Deck 46: Integumentary System

Question 1

A client has experienced a severe sunburn.The nurse is aware that is an example of which of these burn classifications?

A)first-degree
B)second-degree
C)third-degree
D)fourth-degree

Answer 1

first-degree

Question 2

Which of these factors is the MOST common cause of altered wound healing?

A)advanced age
B)smoking
C)hemorrhage
D)infection

Answer 2

infection

Question 3

In caring for autografts of a client's burn wound,the nurse would follow strict aseptic care of the donor site and the newly grafted wound,and take which of these actions?

A)Irrigate each site with prescribed antibiotic solution,and let the wound air dry.
B)Massage the tissue around the grafts to increase the blood supply and speed up healing.
C)Apply the prescribed pressure dressings to the sites.
D)Remove the pressure dressings every other day.

Answer 3

Apply the prescribed pressure dressings to the sites.

Question 4

A client has numerous petechiae over the face,neck,and upper chest and areas of ecchymosis on the abdomen and upper legs.Which of these skin parameters has the nurse assessed?

A)integrity
B)texture
C)turgor
D)vascularity

Question 5

Temporary grafts to a burn wound,such as homografts,heterografts,and synthetic skin substitutes,perform which of these functions?

A)prevent water,electrolyte,and protein loss
B)provide for strict rest of the affected area
C)minimize infection of the wound site
D)replace the lost skin so that further grafting is not necessary if granulation tissue is formed

Question 6

A nurse notes that a client's skin is loose,thin,and wrinkled.Which of these skin parameters has the nurse assessed?

A)integrity
B)moisture
C)texture
D)turgor

Question 7

A wound that involves minimal tissue loss with well-approximated edges will heal by which of these methods?

A)primary intention
B)secondary intention
C)tertiary intention
D)quartile intention

Question 8

A client is severely burned in a gas explosion,and charred underlying muscles and bones and dark networks of thrombosed capillaries are visible.What degree of burn damage does this represent?

A)first-degree
B)second-degree
C)third-degree
D)fourth-degree

Question 9

Immediately after sustaining a severe burn wound,the nurse would anticipate the client's nutritional needs would usually be met by which of these methods?

A)intravenous (IV)fluids only
B)nasogastric tube feedings
C)six to eight small feedings daily with supplemental milk shakes
D)total parenteral nutrition

Question 10

A client asks why a burn is debrided each day.Which of these responses by the nurse would be MOST appropriate?

A)"By removing the eschar daily,infection and tissue sloughing can be prevented and healthy tissue can be covered with skin grafts."
B)"By submersion in a whirlpool bath,we can better exercise the limbs to prevent contractures."
C)"This is a cleaning bath given so that fresh dressings may be applied to the areas."
D)"We decrease the chance of infection by immersion in antibiotic solutions with each debriding bath."

Question 11

A client is admitted to the burn unit after sustaining both partial-thickness and full-thickness burns over 55% of the body.The client tells the nurse the burn must not be too severe because there is not much pain.The nurse recognizes this comment reflects which of these factors?

A)The client is in a state of denial.
B)The client is in physical shock.
C)The analgesics administered to the client in the emergency department are effective.
D)The majority of the client's injuries are third-degree burns.

Question 12

Which of these dietary modifications is indicated for a client recuperating from a moderate to severe burn?

A)protein and caloric intake increased by twice the regular requirements
B)carbohydrates increased by one-half the normal requirements
C)fat increased by two to four times the regular requirements
D)supplemental fiber

Question 13

The skin of a client's feet is very taut with edema.Which of these skin parameters has the nurse assessed?

A)integrity
B)texture
C)turgor
D)vascularity

Question 14

A client is admitted with severe burns over the anterior of both legs and the lower abdomen and genitals.The nurse should anticipate preparing for which of these procedures?

A)administration of 100% humidified oxygen
B)endotracheal tube insertion
C)insertion of a chest tube
D)insertion of two large-caliber venous catheters

Question 15

Which phase of wound healing lasts the longest period of time?

A)initial
B)defensive
C)reconstructive
D)maturation

Question 16

All persons coming into contact with a client sustaining burn injury must wear:

A)gown and gloves
B)masks and gloves
C)gowns,gloves,masks,and caps
D)gowns,gloves,and caps

Question 17

A client has a stasis ulcer on the left ankle.Nursing assessment of this open area involves which skin assessment parameter?

A)integrity
B)moisture
C)turgor
D)vascularity

Question 18

What is the BEST method of applying a topical agent to a burn?

A)spraying
B)sterile gauze
C)sterile glove
D)sterile spatula

Question 19

The prognosis in burn cases depends upon the severity of the burn,surface area involved,and which of these client factors?

A)preinjury health status
B)ethnic background
C)gender
D)nutritional intake

Question 20

Application of which of these medications on large,open burn wounds can decrease infection and promote healing without serious side effects?

A)povidone-iodine (Betadine)
B)bacitracin (Baciguent)
C)gentamicin (Garamycin)
D)neomycin (Myciguent)

Question 21

A client who has AIDS develops cutaneous T-cell lymphoma,which is characterized by:

A)ready susceptibility to treatment and cure
B)initial appearance of moles that are irregular in shape
C)superficial infection of the dermis and epidermis
D)metastasis to vital organ systems,even if treatment improves the skin's condition

Question 22

All of the following nursing interventions are used to prevent contractures in severely burned clients.Which intervention also provides increased circulation and improved muscle tone?

A)doing active exercise
B)maintaining correct alignment
C)performing range-of-motion exercises
D)supporting limbs with splints and pillows

Question 23

Which of these therapies is used in the medical treatment of squamous cell carcinoma?

A)chemosurgery
B)chemotherapy
C)electrosurgery
D)radiation therapy

Question 24

A client shows the nurse a "ringworm" on the left forearm.What over-the-counter topical antifungal drug could the nurse recommend to the client to treat this lesion?

A)acyclovir
B)lindane (Kwell)
C)miconazole nitrate (Micatin)
D)nitric acid

Question 25

For a client who has herpes simplex virus type 2 with painful genital lesions,oral administration of which medication helps shorten an acute episode and prevent recurrence of this illness?

A)lindane (Kwell)
B)miconazole nitrate (Micatin)
C)nitric acid
D)acyclovir (Zovirax)

Question 26

In addition to malignant melanoma,which of these skin disorders may metastasize to other body tissues and cause death?

A)squamous cell carcinoma
B)basal cell carcinoma
C)lipoma
D)angioma

Question 27

What is considered the BEST treatment for a port-wine angioma?

A)surgical debridement
B)cosmetics
C)radical surgical excision
D)skin grafting over the lesion

Question 28

Which of these statements about a nurse who has never had chickenpox caring for a client with herpes zoster during the draining,open lesions phase of the illness is TRUE?

A)The nurse is at risk of contracting herpes zoster.
B)The nurse could contract herpes simplex virus type 1 or 2.
C)The nurse may develop chickenpox as a result of this exposure.
D)The nurse would not be at risk for developing any condition if consistently using universal precautions.

Question 29

A client has clusters of small vesicles over the thoracic region and describes severe pain and itching of the affected areas.Herpes zoster is diagnosed,and the client will be treated with which of these medications?

A)acyclovir (Zovirax)
B)lindane (Kwell)
C)miconazole nitrate (Micatin)
D)nitric acid

Question 30

Which of these statements about the characteristics of malignant melanoma is TRUE?

A)It begins as a preexisting mole or nevus.
B)The nevus is regular in shape.
C)The nevus is a uniform light-brown color.
D)The nevus is smaller than 6 millimeters in diameter.

Question 31

Confusion,disorientation,and a decreased level of consciousness may occur in severely burned clients related to which of these factors?

A)anxiety
B)depression
C)fluid and electrolyte imbalances
D)severe pain

Question 32

A client who has diabetes and is overweight develops a carbuncle at the nape of the neck,which is incised and drained.The client asks the nurse what caused the carbuncle to grow.Which of these responses is the MOST appropriate response?

A)"Your diabetes probably increased your susceptibility to infection."
B)"It's the result of poor hygiene."
C)"The staphylococcus organism is present on the skin,and a hair follicle probably became infected."
D)"Your obesity and constant perspiration may have caused it."

Question 33

Which of these statements about the cause of significant skin damage is TRUE?

A)It results from cumulative sun exposure.
B)It is genetically inherited.
C)It results from ingesting carcinogenic foods and other substances.
D)It results from tanning bed usage.

Question 34

Which of the following nursing observations of the client who is severely burn injured would indicate a less-than-desirable client status and should be immediately reported to the doctor?

A)a change in the client's level of consciousness from confused to alert
B)hourly urine output below 30 mL
C)pulse oximetry reading that remains above 90%
D)productive cough

Question 35

A basic rule for the nurse when caring for clients who are experiencing impaired skin integrity related to an infectious disorder of the skin would be to:

A)avoid the use of soaps due to their drying effect
B)cleanse the skin with comfortably hot water to facilitate removal of crusts and ointment residues
C)massage the skin in an outward circle to facilitate healing
D)wear gloves

Question 36

An older adult client develops herpes zoster and asks the nurse how this can happen,having had chickenpox as a child.What is the nurse's MOST appropriate response?

A)"Have you been exposed to chickenpox recently?"
B)"Herpes zoster is related to the chickenpox virus,and you have just caught shingles."
C)"You only developed partial immunity to the virus that causes it."
D)"You must not have actually had chickenpox as a child."

Question 37

Surgical removal is recommended for which type of benign skin tumor if it causes pressure on surrounding nerves or interferes with normal body function?

A)angioma
B)keloid
C)lipoma
D)nevi

Question 38

A client develops a severe case of generalized scabies.The nurse should instruct the client to:

A)apply lindane (Kwell)topically to the entire body at bedtime
B)change bed linens daily
C)treat only those family members who have symptoms
D)use cold water to wash all underclothing,bed linens,and bath linens

Question 39

The older adult client is at greater risk for complications and delayed healing in a severe burn injury because of normal physiologic changes such as:

A)increased renal blood flow and glomerular filtration rate
B)impaired circulation and impaired tissue nutrition
C)enhanced skin resiliency
D)decreased need for oxygen and decreased cardiac output

Question 40

When teaching a client about basal cell carcinoma,the nurse would be sure to include which of the following?

A)It appears as a nodular lesion in the epidermis.
B)It is the most frequent type of skin cancer.
C)It usually begins in a preexisting mole (nevus).
D)It can metastasize to other body tissues.

Question 41

Contact dermatitis can be caused by which of the following substances?

A)oral penicillin
B)topical antibiotics
C)aluminum
D)cosmetics

Question 42

Which of these foods would the nurse recommend to a client to assist healing of a stasis ulcer?

A)pasta with cheese
B)sausage and red beans
C)flounder with rice
D)roast beef and baked potato

Question 43

Which of these nursing interventions is MOST appropriate for the client who has psoriasis?

A)applying medicated soaps and lotions to lesions
B)helping the client focus on personal attributes that contribute to effective functioning and a positive self-image
C)keeping the lesions well covered
D)using plenty of sunscreen when going outside

Question 44

Which of these nursing diagnoses would be appropriate for the client who has psoriasis?

A)Chronic pain
B)Risk for infection
C)Risk for self-mutilation
D)Fluid and electrolyte imbalance

Question 45

A client has contracted pediculosis capitis.Which of these aspects would the nurse include in client teaching?

A)Apply an antibiotic ointment to the affected area twice a day.
B)Comb the nits out of the scalp,and discard them in the trash.
C)Discard any clothing worn since the infection developed.
D)Shampoo the hair with Kwell now,and repeat in 10 days.

Question 46

What is the single MOST effective way to prevent a client from developing pressure ulcers?

A)diet rich in vitamin C and protein
B)massage of bony prominences
C)frequent repositioning
D)use of pillows

Question 47

The nurse is caring for a client who has an ulceration appearing as a deep crater with undermining of adjacent tissue loss.The nurse recognizes that this client has which type of ulcer present?

A)stage I
B)stage II
C)stage III
D)stage IV

Question 48

Etretinate (Tegison)is used to treat clients who have severe psoriasis that is not amenable to other therapies.Which of these statements should the nurse include when teaching the client about this medication?

A)"Effective contraception is a must during treatment and for at least 1 month after treatment."
B)"Expect drowsiness after each dose."
C)"Nausea should be reported to your health care provider."
D)"Your urine may normally be colored orange from this medication."

Question 49

The physician orders a dressing for a client with a wound.The student nurse is aware that the purpose of applying dressings includes which of the following? (Select all that apply. )

A)to promote homeostasis
B)to promote thermal insulation of the wound
C)to promote healing by reflecting light
D)to promote splinting or support for the wound
E)to provide concealment from the client

Question 50

A client who has poor venous circulation can lead to the development of which of these conditions?

A)contact dermatitis
B)exfoliative dermatitis
C)psoriasis
D)stasis dermatitis

Question 51

An older adult client is admitted to a long-term care facility.The nurse should automatically place which of these support surfaces on the client's bed?

A)air-filled mattress
B)egg-crate mattress
C)waterproof draw sheet
D)electric warming blanket

Question 52

A client develops large,red patches covered with thick,silvery scales on the arms and knees,and psoriasis is diagnosed.Client teaching about this disease should include which of these aspects?

A)Its exact cause is unknown.
B)After initial symptoms are treated,they will not recur.
C)The disease is progressive and fatal.
D)Psychotherapy can alleviate its symptoms.

Question 53

Photochemotherapy (PUVA)is used to treat severe psoriasis by combining the use of methoxsalen with ultraviolet A light waves to:

A)cause remission of the disease
B)cure the disease
C)result in the full-blown recurrence of the disease,which may then be surgically removed
D)slow cell division,which relieves symptoms

Question 54

Which of these intrinsic factors contributes to development of pressure ulcers?

A)impaired mobility
B)shearing
C)friction
D)moisture

Question 55

Which of the following is a major symptom of contact dermatitis?

A)scaling
B)blanching of skin
C)loss of skin surface
D)pruritus

Question 56

Which of these statements about exfoliative dermatitis is TRUE?

A)Overwhelming systemic infections or massive loss of body fluids and electrolytes can cause death.
B)Severe pruritus can be controlled with oral antihistamines.
C)Skin inflammation will gradually heal.
D)Systemic symptoms include weight loss.

Question 57

Management of a client with a stage III ulceration would include which of the following? (Select all that apply. )

A)frequently assessing lung sounds
B)frequently changing position
C)air-filled mattress
D)debridement of the wound bed
E)encouraging intake of foods high in vitamin C and protein