integumentary evolve

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A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan?

"Clean the mouth with a soft toothbrush or a gentle spray. Chemotherapy destroys the rapidly dividing cells of the oral mucosa; frequent gentle oral hygiene limits additional trauma. Although it is recommended to rinse the mouth every 2 hours, the client does not need to brush teeth and clean the mouth as often. Lemon juice is too caustic to the compromised mucosa. Flossing can disrupt and traumatize the gum surfaces; oral hygiene is needed more than once a day. Commercial mouthwashes contain alcohol, which is irritating to the mucosa.

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly porportional. There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound?

Negative pressure wound therapy. Negative pressure wound therapy is a new technology used to reduce chronic ulcers by removing fluids from the wound and enhancing granulation. Electrical stimulation is done by the application of low-voltage current to a wound area to increase blood vessel growth and promote granulation. Topical growth factors are the normal body substances that stimulate cell movement and growth. Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue oxygen concentration.

The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." Which information should the nurse consider about rabies when planning care for this client

Rabies is an acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system.

After assessing the color of a client's nail beds, the primary healthcare provider concludes that the client has trauma to the nail beds. Which variations in nail color might the client have?

Red. A red color is an indication of trauma to the nail bed. A blue color is an indication of respiratory failure. A white color is an indication of anemia, chronic liver, or kidney disease. A yellow-brown color is an indication of jaundice or cardiac failure.

Which surgery is used to treat excessive wrinkling or sagging of facial skin?

Rhytidectomy

Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs?

Telangiectasia

A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. What could be the possible condition in the client?

Tinea pedis. Tinea pedis is a fungal infection with an itching sensation associated with pain. It is clinically manifested as interdigital scaling and maceration and a scaly plantar surface, sometimes with erythema and blistering. Tinea cruris is a fungal infection that is clinically manifested with well-defined scaly plaque in the groin area. Tinea corporis is clinically manifested as an erythematous, annular, ring-like scaly appearance with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.

The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance?

the incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations.

Which skin color in a client indicates an increased urochrome level?

yellow-orange. A yellow-orange skin color indicates an increased urochrome level. A red-colored face, cheeks, nose, and upper chest indicate increased blood flow to the skin. A bluish color of the nail beds indicates an increase in deoxygenated blood in the body. A reddish-blue color of the distal extremities indicates decreased peripheral circulation.


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