MS: Dermatological

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? A. Cadaver skin B. Pig skin C. Amniotic membranes D. Beef collagen

B. Heterografts are obtained from an animal, usually a pig.

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? A. Zoster vaccine B. Acyclovir C. Amoxicillin D. Infliximab

B. The nurse should anticipate a prescription for acyclovir, an antiviral medication, because it inhibits replication of the virus that causes herpes zoster.

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is most serious. Which of the following responses by the nurse is appropriate? A. Basal cell carcinomas B. Melanomas C. Actinic keratoses D. Squamous cell carcinomas

B. Melanomas are malignant neoplasms with atypical melanocytes in both the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases in the bone, liver, lungs, spleen, the CNS, and lymph nodes.

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1° C (102.4° F)

D. An elevated temperature is an indication of infection and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms.

A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which the following skin lesions? A. Papules B. Macules C. Wheals D. Vesicles

A A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles. A macule is flat, variably shaped, discolored, and small, typically smaller than 10 mm in diameter. A macule is a change in the color of the skin. Freckles and the rash associated with rubella are types of macules. Wheals, also known as hives, are transient, elevated, irregularly shaped lesions caused by localized edema. Wheals are a common manifestation of an allergic reaction. A vesicle is a circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise with herpes simplex, poison ivy, and chickenpox.

A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be on a special shower table" B. "The water temperature will be cool to ease my pain" C. "The nurse will use a firm-bristled brush to remove loose skin." D. "The nurse will use scissors to open small blisters"

A. "I will be on a special shower table." The special shower table facilitates examination and debridement of the wound during hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature and there is a lower risk of wound infection. "The water temperature will be very cool to ease my pain." The nurse should use warm water during the hydrotherapy treatment to help the client maintain adequate body temperature. "The nurse will use a firm-bristled brush to remove loose skin." The nurse should use soft washcloths or gauze to gently scrub and debride the wounds. "The nurse will use scissors to open small blisters." The nurse should leave small blisters intact; however, she will open large blisters.

A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement? A. Immobilize the limb at the level of the heart. B. Apply a tourniquet to the affected limb. C. Use a sterile scapula to incise the wound. D. Apply ice to the skin over the snakebite wound.

A. The emergency management of a client who has a snakebite focuses on limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart.

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image. A. "May I go with my family to the visitor's lounge?" B. "I'll see my friends when I get home." C. "My dad is coming to visit. Can you fix my hair for me?" D. "I told my cousins I'm in protective isolation."

A. This statement demonstrates a positive self-image. The client is asking to visit with her family in a public setting.

A nurse is providing discharge instructions to a cient who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a potential malignancy of a mole? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color

A. Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every mont

A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which of the following traits places a client at risk for developing malignant melanoma? A. Brown eyes B. Light skin C. Black hair D. Dark skin

B. Light skin and less pigmentation place a client at risk for developing malignant melanoma.

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL

B. This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN

B. Transient leukopenia is an adverse effect of silver sulfadiazine.

A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which of the following nutrients promotes wound healing? A. Vitamin B1 B. Calcium C. Vitamin C D. Potassium

C. A diet high in protein and vitamin C is recommended because these nutrients promote wound healing.

A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? A. Apply a broad-spectrum sunscreen 5 min before sun exposure. B. Wear a sun visor instead of a hat when outside in the sun. C. Avoid exposure to the midday sun. D. Use a tanning booth instead of sunbathing outdoors.

C. The nurse should instruct clients to avoid skin exposure to the sun, especially during the midday hours of 1000 to 1600 because sun rays are the strongest at that time.

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite

C. When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled and the skin does not blanch.

A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A. Partial-thickness burn B. Stage III pressure ulcer C. Surgical incision D. Dehisced sternal wound

C. With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention.

A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer a which of the following stages? A. IV B. I D. III C. II

D Stage I pressure ulcer: the skin is intact with an area of persistent, nonblanchable redness, usually over a bony prominence, that might feel warm or cool when touched. The tissue is swollen and congested, and the client might report discomfort at the site. With darker skin tones, the ulcer can appear blue or purple and different from other skin areas. Stage II pressure ulcer: there is partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage. Stage III: is full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer might extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stage IV: the client has full-thickness tissue loss, with destruction, tissue necrosis, and visible damage to muscle, bone, or supporting structures. Sinus tracts, deep pockets of infection, tunneling, and undermining can occur.

A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of a malignant melanoma? A. Rough, dry, scaly lesion B. Firm nodule with crust C. Pearly papule with ulcerated center D. Irregularly shaped lesion with blue tones

D. Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client's upper back and lower legs.

A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures? A. Curettage B. External radiation therapy C. Regional chemotherapy D. Surgical excision

D. The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting.

A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? A. "Move between the bed and the wheelchair once every 2 hours." B. "Make sure that your caregiver massages your skin daily." C. "Use a rubber ring when sitting at the bedside." D. "Shift your weight in the wheelchair every 15 minutes."

D. This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure.