Integumentary System Disorders | NCLEX Quiz 170

1. A female client with second- and third-degree burns on the arms receives autografts. Two days later. the nurse finds the client doing arm exercises. The nurse knows that this client should avoid exercise because it may:

Dislodge the autografts.

Increase edema in the arms.

Increase the amount of scarring.

Decrease circulation to the fingers.

Because exercising the autograft sites may dislodge the grafted tissue. the nurse should advise the client to keep the grafted extremity in a neutral position. None of the other options results from exercise

Explanation

Because exercising the autograft sites may dislodge the grafted tissue. the nurse should advise the client to keep the grafted extremity in a neutral position. None of the other options results from exercise

2. The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to:

Use cosmetic camouflage techniques.

Protect the graft from direct sunlight.

Continue physical therapy.

Apply lubricating lotion to the graft site.

To avoid burning and sloughing. the client must protect the graft from direct sunlight. The other three interventions are helpful to the client and his recovery but are less important.

Explanation

To avoid burning and sloughing. the client must protect the graft from direct sunlight. The other three interventions are helpful to the client and his recovery but are less important.

3. Following a full-thickness (third-degree) burn of his left arm. a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure. he will restrict:

Range of motion.

Protein intake.

Going outdoors.

Fluid ingestion.

To prevent disruption of the artificial skin’s adherence to the wound bed. the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

Explanation

To prevent disruption of the artificial skin’s adherence to the wound bed. the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

4. A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:

Cancer of the ovaries.

Cancer of the uterus.

Cancer of the cervix.

Cancer of the vagina.

A female client with genital herpes simplex is at increased risk for cervical cancer. Genital herpes simplex isn’t a risk factor for cancer of the ovaries. uterus. or vagina.

Explanation

A female client with genital herpes simplex is at increased risk for cervical cancer. Genital herpes simplex isn’t a risk factor for cancer of the ovaries. uterus. or vagina.

5. Which of the following is the initial intervention for a male client with external bleeding?

Elevation of the extremity

Pressure point control

Direct pressure

Application of a tourniquet

Applying direct pressure to an injury is the initial step in controlling bleeding. For severe or arterial bleeding. pressure point control can be used. Pressure points are those areas where large blood vessels can be compressed against bone: femoral. brachial. facial. carotid. and temporal artery sites. Elevation reduces the force of flow. but direct pressure is the first step. A tourniquet may further damage the injured extremity and should be avoided unless all other measures have failed.

Explanation

Applying direct pressure to an injury is the initial step in controlling bleeding. For severe or arterial bleeding. pressure point control can be used. Pressure points are those areas where large blood vessels can be compressed against bone: femoral. brachial. facial. carotid. and temporal artery sites. Elevation reduces the force of flow. but direct pressure is the first step. A tourniquet may further damage the injured extremity and should be avoided unless all other measures have failed.

6. Dr. Martinez prescribes 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?

“This makes the skin feel soft.”

“This prevents evaporation of water from the hydrated epidermis.”

“This minimizes cracking of the dermis.”

“This prevents inflammation of the skin.”

Applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis. the skin’s upper layer. Although emollients make the skin feel soft. this effect occurs whether or not the client has just bathed or showered. An emollient minimizes cracking of the epidermis. not the dermis (the layer beneath the epidermis). An emollient doesn’t prevent skin inflammation.

Explanation

Applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis. the skin’s upper layer. Although emollients make the skin feel soft. this effect occurs whether or not the client has just bathed or showered. An emollient minimizes cracking of the epidermis. not the dermis (the layer beneath the epidermis). An emollient doesn’t prevent skin inflammation.

7. Nurse Tamara 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 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.

To prevent the spread of scabies in other hospitalized clients. the nurse should isolate the client’s bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client’s condition. a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn’t require enteric precautions because the mites aren’t found on feces.

Explanation

To prevent the spread of scabies in other hospitalized clients. the nurse should isolate the client’s bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client’s condition. a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn’t require enteric precautions because the mites aren’t found on feces.

8. A male client with a solar burn of the chest. back. face. and arms is seen in urgent care. The nurse's primary concern should be:

Fluid resuscitation.

Infection.

Body image.

Pain management.

With a superficial partial thickness burn such as a solar burn (sunburn). the nurse’s main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

Explanation

With a superficial partial thickness burn such as a solar burn (sunburn). the nurse’s main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

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

“Avoid sexual intercourse until you’ve completed treatment. which takes 14 to 21 days.”

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

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

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

Adults and children with gonorrhea may develop gonococcal conjunctivitis by touching the eyes with contaminated hands. The client should avoid sexual intercourse until treatment is completed. which usually takes 4 to 7 days. and a follow-up culture confirms that the infection has been eradicated. A client who doesn’t refrain from intercourse before treatment is completed should use a condom in addition to informing sex partners of the client’s health status and instructing them to wash well after intercourse. Meningitis and widespread CNS damage are potential complications of untreated syphilis. not gonorrhea.

Explanation

Adults and children with gonorrhea may develop gonococcal conjunctivitis by touching the eyes with contaminated hands. The client should avoid sexual intercourse until treatment is completed. which usually takes 4 to 7 days. and a follow-up culture confirms that the infection has been eradicated. A client who doesn’t refrain from intercourse before treatment is completed should use a condom in addition to informing sex partners of the client’s health status and instructing them to wash well after intercourse. Meningitis and widespread CNS damage are potential complications of untreated syphilis. not gonorrhea.

10. 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.

To prevent eye discomfort. the client must protect the eyes for 48 hours after taking medication for photochemotherapy. Protecting the eyes for a shorter period increases the risk of eye injury.

Explanation

To prevent eye discomfort. the client must protect the eyes for 48 hours after taking medication for photochemotherapy. Protecting the eyes for a shorter period increases the risk of eye injury.