Integumentary System Disorders | NCLEX Quiz 169

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

An I.V. corticosteroid.

An I.V. antibiotic.

An oral antibiotic.

A topical agent.

Although many drugs are used to treat skin disorders. topical agents — not I.V. or oral agents — are the mainstay of treatment.

Explanation

Although many drugs are used to treat skin disorders. topical agents — not I.V. or oral agents — are the mainstay of treatment.

2. A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers. 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.

The most important intervention to prevent pressure ulcers is frequent position changes. which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved. capillaries become occluded. reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises. the nurse moves each joint through its range of movement. which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

Explanation

The most important intervention to prevent pressure ulcers is frequent position changes. which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved. capillaries become occluded. reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises. the nurse moves each joint through its range of movement. which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

3. Nurse Mary is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect?

Polyurethane foam mattress

Ring or donut

Gel flotation pad

Water bed

Rings or donuts aren’t to be used because they restrict circulation. Foam mattresses evenly distribute pressure. Gel pads redistribute with the client’s weight. The water bed also distributes pressure over the entire surface.

Explanation

Rings or donuts aren’t to be used because they restrict circulation. Foam mattresses evenly distribute pressure. Gel pads redistribute with the client’s weight. The water bed also distributes pressure over the entire surface.

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

A urine output consistently above 100 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

In a client with burns. the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused. they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus. the expected urine output of a 155-lb client is 35 ml/hour. and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn’t a goal. In fact. a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators.

Explanation

In a client with burns. the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused. they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus. the expected urine output of a 155-lb client is 35 ml/hour. and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn’t a goal. In fact. a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators.

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

“All family members will 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.”

When someone in a group of persons sharing a home contracts scabies. each individual in the home needs prompt treatment whether he’s symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

Explanation

When someone in a group of persons sharing a home contracts scabies. each individual in the home needs prompt treatment whether he’s symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

6. A female 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?

Spontaneously occurring wheals

A fungus that enters the skin’s surface. causing infection

Inflammation of a hair follicle

Irritation of opposing skin surfaces caused by friction

Intertrigo refers to irritation of opposing skin surfaces caused by friction. Spontaneously occurring wheals occur in hives. A fungus that enters the skin surface and causes infection is a dermatophyte. Inflammation of a hair follicle is called folliculitis.

Explanation

Intertrigo refers to irritation of opposing skin surfaces caused by friction. Spontaneously occurring wheals occur in hives. A fungus that enters the skin surface and causes infection is a dermatophyte. Inflammation of a hair follicle is called folliculitis.

7. Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest How should the nurse apply this topical agent?

With a circular motion. to enhance absorption

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

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

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

When applying a topical agent. the nurse should begin at the midline and use long. even. outward. and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.

Explanation

When applying a topical agent. the nurse should begin at the midline and use long. even. outward. and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.

8. A female client with herpes zoster is prescribed acyclovir (Zovirax). 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause:

Palpitations.

Dizziness.

Diarrhea.

Metallic taste.

Oral acyclovir may cause such adverse GI effects as diarrhea. nausea. and vomiting. It isn’t associated with palpitations. dizziness. or a metallic taste.

Explanation

Oral acyclovir may cause such adverse GI effects as diarrhea. nausea. and vomiting. It isn’t associated with palpitations. dizziness. or a metallic taste.

9. When caring for a male client with severe impetigo. the nurse should include which intervention in the plan of care?

Placing mitts on the client’s hands

Administering systemic antibiotics as prescribed

Applying topical antibiotics as prescribed

Continuing to administer antibiotics for 21 days as prescribed

Impetigo is a contagious. superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe. the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis. a dangerous complication. The client’s nails should be kept trimmed to avoid scratching; however. mitts aren’t necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetigo.

Explanation

Impetigo is a contagious. superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe. the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis. a dangerous complication. The client’s nails should be kept trimmed to avoid scratching; however. mitts aren’t necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetigo.

10. Nurse Harry documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing?

Inflammatory

Migratory

Proliferative

Maturation

The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells. synthesis of scar tissue by fibroblasts. and development of new cells that grow across the wound. In the inflammatory phase. a blood clot forms. epidermis thickens. and an inflammatory reaction occurs in the subcutaneous tissue. During the proliferative phase. the actions of the migratory phase continue and intensify. and granulation tissue fills the wound. In the maturation phase. cells and vessels return to normal and the scab sloughs off.

Explanation

The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells. synthesis of scar tissue by fibroblasts. and development of new cells that grow across the wound. In the inflammatory phase. a blood clot forms. epidermis thickens. and an inflammatory reaction occurs in the subcutaneous tissue. During the proliferative phase. the actions of the migratory phase continue and intensify. and granulation tissue fills the wound. In the maturation phase. cells and vessels return to normal and the scab sloughs off.