b. thin, reddened layers of epidermis c. thick skin with deep, visible burrows d. thinning skin that may appear translucent
a
the nurse is caring for a wheelchair-bound client. which piece of equipment impedes circulation to the area it's meant to protect? a. air-fluidized bed b. ring or donut c. gel flotation pad d. water bed
b
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)? a. Assist the client in cleaning around the Unna boot. b. Evaluate foot sensation and movement every shift. c. Monitor capillary perfusion every shift. d. Teach the family members the signs of infection.
a
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? a. avoid sharing combs and brushes b. wash hair with a dandruff-preventing shampoo c. keep hair length short and well trimmed d. allow hair to air dry after shampooing
a
the nurse is caring for a client with a wound that requires sharp debridement. when the client rests pain medication prior to the procedure, the health care provider (HCP) responds, "this is a quick procedure, so that is not necessary" the HCP begins to set up a sterile field. how should the nurse respond? a. tell the hcp nurse will administer the prescribed PRN analgesic and the procedure can be started in 20-30 minutes b. ask if the client thinks the procedure can be tolerated without analgesia since the debridement will only take a few minutes c. ask the client to rate the current severity of pain on a scale of 1-10 to determine the need for analgesia during the procedure d. tell the HCP that performing the procedure without pain medication is unethical and will be reported
a
the nurse is caring for a postoperative client and finds that the dressing has not been changed from the previous shift. which action can the nurse take to ensure the client receives the necessary dressing changes? a. write the order in the client's care plan b. put a sign above the head of the client's bed c. tell the nurse on the upcoming shift about the treatment of the report d. document the dressing change in the narrative note
a
which action by the nurse displays client advocacy during a skin assessment? a. ensuring client privacy by pulling the curtain closed b. asking the client if he has any skin lesions c. performing a visual inspection of the skin d. transferring the client in the other bed out of the room
a
A college student living in the dormitory comes to the school health clinic stating, "I think I have ringworm on the bottom of my foot." What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply. a. Be sure to wear shower shoes when using a public shower. b. Change socks at least once a day. c. Wear shoes that prevent air from circulating around the feet. d. Keep skin clean and dry. e. Do not cut toenails short.
a, b, d
a client arrives in the clinic with dressed with long sleeves and long pants in the summer and states, "i have to cover these lesions, they look awful. I have a plaque psoriasis." what data gathered and documented by the nurse would correlate with the client's statement? select all that apply a. red, raised patches on the skin b. silvery white coated patches c. fluid filled vesicles d. generalized pustules e. reports of itching
a, b, e
a child is diagnosed with Kawasaki disease. which changes in the mouth area would the nurse observe with this disorder? select all that apply. a. swollen lymph nodes in the neck b. tonsillar exudate c. vesicular lesions d. dry, cracked lips; strawberry tongue e. toothache
a, d
A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. What should the nurse say? a. "once the client is moved out, I will come back and talk to you about it" b. "Im sorry but I can't share confidential information" c. "im moving the client because the client has a communicable infection" d. "theres a porblem with the client right now, and the client needs to be in a private room"
b
A family that recently went camping brings their child to the clinic with a report of a rash after a tick bite. Which finding should the nurse expect to see in a child with Lyme disease? a. erythematous rash surrounding a necrotic lesion b. bright rash with red outer border circling the bite site c. onset of a diffuse rash over the entire body 2 months after exposure d. a linear rash of papules and vesicles that occurs 1-3 days after exposure
b
a 6 year old child has had recent diagnosis of Lyme disease. which medication would the nurse expect health care provider to order if the child has an allergy to penicillin? a. amoxicillin b. cefuroxime c. doxycycline d. clindamycin
b
a client with severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the IV route. the nurse should monitor the client for which adverse to this drug? a. aplastic anemia b. ototoxicity c. hypokalemia d. seizures
b
a nursing is reinforcing home care instructions for a client who has recently had a skin graft. which instruction is appropriate for the nurse to give the client? a. wash the area with soap and water daily b. cover the area when in direct sunlight c. message the area three times a day d. apply lubricating lotion to the graft site
b
the nurse is admitting a client who states, "I was bit by a brown recluse spider." which observations made by the nurse would indicate the client's report is accurate? a. bull's eye rash b. painful rash around a necrotic lesion c. herald patch of oval lesion d. line of papules and vesicles that appear 1 to 3 days after exposure
b
which intervention has the highest priority when providing skin care to a bedridden client? a. changing the bed linens frequently for an incontinent client b. keeping the skin clean and dry without using harsh soaps c. gently massaging the skin around the pressure areas d. rubbing moisturizing lotion around the pressure areas
b
a child fell at camp and sustained a bruise to the thigh. which description would accurately describe the bruise after 1 week? a. resolved b. reddish blue c. greenish yellow d. dark blue to bluish brown
c
a client admitted 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? a. administer 4 mg lorazepam b. allow client uninterrupted rest time c. obtain oxygen saturation using pulse oximetry d. obtain the client's blood pressure
c
a client received burns to his entire back and left arm. using the rules of nines, the nurse calculates that he has sustained burns to which percentage of his body? a. 9% b. 18% c. 27% d. 36%
c
a female client with genital herpes simplex is being treated in the outpatient department. the nurses teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. genital herpes simplex increases the risk of: a. cancer of the ovaries b. cancer of the uterus c. cancer of the cervix d. cancer of the vagina
c
a nurse is caring for a client who is at risk for skin. to decrease the risk, the nurse must help ensure that the client remains adequately hydrated. which action can the nurse take to help determine the client's fluid needs? a. obtain the client's weight daily b. perform a calorie count c. measure intake and output d. obtain vital signs
c
laboratory test results confirm the client's wound is infected with methicillin-resistant staphylococcus aureus. which type of isolation precautions should the nurse institute for this client? a. droplet b. respiratory c. contact d. standard
c
nurse is caring for a 12-year-old child diagnosis of eczema. which nursing interventions are appropriate for a child with eczema? a. administer antibiotics as prescribed b. administer antifungals as ordered c. administer tepid baths, and use moisturizer immediately after the bath d. administer hot baths, and pat dry or air dry the affected areas
c
the nurse is caring for a 4 year old with full thickness burn. before sending the child to hydrotherapy for a schedule woubd debridgement, which nursing action is a priority? a. administer a fluid bolus of 500 ml b. initiate antibiotics as prescribed c. implement pain control measures d. provide high-protein drinks
c
the nurse is collecting data from several clients at the clinic. which client does the nurse determine is most likely to receive the zostavax vaccine for the prevention of shingles? a. 24-year-old client that will be traveling out of the country b. 6-month-old infant having surgery to repair a cleft lip c. 62-year-old client that had a mild case d. 38-year-old pregnant client that has gestational diabetes
c
the nurse is gathering data from a client with an abdominal incision and suspects there is a potential delayed wound healing. which observation most likely supports this finding? a. sutures dry and intact b. wound edges in close approximation c. purulent drainage on a soiled wound dressing d. sanguineous drainage in a wound-collection drainage bag
c
the nurse is reinforcing education to parents of an infant about burn prevention. which instructions should be reinforced regarding burns from tap water? a. set the water-heater temperature at 130 F (54.4 C) or less b. run the hot water first, then adjust the temperature with cold water c. before putting the infant in the tub, test the water with a hand d. supervise an infant in the bathroom, only leaving the infant for a few seconds if needed
c
when assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is a. planning for the client's rehabilitation and discharge b. providing emotional support to the client and family c. maintaining the client's fluid, electrolyte, and acid-base balance d. preserving full range of motion in all affected joints
c
the parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of MRSA at the camp. what education can the nurse reinfornce in order to help with prevention of this infection? select all that apply a. request a prescription for an antibiotic prior to going b. use an antibiotic ointment prophylactically on skin c. keep cuts and scrapes clean and covered d. wash hands with soap and water regularly e. avoid sharing towels and razors with others
c, d, e
A client understands what resources are available to help him perform wound care at home when he states the following: a. "I'll call the social worker if I run out of supplies." b. "I'm so relieved that I have a home health care nurse to take care of my wound for me." c. "I'll schedule an appointment with my physician to have my dressing changed." d. "Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need."
d
Which nursing diagnosis would be the priority for a client who has just been admitted to the hospital with burns? a. body image disturbance b. risk for altered nutrition c. impaired social interaction d. impaired skin integrity
d
