Integumentary System Disorders | NCLEX Quiz 171

During the acute phase of a burn. the nurse should assess the client’s circulatory and respiratory status. vital signs. fluid intake and output. ability to move. bowel sounds. wounds. and mental status. Information about the client’s lifestyle and alcohol and tobacco use may be obtained later when the client’s condition has stabilized.

When caring for a client. the nurse must first wash her hands. Putting on gloves. removing the dressing. and observing the drainage are all parts of performing a dressing change after hand washing is completed.

Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort. erythema. and edema. After tissue and blood cultures are obtained. antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue. fever. chills. headache. and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

In a dark-skinned client. the nurse examines the lips. tongue. nail beds. conjunctivae. and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis. the lips and tongue are gray; the palms. soles. conjunctivae. and nail beds have a bluish tinge.

A turning schedule with a signing sheet will help ensure that the client gets turned and. thus. help prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage. which could damage capillaries. When moving the client. the nurse should lift — rather than slide — the client to avoid shearing.

Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

As edema develops on circumferential burns. eschar forms a tight. constricting band. compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn’t likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn’t alter physical mobility. A client with burns on the lower portions of both legs isn’t likely to have femoral artery occlusion.

Bed or chair confinement. inability to move. loss of bowel or bladder control. poor nutrition. absent or inconsistent caregiving. and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk. as presented in the options. is the decreased sensory perception. Options A. B. and D identify physiological conditions. which are the risk priorities.

Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort. erythema. and edema. After tissue and blood cultures are obtained. antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue. fever. chills. headache. and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

Psoriasis occurs equally among women and men. although the incidence is lower in darker skinned races and ethnic groups. A genetic predisposition has been recognized in some cases. Emotional distress. trauma. systemic illness. seasonal changes. and hormonal changes are linked to exacerbations.