Integumentary Disorders

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

• Explain to the client what is happening and provide support.

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

• Push the protruding organs back into the abdominal cavity.

• Ask the client to drink as much fluid as possible.

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? __ %

A client, who is bound to a wheelchair, comes to the clinic for follow-up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid dressings every 3 to 5 days. During the past few weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair he uses a cushion. During his appointment the nurse notes that he isn't using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse approach the client about his treatment regimen?

• Do nothing because the client is able to make his own care decisions.

• Tell the client not to return to the clinic because he isn't following the treatment plan.

• Explain pressure ulcer development in terms he understands.

• Provide a brief anatomy and physiology lesson on how pressure ulcers develop.

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?

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

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

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

• That's none of your business.

A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?

• To make the skin feel soft.

• To prevent evaporation of water from the hydrated epidermis.

• To minimize cracking of the dermis.

• To prevent skin inflammation.

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

• Albumin

• Dextrose 5% in water (D5W)

• Lactated Ringer's solution

• Normal saline solution with 20 mEq of potassium per 1,000 ml

Which nutritional deficiency may delay wound healing?

• Lack of vitamin D

• Lack of vitamin C

• Lack of vitamin E

• Lack of calcium

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

• Ineffective airway clearance related to edema of the respiratory passages

• Impaired physical mobility related to the disease process

• Disturbed sleep pattern related to facility environment

• Risk for infection related to breaks in the skin

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

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

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

• Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms.

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

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

• The client's lifestyle.

• Alcohol use.

• Tobacco use.

• Circulatory status.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:

• Planning for the client's rehabilitation and discharge.

• Providing emotional support to the client and family.

• Maintaining the client's fluid, electrolyte, and acid-base balance.

• Preserving full range of motion in all affected joints.

Which nursing intervention can help a client maintain healthy skin?

• Keeping the client well hydrated

• Avoiding bathing the client with mild soap

• Removing adhesive tape quickly from the skin

• Recommending wearing tight-fitting clothes in hot weather

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:

• Dislodge the autografts.

• Increase edema in the arms.

• Increase the amount of scarring.

• Decrease circulation to the fingers.

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

• An I.V. corticosteroid.

• An I.V. antibiotic.

• An oral antibiotic.

• A topical agent.

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

• All family members need to be treated.

• If someone develops symptoms, tell him to see a physician right away.

• Just be careful not to share linens and towels with family members.

• After you're treated, family members won't be at risk for contracting scabies.

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?

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

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

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

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

A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

• Apply one applicator of terconazole intravaginally at bedtime for 7 days.

• Apply one applicator of tioconazole intravaginally at bedtime for 7 days.

• Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days.

• Apply sulconazole nitrate twice daily by massaging it gently into the lesions.

A nurse visits the employee health department because of mild itching and a rash on both hands. During the assessment interview, the employee health nurse should focus on:

• Medication allergies.

• Life stressors the nurse may be experiencing.

• Chemical and latex glove use.

• Laundry detergent or bath soap changes.

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

• Wear only synthetic fabrics.

• Use a topical skin moisturizer daily.

• Bathe only three times per week.

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

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?

• The LPN speaks directly to the physician.

• The LPN informs the RN when a wound heals.

• The LPN informs the RN only if a wound worsens.

• 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?

• I'll limit my intake of protein.

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

• My foot should feel cold.

• I'll eat plenty of fruits and vegetables.

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 urine output consistently above 40 ml/hour

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

• Body temperature readings all within normal limits

• An electrocardiogram (ECG) showing no arrhythmias

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?

• Impetigo

• Scabies

• Contact dermatitis

• Dermatophytosis

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

• Continue physical therapy.

• Protect the graft from direct sunlight.

• Use cosmetic camouflage techniques.

• Apply lubricating lotion to the graft site.

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

• Minoxidil (Rogaine)

• Tretinoin (retinoic acid [Retin-A])

• Zinc oxide gelatin

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

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

• Lindane (Kwell)

• Diazepam (Valium)

• Mafenide (Sulfamylon)

• Meperidine (Demerol)

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

• Do nothing until the chemical agent is identified.

• Irrigate the wounds with water.

• Wash the wounds with soap and water and apply a barrier cream.

• Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

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:

• Palpitations.

• Dizziness.

• Diarrhea.

• A metallic taste.

Which term describes a fungal infection of the scalp?

• Tinea capitis

• Tinea corporis

• Tinea cruris

• Tinea pedis

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?

• Right-sided visual deficit and dysarthria

• Incontinence and right-sided hemiparesis

• Dysarthria and left-sided visual deficit

• Constipation and lower extremity weakness

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

• Family history of pressure ulcers

• Presence of pressure ulcers on the client

• Potential areas of pressure ulcer development

• Overall risk of developing pressure ulcers

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?

• Aplastic anemia

• Ototoxicity

• Cardiac arrhythmias

• Seizures

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

• Temporal area

• Top of the head

• Behind the ears

• Middle area

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?

• Deficient knowledge related to potential diagnosis of basal cell carcinoma

• Fear related to potential diagnosis of malignant melanoma

• Risk for impaired skin integrity related to potential squamous cell carcinoma

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

A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should:

• Turn him frequently.

• Perform passive range-of-motion (ROM) exercises.

• Reduce the client's fluid intake.

• Encourage the client to use a footboard.

A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:

• Wash her hands, apply a pediculicide to the client's scalp, and remove any observable mites.

• Isolate the client's bed linens until the client is no longer infectious.

• Notify the nurse in the day surgery unit of a potential scabies outbreak.

• Place the client on enteric precautions.

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?

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

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

• Apply sunscreen even on overcast days.

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

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:

• Apply maximum bandages to allow for absorption of drainage.

• Wrap elastic bandages distally to proximally on dependent areas.

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

• Remove bandages with clean gloves.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

• A compromised skin graft.

• A malignant tumor.

• Pneumonia.

• Hyperthermia.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

• Scale

• Crust

• Ulcer

• Scar

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?

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

• Urine output of 20 ml/hour

• White pulmonary secretions

• Rectal temperature of 100.6° F (38° C)

A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

• I may experience itching and irritation at the site of the testing.

• If I notice tingling in my lips or mouth, gargling may help the symptoms.

• I'll go directly to the pharmacy with my EpiPen prescription.

• The test may be mildly uncomfortable.

A nurse is caring for a client who requires a wheelchair. Which piece of equipment impedes circulation to the area it's meant to protect?

• Specialty mattress

• Ring or donut

• Gel flotation pad

• Water bed

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

• Turn and reposition the client at least once every 8 hours.

• Vigorously massage lotion over bony prominences.

• Develop a written, individual turning schedule.

• Slide the client, rather than lifting, when turning.

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?

• 18%

• 27%

• 30%

• 36%

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

• Strict

• Contact

• Respiratory

• Enteric

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?

• Macular degeneration

• Asthma

• Multiple sclerosis

• Peripheral vascular disease

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

• First intention.

• Second intention.

• Third intention.

• Fourth intention.