Integumentary Disorders
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- 1.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.
- 2.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.
- 3.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.
- 4.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.
- 5.Which term describes a fungal infection of the scalp?
- A.
Tinea capitis
- B.
Tinea corporis
- C.
Tinea cruris
- D.
Tinea pedis
- 6.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.
- 7.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).
- 8.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.
- 9.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
- 10.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.
- 11.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
- 12.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
- 13.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.
- 14.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
- 15.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
- 16.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
- 17.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.
- 18.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.
- 19.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.
- 20.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
- 21.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
- 22.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.
- 23.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
- 24.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.
- 25.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
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