PrepU : Tissue Integrity ML7

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?

"Have you been eating a large amount of carotene-rich foods?"

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply. -family history of pressure ulcers -overall risk of developing pressure ulcers -indwelling catheter output -potential areas of pressure ulcer development -presence of pressure ulcers on the client

-presence of pressure ulcers on the client -overall risk of developing pressure ulcers -potential areas of pressure ulcer development

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27%

The nurse is conducting an admission history and physical examination of a client with a history of contact dermatitis. The nurse assesses whether the client uses which medication classification?

Corticosteroids

A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal? External auditory canal erythema Tympanic membrane pearly gray Umbo in the center of the tympanic membrane Manubrium superior to the umbo

External auditory canal erythema

Pressure ulcers are caused by: Low capillary pressure Extrinsic factors Increased mobility Necrosis

Extrinsic factors

The nurse identifies which of the following as an age-related change in the respiratory system? Increased cough efficiency Increased vital capacity Increased residual lung volume Increased diffusion capacity

Increased residual lung volume

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area? Greater trochanter Lateral malleolus Scapula Ischial tuberosity

Ischial tuberosity

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

LR (LR replaces lost sodium & corrects metabolic acidosis)

Which of the following could be a possible cause of cyanosis? Low tissue oxygenation Anemia Carbon monoxide poisoning Fever

Low tissue oxygenation

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? Povidone-iodine-soaked gauze Moist sterile saline gauze Dry sterile dressing Sterile petroleum gauze

Moist sterile saline gauze

A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit? Moon face Hypotension Pale thick skin Weight loss

Moon face

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?

Rinsing the area with copious amounts of water

The nurse is examining the area behind the patient's auricle and sees a flaky scaliness. What disorder does the nurse suspect the patient has? Tophi Seborrheic dermatitis Acute external otitis Sebaceous cysts

Sebaceous cysts

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk?

Serum albumin

What stage am I? Pressure ulcer that is an area of erythema that does NOT blanch with pressure?

Stage 1

What stage am I? Ulcer extends into the subcutaneous tissue

Stage 3

Which of the following is a term used to describe a soft tissue injury produced by a blunt force?

contusion

A fracture is considered pathologic when it: involves damage to the skin or mucous membranes. occurs through an area of diseased bone. results in a fragment of bone being pulled away by a ligament or tendon and its attachment. presents as one side of the bone being broken and the other side being bent.

occurs through an area of diseased bone.

Skin color r/t: anemia

pallor

The nurse is assessing a victim who is reported to have been exposed to sulfur mustard. The nurse's assessment should include evaluation for?

partial-thickness burns.

Which of the following describes a total absence of pigment melanin? Albinism Vitiligo Anemia Cyanosis

partial-thickness burns.

Skin color r/t: fever or HTN

pink

Skin color r/t: CO2 poisoning?

red

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area?

1%

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions? Corticosteroids Analgesics Antiviral Antipyretics

Antiviral

Which of the following clinical manifestations increases the risk for evisceration in the postoperative client? Hypovolemia Valsalva maneuver Hypoxia Edema

Hypoxia

The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include? (Select all that apply.) Looking for any associated chest injuries Assessing for manifestations of hemorrhage Covering any protruding viscera with sterile dressings soaked in normal saline solution Irrigating the wound with normal saline and a syringe Exploring the abdominal wound with a gloved finger

Looking for any associated chest injuries Assessing for manifestations of hemorrhage Covering any protruding viscera with sterile dressings soaked in normal saline solution

A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. The nurse's postoperative plan of care should include which action? Determine the client's ability to manage stoma care. Suggest a visit to a local ostomy group. Maintain skin and stomal integrity. Show pictures and drawings of placement of the stoma.

Maintain skin and stomal integrity.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? Fluorouracil (5-fluorouracil, 5-FU [Efudex]) Zinc oxide gelatin Minoxidil (Rogaine) Tretinoin (retinoic acid [Retin-A])

Minoxidil (Rogaine)

A patient is scheduled for Mohs microscopic surgery for removal of a skin cancer lesion on his forehead. The nurse knows to prepare the patient by explaining that this type of surgery requires: A process of deep-freezing the tumor, thawing and refreezing. Removal of the tumor, layer by layer. The use of radiation therapy. Destruction of the tissue by electrical energy.

Removal of the tumor, layer by layer.

The nurse instructs a client receiving chemotherapy on actions to prevent the development of stomatitis. Which client statement indicates to the nurse that teaching has been effective? "I will limit alcoholic beverages to one a day." "I will reduce smoking to after meals only." "I will brush my teeth after every meal." "I will eat spicy foods with a cool beverage."

"I will brush my teeth after every meal."

The nurse is performing a skin assessment on a bedbound client who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than how many minutes?

1 hour (60 minutes)

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?

Administer an analgesic as ordered.

Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation? Anticoagulant Potassium supplement Antihypertensive Diuretic

Anticoagulant

In a client with burns on the legs, which nursing intervention helps prevent contractures? Elevating the foot of the bed Hyperextending the client's palms Applying knee splints Performing shoulder range-of-motion exercises

Applying knee splints

Which term refers most precisely to a localized skin infection of a single hair follicle?

Furuncle

A client is scheduled for a renal arteriogram. When the nurse checks the chart for allergies to shellfish or iodine, she finds no allergies recorded. The client is unable to provide the information. During the procedure, the nurse should be alert for which finding that may indicate an allergic reaction to the dye used during the arteriogram?

Pruritus

A patient is diagnosed with psoriasis after developing scales on the scalp, elbows, and behind the knees. The patient asks the nurse where this was "caught." What is the best response by the nurse? Psoriasis is an inflammatory dermatosis that results from a superficial infection with Staphylococcus aureus. Psoriasis results from excess deposition of subcutaneous fat. Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin. Psoriasis comes from dermal abrasion.

Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin.

The nurse is reading the previous shift's documentation of an open area on the client's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the client's sacrum will reveal a pressure ulcer in which stage?

Stage 2

What stage am I? Ulcer extends to the underlying muscle and BONE

Stage 4

A patient is diagnosed with seborrheic dermatitis on the face and is prescribed a corticosteroid preparation for use. What should the nurse educate the patient about regarding use of the steroid on the face? Use very warm water to clean the face prior to applying the medication. Avoid using the medication around the eyelids because it may cause cataracts and glaucoma. Scrape the scaly patches off prior to applying the medication. Wash the face several times a day and reapply the medication.

Avoid using the medication around the eyelids because it may cause cataracts and glaucoma.

The nurse recognizes which condition as an integumentary manifestation of chronic renal failure? Asterixis Seizures Gray-bronze skin color Tremors

Gray-bronze skin color

A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has?

Obstructive jaundice

A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply. Endocrine glands Skin Subcutaneous tissue Fingernails Hair

skin fingernails hair