Integumentary Disorders

A nurse is providing education to the family of a client scheduled for discharge. The client, who has severe cognitive impairments, is a recent quadriplegic. The family has questions about the need to perform range-of-motion of exercises with the client. What information should the teaching session include? Select all that apply.

• A.

  Use sheepskin pads in the bed and wheelchair.

• B.

  The skin and underlying structures will begin to become anoxic after 2 hours of unrelieved pressure.

• C.

  Friction and shear increase a paralyzed client's risk of pressure ulcers.

• D.

  Positioning the client at 90 degrees from the head of the bed is most therapeutic.

• E.

  You need to perform range-of-motion exercises only when the client asks you to do so.

The physician orders "acyclovir (Zovirax), 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause:

• A.

  Palpitations.

• B.

  Dizziness.

• C.

  Diarrhea.

• D.

  A metallic taste.

A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

• A.

  The client's serum sodium levels are elevated.

• B.

  The client exhibits metabolic alkalosis.

• C.

  The client's urinary output has fallen below 30 ml/hour.

• D.

  The client's complete blood count readings reflect a reduced hematocrit.

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

• A.

  During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth.

• B.

  Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days.

• C.

  Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms.

• D.

  A client with genital herpes lesions may have sexual contact but must use a condom.

Which term describes a fungal infection of the scalp?

• A.

  Tinea capitis

• B.

  Tinea corporis

• C.

  Tinea cruris

• D.

  Tinea pedis

During the acute phase of a burn, a nurse should assess:

• A.

  The client's lifestyle.

• B.

  Alcohol use.

• C.

  Tobacco use.

• D.

  Circulatory status.

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan?

• A.

  Wear only synthetic fabrics.

• B.

  Use a topical skin moisturizer daily.

• C.

  Bathe only three times per week.

• D.

  Keep the thermostat above 75° F (23.9° C).

A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage?

• A.

  Minimize sun exposure from 1 to 4 p.m., when the sun is strongest.

• B.

  Use a sunscreen with a sun protection factor of 6 or higher.

• C.

  Apply sunscreen even on overcast days.

• D.

  When at the beach, sit in the shade to prevent sunburn.

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

• A.

  Right-sided visual deficit and dysarthria

• B.

  Incontinence and right-sided hemiparesis

• C.

  Dysarthria and left-sided visual deficit

• D.

  Constipation and lower extremity weakness

A nurse is changing a dressing and providing wound care. Which activity should she perform first?

• A.

  Assess the drainage in the dressing.

• B.

  Slowly remove the soiled dressing.

• C.

  Wash her hands thoroughly.

• D.

  Put on latex gloves.

A client with atopic dermatitis is ordered a potent topical corticosteroid to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

• A.

  Related to potential interactions between the topical corticosteroid and other ordered drugs

• B.

  Related to vasodilatory effects of the topical corticosteroid

• C.

  Related to percutaneous absorption of the topical corticosteroid

• D.

  Related to topical corticosteroid application to the face, neck, and intertriginous sites

A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter?

• A.

  Family history of pressure ulcers

• B.

  Presence of pressure ulcers on the client

• C.

  Potential areas of pressure ulcer development

• D.

  Overall risk of developing pressure ulcers

A client returns from the operating room with a partial-thickness skin graft on his left arm. The donor tissue was taken from his left hip. In planning his immediate postoperative care, which interventions should the nurse include? Select all that apply.Change the dressing on the graft site every 8 hours.

• A.

  Change the dressing on the graft site every 8 hours.

• B.

  Elevate the left arm and provide complete rest of the grafted area.

• C.

  Administer pain medication every 4 hours as ordered for pain in the donor site.

• D.

  Perform range-of-motion (ROM) exercises to the left arm every 4 hours.

• E.

  Monitor the pulse in the left arm every 4 hours.

• F.

  Encourage the client to ambulate as desired on the first postoperative day.

A client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief complaint was intertrigo. This term refers to which condition?

• A.

  Spontaneously occurring wheals

• B.

  A fungus that enters the skin's surface, causing infection

• C.

  Inflammation of a hair follicle

• D.

  Irritation of opposing skin surfaces caused by friction

During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring?

• A.

  Removing eschar from the skin

• B.

  Applying continuous-compression wraps

• C.

  Wearing clothing to protect the burn from the sun

• D.

  Maintaining wound care irrigation

A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, his vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.

• A.

  Cleaning the burns with hydrogen peroxide

• B.

  Covering the burns with saline-soaked towels

• C.

  Starting an I.V. infusion of lactated Ringer's solution

• D.

  Placing ice directly on the burn areas

• E.

  Administering 6 mg of morphine I.V.

• F.

  Administering tetanus prophylaxis as ordered

A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client's nursing care plan? Select all that apply.

• A.

  Use pressure-reduction devices.

• B.

  Increase carbohydrates in the diet.

• C.

  Reposition every 1 to 2 hours.

• D.

  Teach the family how to care for the wound.

• E.

  Clean the area around the ulcer with mild soap.

A registered nurse (RN) is working with the licensed 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 a 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.

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates effective teaching?

• A.

  I'll limit my intake of protein.

• B.

  I'll make sure that the bandage is wrapped tightly.

• C.

  My foot should feel cold.

• D.

  I'll eat plenty of fruits and vegetables.

A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

• A.

  Temporal area

• B.

  Top of the head

• C.

  Behind the ears

• D.

  Middle area

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

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:

• A.

  Do nothing; the client's skin is intact.

• B.

  Give the client a donut ring to reduce pressure on the affected area.

• C.

  Contact the client's family.

• D.

  Document the condition of the client's skin.

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction?

• A.

  Aplastic anemia

• B.

  Ototoxicity

• C.

  Cardiac arrhythmias

• D.

  Seizures

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:

• A.

  Dislodge the autografts.

• B.

  Increase edema in the arms.

• C.

  Increase the amount of scarring.

• D.

  Decrease circulation to the fingers.

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

• A.

  A urine output consistently above 40 ml/hour

• B.

  A weight gain of 4 lb (2 kg) in 24 hours

• C.

  Body temperature readings all within normal limits

• D.

  An electrocardiogram (ECG) showing no arrhythmias

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

• A.

  Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg

• B.

  Urine output of 20 ml/hour

• C.

  White pulmonary secretions

• D.

  Rectal temperature of 100.6° F (38° C)

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? __ %

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is:

• A.

  Erythema.

• B.

  Leukocytosis.

• C.

  Pressurelike pain.

• D.

  Swelling.

A day-care worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears:

• A.

  Erythematous with raised papules.

• B.

  Dry and scaly with flaking skin.

• C.

  Inflamed with weeping and crusting lesions.

• D.

  Excoriated with multiple fissures.

A client with a sacral pressure ulcer is limited to 2 hours of chair sitting two times per day. She is scheduled for physical therapy three times per day and dressing changes two times per day. How can the nurse best coordinate this client's care?

• A.

  Ask the physician if physical therapy can be changed to twice per day so the client needs to get out of bed only twice.

• B.

  Coordinate physical therapy with getting the client out of bed for breakfast and dinner, then request bedside physical therapy for the third session.

• C.

  Request bedside physical therapy for all three sessions so the client can get out of bed when she wants.

• D.

  Ask the physician to discontinue physical therapy until the client has no activity limitations.

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:

• A.

  Apply maximum bandages to allow for absorption of drainage.

• B.

  Wrap elastic bandages distally to proximally on dependent areas.

• C.

  Wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return.

• D.

  Remove bandages with clean gloves.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

• A.

  Explain to the client what is happening and provide support.

• B.

  Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

• C.

  Push the protruding organs back into the abdominal cavity.

• D.

  Ask the client to drink as much fluid as possible.

Which intervention has the highest priority when providing skin care to a bedridden client?

• A.

  Changing the client's position frequently

• B.

  Keeping the skin clean and dry without using harsh soaps

• C.

  Gently massaging the skin around the pressure areas

• D.

  Rubbing moisturizing lotion over the pressure areas

A client has a foot ulcer that hasn't shown signs of improvement over the past several months. Which medical condition is most likely causing the delay in wound healing?

• A.

  Macular degeneration

• B.

  Asthma

• C.

  Multiple sclerosis

• D.

  Peripheral vascular disease

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.

  You don't have to worry; you can't catch pediculosis.

• B.

  I'm sorry; I can't share confidential information.

• C.

  I'm moving the client because he has a communicable infection.

• D.

  That's none of your business.

A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown?

• A.

  Leg rest of the wheelchair

• B.

  Absence of sensation in the lower extremities and immobility

• C.

  Sitting in the wheelchair for long periods of time

• D.

  Specialty boots

A client presents to the physician's office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The physician diagnoses scabies. Which teaching points should the nurse review with the client? Select all that apply.

• A.

  The disease is actively contagious only when the lesions are open.

• B.

  Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing.

• C.

  The most commonly infected areas are the hands, feet, and neck.

• D.

  Severe itching of the affected areas, especially at night, is a common finding.

• E.

  Only the infected individual needs to use the prescribed medication.

• F.

  All of the client's linens and clothing should immediately be washed in hot water.

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect?

• A.

  Impetigo

• B.

  Scabies

• C.

  Contact dermatitis

• D.

  Dermatophytosis

A client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to order:

• A.

  An I.V. corticosteroid.

• B.

  An I.V. antibiotic.

• C.

  An oral antibiotic.

• D.

  A topical agent.

A client has a circular rash on her leg, accompanied by malaise, fever, headache, and joint aches. Laboratory studies and physical examination findings confirm that she has Lyme disease. Her physician orders tetracycline hydrochloride (Sumycin), 500 mg P.O. q.i.d. Which instruction about taking tetracycline should the nurse give the client?

• A.

  Take the drug on an empty stomach.

• B.

  Take the drug with food or milk.

• C.

  Take the drug with an antacid that contains magnesuim to reduce irritability.

• D.

  Take the drug with an iron supplement.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

• A.

  Complaints of intense thirst

• B.

  Moderate to severe pain

• C.

  Urine output of 70 ml the first hour

• D.

  Hoarseness of the voice

At an outpatient clinic, a nursing assistant interviews a client and documents her findings as follows. After reading the chart note, a nurse begins planning based on which nursing diagnosis?

• A.

  Deficient knowledge related to potential diagnosis of basal cell carcinoma

• B.

  Fear related to potential diagnosis of malignant melanoma

• C.

  Risk for impaired skin integrity related to potential squamous cell carcinoma

• D.

  Readiness for enhanced knowledge of skin care precautions related to benign mole

When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?

• A.

  Placing mitts on the client's hands

• B.

  Administering systemic antibiotics as ordered

• C.

  Applying topical antibiotics as ordered

• D.

  Continuing to administer antibiotics for 21 days as ordered

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

• A.

  First intention.

• B.

  Second intention.

• C.

  Third intention.

• D.

  Fourth intention.

Which instruction is the most important to give a client who has recently had a skin graft?

• A.

  Continue physical therapy.

• B.

  Protect the graft from direct sunlight.

• C.

  Use cosmetic camouflage techniques.

• D.

  Apply lubricating lotion to the graft site.

A client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction?

• A.

  Avoid sexual intercourse until you've completed treatment, which takes 14 to 21 days.

• B.

  Wash your hands thoroughly to avoid transferring the infection to your eyes.

• C.

  If you have intercourse before treatment ends, tell sexual partners of your status and have them wash well after intercourse.

• D.

  If you don't get treatment, you may develop meningitis and suffer widespread central nervous system (CNS) damage.

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?

• A.

  18%

• B.

  27%

• C.

  30%

• D.

  36%

A nurse plans to apply dexamethasone cream to a client's dermatitis over the anterior chest. How should the nurse apply this topical agent?

• A.

  With a circular motion, to enhance absorption

• B.

  With an upward motion, to increase blood supply to the affected area

• C.

  In long, even, outward, and downward strokes in the direction of hair growth

• D.

  In long, even, outward, and upward strokes in the direction opposite hair growth

A nurse has noticed an increase in the development of pressure ulcers on the nursing unit. Given the seriousness of the matter, what should the nurse do first?

• A.

  Formally report her concerns to the nurse-manager.

• B.

  Begin an investigation concerning potential causes of the pressure ulcers.

• C.

  Review the charts of the clients involved to assess for patterns and trends.

• D.

  Do nothing; this problem isn't the nurse's responsibility.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?

• A.

  Minoxidil (Rogaine)

• B.

  Tretinoin (retinoic acid [Retin-A])

• C.

  Zinc oxide gelatin

• D.

  Fluorouracil (5-fluorouracil, 5-FU [Efudex])