Integumentary System Disorders | NCLEX Quiz 168

1. Which nursing intervention can help a client maintain healthy skin?

Keep the client well hydrated.

Avoid bathing the client with mild soap.

Remove adhesive tape quickly from the skin.

Recommend wearing tight-fitting clothes in hot weather.

Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body’s first line of defense. To help a client maintain healthy skin. the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn’t remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.

Explanation

Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body’s first line of defense. To help a client maintain healthy skin. the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn’t remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.

2. When planning care for a male 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

When caring for a client with upper torso burns. the nurse’s primary goal is to maintain respiratory integrity. Therefore. option A should take the highest priority. Option B isn’t appropriate because burns aren’t a disease. Option C and D may be appropriate. but don’t command a higher priority than option A because they don’t reflect immediately life-threatening problems.

Explanation

When caring for a client with upper torso burns. the nurse’s primary goal is to maintain respiratory integrity. Therefore. option A should take the highest priority. Option B isn’t appropriate because burns aren’t a disease. Option C and D may be appropriate. but don’t command a higher priority than option A because they don’t reflect immediately life-threatening problems.

3. A female 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 to this drug?

Aplastic anemia

Ototoxicity

Cardiac arrhythmias

Seizures

The most significant adverse reactions to gentamicin and other aminoglycosides are ototoxicity (indicated by vertigo. tinnitus. and hearing loss) and nephrotoxicity (indicated by urinary cells or casts. oliguria. proteinuria. and reduced creatinine clearance). These adverse reactions are most common in elderly and dehydrated clients. those with renal impairment. and those receiving concomitant therapy with another potentially ototoxic or nephrotoxic drug. Gentamicin isn’t associated with aplastic anemia. cardiac arrhythmias. or seizures.

Explanation

The most significant adverse reactions to gentamicin and other aminoglycosides are ototoxicity (indicated by vertigo. tinnitus. and hearing loss) and nephrotoxicity (indicated by urinary cells or casts. oliguria. proteinuria. and reduced creatinine clearance). These adverse reactions are most common in elderly and dehydrated clients. those with renal impairment. and those receiving concomitant therapy with another potentially ototoxic or nephrotoxic drug. Gentamicin isn’t associated with aplastic anemia. cardiac arrhythmias. or seizures.

4. A female client is brought to the emergency department with second- and third-degree 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%

The Rule of Nines divides body surface area into percentages that. when totaled. equal 100%. According to the Rule of Nines. the arms account for 9% each. the anterior legs account for 9% each. and the anterior trunk accounts for 18%. Therefore. this client’s burns cover 36% of the body surface area.

Explanation

The Rule of Nines divides body surface area into percentages that. when totaled. equal 100%. According to the Rule of Nines. the arms account for 9% each. the anterior legs account for 9% each. and the anterior trunk accounts for 18%. Therefore. this client’s burns cover 36% of the body surface area.

5. A male 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 scale is the characteristic secondary lesion occurring in psoriasis. Although crusts. ulcers. and scars also are secondary lesions in skin disorders. they don’t accompany psoriasis.

Explanation

A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts. ulcers. and scars also are secondary lesions in skin disorders. they don’t accompany psoriasis.

6. A male 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 a day for 7 days.”

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

A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours. six times a day for 7 days. Terconazole and tioconazole are used to treat vulvovaginal candidiasis. Sulconazole nitrate is used to treat tinea versicolor.

Explanation

A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours. six times a day for 7 days. Terconazole and tioconazole are used to treat vulvovaginal candidiasis. Sulconazole nitrate is used to treat tinea versicolor.

7. In a female client with burns on the legs. which nursing intervention helps prevent contractures?

Applying knee splints

Elevating the foot of the bed

Hyperextending the client’s palms

Performing shoulder range-of-motion exercises

Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders. but not in the legs.

Explanation

Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders. but not in the legs.

8. A male 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 delivery.

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 can have sexual contact but must use a condom.

Herpes simplex may be passed to the fetus transplacentally and. during early pregnancy. may cause spontaneous abortion or premature delivery. Genital herpes simplex lesions typically are painful. fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms. such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.

Explanation

Herpes simplex may be passed to the fetus transplacentally and. during early pregnancy. may cause spontaneous abortion or premature delivery. Genital herpes simplex lesions typically are painful. fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms. such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.

9. A female adult client with atopic dermatitis is prescribed 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?

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

Related to vasodilatory effects of the topical corticosteroid

Related to percutaneous absorption of the topical corticosteroid

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

A potent topical corticosteroid may increase the client’s risk for injury because it may be absorbed percutaneously. causing the same adverse effects as systemic corticosteroids. Topical corticosteroids aren’t involved in significant drug interactions. These preparations cause vasoconstriction. not vasodilation. A potent topical corticosteroid rarely is prescribed for use on the face. neck. or intertriginous sites because application on these areas may lead to increased adverse effects.

Explanation

A potent topical corticosteroid may increase the client’s risk for injury because it may be absorbed percutaneously. causing the same adverse effects as systemic corticosteroids. Topical corticosteroids aren’t involved in significant drug interactions. These preparations cause vasoconstriction. not vasodilation. A potent topical corticosteroid rarely is prescribed for use on the face. neck. or intertriginous sites because application on these areas may lead to increased adverse effects.

10. A male 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 would best prevent 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.”

Sunscreen should be applied even on overcast days. because the sun’s rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn’t guarantee protection against sunburn because sand. concrete. and water can reflect more than half the sun’s rays onto the skin.

Explanation

Sunscreen should be applied even on overcast days. because the sun’s rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn’t guarantee protection against sunburn because sand. concrete. and water can reflect more than half the sun’s rays onto the skin.