Integumentary System Level 1 & 2

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse’s priority concern?

1 Loss of skin integrity caused by the burns 2 Potential infection as a result of the burn injury Correct3 Inadequate gas exchange caused by smoke inhalation 4 Decreased fluid volume because of the depth of the burns Maintaining a patent airway is the priority; because of the proximity of the chest and face to the nose and mouth, inhalation burns also may have occurred. Although loss of skin integrity caused by the burns is important, it is not the priority at this time. Although potential for infection as a result of the burn injury is important, it is not the priority. Although fluid needs are important, the gas exchange is priority.

Which skin color alteration may be observed in a client diagnosed with methemoglobinemia?

1 Red Correct2 Blue 3 White 4 Yellow-orange Blue discoloration of the skin may indicate an increase in deoxygenated blood, which is associated with methemoglobinemia. Red (erythema) may be associated with generalized inflammation. White (pallor) may indicate a decreased level of hemoglobin. It may signify a risk of anemia and shock. A yellow-orange skin discoloration may indicate jaundice and is associated with liver disorders.

What are the side effects of oral psoralen in phototherapy? Select all that apply.

Incorrect1 Atrophy Correct2 Sunburn Incorrect3 Mucositis 4 Occular damage Correct5 Persistent pruritus Oral psoralen is one form of phototherapy used in the treatment of many dermatologic conditions. Sunburn and persistent pruritus are side effects of oral psoralen. Atrophy, mucositis, and ocular damage are the adverse reactions of radiation therapy.

A nurse is assessing a newly admitted client with the pressure ulcer indicated in the picture. Which pressure ulcer stage should the nurse document on the admission history and physical?

Incorrect1 Stage I Correct2 Stage II 3 Stage III 4 Stage IV A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater; has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum-filled blister. A stage I ulcer has tissue injury with intact skin with nonblanchable redness of a localized area; the ulcer may appear with persistent red, blue, or purple hues. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present. It presents as a deep crater with or without undermining, and bone, tendon, and muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.

Which complications does the nurse anticipate in the client who has blue-colored nail beds?

1 Thrombocytopenia 2 Polycythemia vera Incorrect3 Methemoglobinemia Correct4 Cardiopulmonary disease A bluish-color to the nail beds is due to an increase in deoxygenated blood that may be due to cardiopulmonary disease. When there is bleeding from the vessels into the tissues, small blue-colored spots are formed (petechiae), which may be due to thrombocytopenia (decreased numbers of platelets). Polycythemia vera is characterized by brown spots on the skin caused by increased melanin production. Methemoglobinemia is a complication in which the mucous membranes appear blue in color due to increased deoxygenated blood in the body.

While assessing the skin of a client, the nurse observes a lesion that has a wavy border. Which type of lesion is present in the client?

1 Annular Incorrect2 Circinate 3 Coalesced Correct4 Serpiginous A lesion with a wavy border indicates a serpiginous lesion. A lesion that is ringlike with raised borders around a flat, clear center indicates an annular lesion. A circular lesion indicates a circinate lesion. A lesion that merges with another and appears confluent indicates a coalesced lesion.

Which physiologic activity is associated with the "proliferative phase" of normal wound healing?

1 White blood cells migrate into the wound Correct2 Epithelial cells grow over the granulation tissue bed 3 Scar tissue gradually becomes thinner and pale in color 4 Vasodilation occurs with increased capillary permeability During the "proliferative phase" of normal wound healing, the epithelial cells grow over the granulation tissue bed. The white blood cells are migrated into the wound during the inflammatory phase. In the maturation phase, the scar tissues gradually become thinner and pale in color. The vasodilation with the increased capillary permeability may occur during the inflammatory phase.

Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor?

1 Proteus 2 Bacteroides Correct3 Pseudomonas 4 Staphylococcus The purulent exudates of greenish-blue pus with a fruity odor signifies the colonization of Pseudomonas. Proteus colonization causes pus with a fishy odor. The colonization of Bacteroides causes brownish pus with a fecal odor. Staphylococcus colonization results in purulent exudate of creamy yellow pus.

Which benign condition of the client’s skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells?

Correct1 Nevi 2 Psoriasis 3 Acne vulgaris 4 Plantar warts Nevi (moles) are hyperpigmented areas that vary in form and size. Nevi are a common benign condition of the skin that is associated with the grouping of normal cells derived from melanocyte-like precursor cells. Psoriasis is an autoimmune chronic dermatitis that involves excessively rapid turnover of epidermal cells. Acne vulgaris is an inflammatory disorder of sebaceous glands. Plantar warts are formed due to a viral infection. Plantar warts appear on the bottom surface of the feet and grow inward because of pressure.

A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey-colored crust and surrounded by erythema. Which infection is suspected by the primary healthcare provider?

Incorrect1 Shingles Correct2 Impetigo 3 Folliculitis 4 Verruca vulgaris Impetigo is a primary bacterial infection most common on the face. This is clinically manifested as vesiculopustular lesions that develop as thick, honey-colored crust surrounded by erythema. Shingles or herpes zoster is a viral infection that usually occurs unilaterally on the trunk, face, and lumbosacral areas. Folliculitis is a bacterial infection seen most commonly on the scalp, beard, and extremities in men. Verruca vulgaris is a viral infection that is clinically manifested as circumscribed, hypertrophic, flesh-colored papule limited to the epidermis.

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity?

1 Utricaria 2 A drug reaction Incorrect3 Atopic dermatitis Correct4 Allergic contact dermatitis Allergic contact dermatitis is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens. Utricaria is an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis. A drug reaction may be caused by any drug such as penicillin that acts as antigen causing hypersensitivity reactions. Atopic dermatitis is a genetically influenced, chronic, relapsing disease associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.

A client with a full-thickness burn receives an allograft. Several days later the client points out that the graft is coming off at the edges. What is the nurse’s best response?

Correct1 "It is a temporary graft; it is expected to fall off." 2 "You must have pulled it loose; I’ll notify your primary healthcare provider." 3 "An infection may be starting; I anticipate that antibiotics will be prescribed." 4 "It is a permanent graft; it is likely that it will need to be replaced." An allograft is a temporary measure; it is expected to come off, and the primary healthcare provider should be notified that it is happening at this time. The response "you must have pulled it loose" is an unwarranted accusation that places guilt on the client; allografts are temporary. The response "an infection may be starting" is inaccurate information that may frighten the client. An allograft is a temporary, not permanent, measure and is expected to fall off.

Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue?

1 Continuous wet gauze Correct2 Moisture-retentive dressing 3 Topical enzyme preparations Incorrect4 -Wet-to-dry damp saline moistened gauze A moisture-retentive dressing is used to promote autolysis in the spontaneous separation of necrotic tissue in wound debridement. Continuous wet gauze is used in promoting dilution of viscous exudate and softening the dry scar. Topical enzyme preparation shows proteolytic action on thick, adherent eschar, causing the breakdown of denatured protein and a more rapid separation of necrotic tissue. In wet-to-dry damp saline-moistened gauze, necrotic debris is mechanically removed but with less trauma to healing tissue.

Which test would the client undergo to receive a diagnosis of systemic lupus erythematosus?

1 Patch test 2 Photo patch test Correct3 Direct immunofluorescence test 4 Indirect immunofluorescence test A direct immunofluorescence test is used in the diagnosis of systemic lupus erythematosus. The patch test and photo patch test are used to evaluate allergic dermatitis and photo allergic reactions. An indirect immunofluorescence test is performed on a blood sample.

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client’s burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

1 Equal 2 Unrelated 3 Inversely related Correct4 Directly proportional There is greater extravasation of fluid into the tissues as the amount of tissue involved increases. Thus the relationship of fluid loss to body surface area is directly proportional. Formulas (e.g., Parkland [Baxter]) are used to estimate fluid loss based on percentage of body surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship is proportional.

Which drug is a newer treatment option for treating metastatic melanoma?

1 Lomustin Correct2 Ipilimumab 3 Carmustine 4 Temozolomide Ipilimumab is a type of immunotherapy and is monoclonal antibody. It is a newer option of drug therapy used in the treatment of metastatic melanoma. Lomustin, carmustine, and temozolomide are established chemotherapy drugs in use for many years for the treatment of metastatic melanoma.

Which functions does the nurse associate with the epidermis? Select all that apply.

1 Serves as an energy reserve Incorrect2 Provides cells for wound healing Incorrect3 Serves as a mechanical shock absorber Correct4 Inhibits proliferation of microorganisms Correct5 Allows the photoconversion of 7-dehydrocholesterol to vitamin D The epidermis inhibits the proliferation of microorganisms because of its dry external surface. It also allows the photoconversion of 7-dehydrocholesterol to vitamin D. The subcutaneous tissue serves as an energy reserve. The dermis helps in providing cells for wound healing. Subcutaneous tissue acts as a mechanical shock absorber.

Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound?

1 Electrical stimulation 2 Topical growth factors 3 Hyperbaric oxygen therapy Correct4 Negative pressure wound therapy Negative pressure wound therapy is a new technology used to reduce chronic ulcers by removing fluids from the wound and enhancing granulation. Electrical stimulation is done by the application of low-voltage current to a wound area to increase blood vessel growth and promote granulation. Topical growth factors are the normal body substances that stimulate cell movement and growth. Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue oxygen concentration.

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client’s burn is different than full-thickness burns. Which information did the nurse recall?

1 Partial-thickness burns require grafting before they can heal. Correct2 Partial-thickness burns are often painful, reddened, and have blisters. 3 Partial-thickness burns cause destruction of both the epidermis and dermis. 4 Partial-thickness burns often take months of extensive treatment before healing. Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the epidermis and only part of the dermis. Recovery from partial-thickness burns with no infection occurs in 2 to 6 weeks.

Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply.

1 Furuncle Incorrect2 Cellulitis Correct3 Impetigo 4 Folliculitis Correct5 Erysipelas Impetigo is caused by group A β-hemolytic streptococci, staphylococci, or a combination of both. Erysipelas is caused by group A β-hemolytic streptococci. Furuncle is a deep infection with staphylococci. Staphylococcus aureus and streptococci are the usual causative agents of cellulitis. Usually staphylococci are responsible for folliculitis.

A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan?

Incorrect1 "Cover the area with a sterile gauze bandage." 2 "Put warm compresses on the site once a day." 3 "Limit lying on the back and unaffected side when sleeping." Correct4 "Avoid applying lotions and powders over the area." Lotions and powders can cause a skin reaction on irradiated areas and should be avoided. Gauze and tape may irritate the skin further and should be avoided. Warm compresses are contraindicated because they may precipitate skin breakdown. The client can assume a position of comfort.

What factors put a client at risk for bacterial infections? Select all that apply.

1 Dry skin Incorrect2 Underweight Correct3 Atopic dermatitis Correct4 Diabetes mellitus Correct5 Systemic antibiotics Atopic dermatitis, diabetes mellitus, and systemic usage of antibiotics and corticosteroids are predisposing factors for bacterial infections. Dry skin may not cause bacterial infections, as moisture on the skin is important for bacterial growth. Being underweight may not cause bacterial infections, whereas obesity is a risk factor for poor wound healing and diabetes mellitus.

Which drug can cause chemical burns?

Anthralin is a strong irritant that has an action similar to tar. So this drug can cause chemical burns with topical use. Prednisone is a corticosteroid applied topically to treat psoriasis. Tazarotene and calcipotriene are teratogenic (cause birth defects).

What could be the possible cause of a scald injury?

1 Contact with grease Correct2 Contact with hot liquids or steam 3 Contact with alkali in oven cleaners Incorrect4 Contact with open flame in house fires Scalding injuries usually result from contact with hot liquids or steam. Contact with grease and the alkali in oven cleaners may cause chemical injuries. An open flame in house fires may cause thermal injuries.

The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches the most effective method for putting out the flames. Which information from the group members indicates successful learning?

1 Slap at the flames. Correct2 Log-roll the victim in the grass. 3 Pour cold liquid over the flames. 4 Remove the victim’s burning clothes. Log-rolling the victim in the grass effectively extinguishes the flames and protects the client from additional injury. Slapping at the flames will not eliminate the oxygen that supports the fire and will fan the flames. Pouring cold liquid over the flames may extinguish the flames, but not as effectively as rolling in the grass. Removing the victim’s burning clothes may or may not protect the client from further injury and is dangerous for the rescuer.

A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client?

1 This decreases catabolism to promote healing at the site of injury. 2 This lowers the metabolic rate in an attempt to help reduce the fever. Incorrect3 This reduces the energy demands on the body in the presence of infection. Correct4 This limits muscle contractions that may force causative organisms into the bloodstream. Exercise will promote extension of the local infection from the leg into the circulation, causing septicemia (sepsis). Although bed rest does decrease catabolism to promote healing at the site of injury, it is not the purpose for bed rest in this situation. Although bed rest does reduce the energy demands on the body in the presence of infection and lowers metabolic rate, it is not the purpose for bed rest in this situation.

A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time?

1 Client with shock 2 Client with anemia Correct3 Client with epilepsy 4 Client with peripheral vascular disease A client with epilepsy does not have any circulatory inadequacy. Therefore the capillary refill time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-positive result). A client with shock has decreased oxygen saturation levels that further prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood circulation for clients with anemia, peripheral vascular disease, or diabetes.

Which description is associated with a hematoma?

Incorrect1 The occurrence of redness in patches of variable size and shape 2 The thickening of the skin with accentuated normal skin markings Correct3 The visible swelling due to extravasation of blood of sufficient size 4 The pinpoint, discrete deposits of blood in the extravascular tissues A hematoma may cause visible swelling due to the extravasation of a sufficient amount of blood. The occurrence of red patches of variable sizes and shapes indicates erythema. The thickening of the skin with accentuated normal skin markings indicates lichenifications. Petechiae are the pinpoint, discrete deposits of blood in the extravascular tissues.

A nurse is assessing four clients for risk factors for developing a pressure ulcer. List in order of priority the client with the greatest risk for developing a pressure ulcer to the client with the smallest risk.

Correct 1. 70-year-old man, admitted with metastatic bone cancer, weighing 80 lbs (36.36 kg), dehydrated, and bed bound Correct 2. 62-year-old woman, admitted because of a cerebrovascular accident (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift Incorrect 3. 78-year-old woman, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory Incorrect 4. 25-year-old man, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory Risk factors for pressure ulcers include inadequate nutrition, dehydration, pain, decreased subcutaneous fat, and confinement to bed, making the 70-year-old man at greatest risk. An inability to sense or move the left side will inhibit changing positions without assistance, making the 62-year-old woman who had the CVA next at risk. Urine and fecal incontinence may result in skin breakdown in the perineal and sacral areas. The 25-year-old male client is at some risk by not being able to communicate verbally and having urinary incontinence. The 78-year-old female client’s nutritional status is acceptable, and she is able to move. This client has minimal risk factors. Because she is scheduled for a knee replacement, which is an elective procedure, it can be assumed that her general health is within acceptable limits. Also, she is continent and ambulatory.

Which integumentary change is associated with delayed wound healing in a client?

Correct1 Decreased cell division 2 Decreased epidermal thickness 3 Decreased immune system cells Incorrect4 Increased epidermal permeability Delayed wound healing is associated with decreased cell division. Decreased thickness of the epidermis may cause skin transparency and fragility. Decreased cells of the immune system are the reason for a decreased skin inflammatory response. Increased epidermal permeability increases the risk for irritation.

A client sustained minor skin injuries following an accident. Which event occurs close to the time of injury?

1 Thinning of the scar tissue 2 Formation of granulation tissue Correct3 Migration of leukocytes to the site of injury 4 Arrival of fibroblasts to the site of infection Beginning at the time of injury and lasting 3 to 5 days is the inflammatory phase in which migration of leucocytes takes place. Scar tissue is formed in the maturation phase. Formation of "granulation" tissue and migration of fibroblasts occurs in the proliferative phase.

Which drug is prescribed for the client to treat severe nodulocystic acne?

1 Imiquimod Correct2 Isotretinoin Incorrect3 Clindamycin 4 Corticosteroids Isotretinoin is used for nodulocystic acne and may provide lasting remission. Imiquimod is a topical immunomodulator used to treat plantar warts. Clindamycin is a topical antibiotic used to treat acne vulgaris to suppress new lesions and minimize scarring. Corticosteroids are contraindicated because use of corticosteroids may cause flare-ups in clients with acne.

Which fungal infection does the client refer to as jock itch?

1 Tinea pedis Correct2 Tinea cruris 3 Tinea corporis 4 Tinea unguium Tinea cruris is a fungal infection commonly referred to as jock itch. It clinically manifests with well-defined scaly plaque in the groin area. Tinea pedis is a fungal infection commonly referred to as athlete’s foot. It is clinically manifested as interdigital scaling and maceration, scaly plantar surfaces, erythema, and blistering. Tinea corporis is a fungal infection commonly referred to as ringworm. It is clinically manifested as an erythematous annular, ringlike, scaly lesion with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.

Which changes to the client’s skin are caused by the atrophy of eccrine sweat glands?

1 Bruises Correct2 Dry skin Incorrect3 Wrinkles 4 Skin shearing Atrophy of the eccrine sweat glands will result in dry skin and decreased body odor. Increased capillary fragility and permeability will result in bruising. Decreased subcutaneous fat, degeneration of elastic fibers, and stiffening of the collagen fibers will result in wrinkles. Decreased subcutaneous fat will result in shearing of the skin.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse’s conclusion?

1 Decreased rate of glomerular filtration Incorrect2 Excessive blood loss through the burned tissues Correct3 Plasma proteins moving out of the intravascular compartment 4 Sodium retention occurring as a result of the aldosterone mechanism The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

Which type of biopsy would the nurse identify as required for removal of entire lesions on the skin?

1 Punch biopsy 2 Shave biopsy Incorrect3 Incisional biopsy Correct4 Excisional biopsy An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.

What is the function of the dermis?

Correct1 Provides cells for wound healing 2 Assists in retention of body heat 3 Acts as mechanical shock absorber Incorrect4 Inhibits proliferation of microorganisms The dermis is present between the epidermis and subcutaneous layers and has such functions as giving the skin its flexibility and strength and providing cells for wound healing. Subcutaneous tissue is the innermost layer of the skin that helps in retention of body heat and acts as a mechanical shock absorber. Epidermis is the outermost layer of skin that inhibits the proliferation of microorganisms.

While assessing the skin of a client, the nurse notices an elevated, solid lesion measuring 4 mm × 4 mm in size. Which type of lesion is observed in the client?

Correct1 Papule 2 Vesicle 3 Pustule 4 Macule A papule is an elevated, solid skin lesion of less than 0.5 to 1 cm in diameter. A macule is a circumscribed, flat area with a change in skin color. The vesicle is a circumscribed, superficial collection of serous fluid. A pustule is an elevated, superficial lesion filled with purulent fluid.

Which surgery is used to treat excessive wrinkling or sagging of facial skin?

1 Rhinoplasty Correct2 Rhytidectomy 3 Dermabrasion 4 Blepharoplasty Rhytidectomy is the removal of excess skin and tissue from the face; this is the surgery used to treat wrinkling or sagging of facial skin. Rhinoplasty is the removal of excessive tissue or cartilage from the nose. Dermabrasion is the process of removing the facial epidermis or a portion of the dermis to treat acne scars. Blepharoplasty is the removal of bulging fat in the periorbital area; this is used to treat bags under the eyes.

During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for?

1 Hypokalemia and hyponatremia Correct2 Hyperkalemia and hyponatremia 3 Hypokalemia and hypernatremia 4 Hyperkalemia and hypernatremia Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?

1 Fluid volume 2 Skin integrity 3 Physical mobility 4 Urinary elimination

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client?

Incorrect1 Fluid volume Correct2 Skin integrity 3 Physical mobility 4 Urinary elimination Necrotizing fasciitis destroys subcutaneous tissue and fascia and predisposes the client to infection and sepsis. Although fluid volume and physical mobility are important, they are not the primary concern at this time. Necrotizing fasciitis is a problem of the integumentary, not the urinary, system.

Which component of skin maintains optimal barrier function?

Correct1 Keratin 2 Melanin 3 Collagen 4 Adipose tissue Keratin is a protein produced by keratinocytes that helps to maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.

which clinical finding occurs due to thinning of the subcutaneous layer?

1 Decreased tone and elasticity 2 Decreased sensory perception Correct3 Increased risk for hypothermia 4 Increased susceptibility to dry skin Thinning of the subcutaneous layer results in increased risk for hypothermia. Degeneration of elastic fibers in the dermis results in decreased tone and elasticity. In the dermis, reduced number and function of nerve endings leads to decreased sensory perception. A decrease in dermal blood flow results in increased susceptibility to dry skin.

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up?

1 "I will leave the skin markings intact." 2 "I will protect the skin from sources of heat." 3 "I will wear soft clothing over the upper body." Correct4 "I will use an oatmeal-based lotion after each treatment." While undergoing radiation therapy, lotions, powders, and ointments should not be applied to the area. The skin markings should not be removed, because they form the parameters for the delivery of radiation. To protect the irradiated skin, sunlight and heat should be avoided. Nonirritating clothing should be worn over the area to prevent trauma to the delicate irradiated skin.

The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing?

Correct1 The scar is firm and inelastic on palpation. 2 Fibrin strands form a scaffold or framework. 3 White blood cells migrate into the wound. Incorrect4 Epithelial cells are grown over the granulation tissue bed. The maturation phase of normal wound healing involves a mature scar that is firm and inelastic when palpated. In the proliferative phase, the fibrin strands form a scaffold or framework. White blood cells migrate into the wound during the inflammatory phase. In the proliferative phase, the epithelial cells are grown over the granulation tissue bed.

A nurse is preparing to change a client’s dressing. Which information should the nurse recall for using surgical asepsis?

Correct1 Keep the area free of microorganisms. 2 Protect self from microorganisms in the wound. 3 Confine the microorganisms to the surgical incision site. 4 Limit the number of opportunistic microorganisms to a minimum. Surgical asepsis means that the defined area will contain no microorganisms. The purpose of personal protective equipment is to protect self from microorganisms in the wound. Confining the microorganisms to the surgical incision site and keeping the number of opportunistic microorganisms to a minimum apply to medical, not surgical, asepsis.

Which description describes a coalesced type of skin lesion configuration?

1 Lesions are well defined with sharp borders. Correct2 Lesions merge together and appear confluent. 3 Lesions are ringlike around flat centers of skin. 4 Lesions have wavy borders that resemble a snake. Coalesced skin lesions merge with one another and appear confluent. Circumscribed skin lesions are well defined with sharp borders. Annular skin lesions are ringlike with raised borders around flat centers of the normal skin. Lesions with wavy borders that resemble a snake are described as serpiginous.

What is the color of a client’s wound caused by skin tears?

Correct1 Red 2 Gray 3 Black 4 Yellow A wound that is caused by skin tears is red in color. A wound caused by a full-thickness or third-degree burn is gray or black in color. Wounds with nonviable necrotic tissue that create an ideal situation for bacterial growth are yellow in color.

A client’s burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare?

1 Enzymatic agents Correct2 Scissors and forceps Incorrect3 Autolytic semi-occlusive dressing 4 Continuous passive-motion device Mechanical debridement means to physically remove dirt, damaged or dead tissue, and cellular debris from a wound or burn so that infection is prevented and healing is promoted. Scissors, forceps, or scalpels may be used along with hydrotherapy. Enzymatic preparations are used to debride chemically by dissolving and removing necrotic tissue. A mechanical device that continually moves an extremity is called continuous passive range of motion and is used for knee surgery. Autolytic debridement includes semi-occlusive or occlusive dressings to soften dry eschar by autolysis.

Which benign condition shows silver scaly plaques on the skin?

1 Nevi Correct2 Psoriasis 3 Urticaria 4 Acne vulgaris A silver scaly plaque on the skin is due to psoriasis and is most commonly seen on the elbows and scalp. Hyperpigmented areas that vary in form and color are due to nevi. Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to urticaria. Non-inflammatory lesions, including open comedones and closed comedones, are due to acne vulgaris.

Which nursing assessment finding is associated with chronic eczema?

1 Localized edema Correct2 Rough and thick skin 3 Decreased skin turgor 4 Increased skin temperature Rough and thick skin may indicate chronic eczema. Localized edema is associated with trauma/inflammation. A decrease in skin turgor may indicate severe dehydration. An increase in skin temperature may be a sign of fever.

The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance?

1 T-tube movement increases. Correct2 Pain at the incision site increases. 3 The nasogastric tube gets irritating. 4 The bandage on the abdomen is constricting. The incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations.

Bacterial Infection?

Correct1 Impetigo Incorrect2 Candidiasis 3 Plantar warts 4 Verucca vulgaris Impetigo is the bacterial infection of skin caused by group A β-hemolytic streptococci or Staphylococcus aureus. Candidiasis is the fungal infection caused by Candida albicans. Plantar warts and verucca vulgaris are viral infections caused by the human papilloma virus.

What are the functions of a client’s subcutaneous layer of skin? Select all that apply.

Correct1 It provides insulation. Correct2 It acts as an energy reservoir. Incorrect3 It prevents systemic dehydration. 4 It provides cells for wound healing. Correct5 It acts as a mechanical shock absorber. The subcutaneous layer provides insulation and acts as an energy reservoir and mechanical shock absorber. The epidermal layer prevents systemic dehydration. The dermal layer provides cells for wound healing.

Which description is associated with fissures?

Incorrect1 Deep erosions that extend beneath the epidermis 2 Thinning of the skin surface with a loss of skin markings Correct3 Linear cracks in the epidermis that extend into the dermis 4 Thickened areas of epidermis with accentuated skin markings Fissures are linear cracks in the epidermis that extend into the dermis. Ulcers may be described as deep erosions extending beneath the epidermis. Atrophy is the thinning of the surface of the skin with a loss of skin markings. Lichenifications are characterized by thick areas of epidermis with accentuated skin markings.

A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation?

Incorrect1 Neurologic 2 Wound Correct3 Pain 4 Skin Assessment of pain must be performed before beginning a potentially painful procedure such as a wound irrigation. A neurologic check is not necessary unless the client’s neurologic status has worsened since the stroke. Both skin and wound checks can be assessed once client comfort has been determined and handled.

Which conditions in a client are associated with a bluish color of the mucous membranes? Select all that apply.

1 Edema Incorrect2 Diabetes mellitus 3 Hemochromatosis Correct4 Methemoglobinemia Correct5 Cardiopulmonary disease A bluish color of the mucous membranes may indicate methemoglobinemia (the presence of methemoglobin in the blood, which is an oxidized form of hemoglobin) and cardiopulmonary disease in the client. The presence of a white color of the mucous membranes may indicate edema in the client. Diabetes mellitus is associated with a yellow-orange color of the palms and soles. The presence of a brown color of the distal lower extremities may indicate hemochromatosis (deposition of iron salts in the tissues).

Which practice would be suitable in the prevention of a pressure ulcer?

1 Positioning a client directly on the trochanter Correct2 Keeping the client’s skin directly off plastic surfaces 3 Keeping the head of the bed elevated above 30 degrees Incorrect4 Placing a rubber ring or donut under the client’s sacral area For the prevention of a pressure ulcer, the client’s skin should be kept directly off plastic surfaces. While the client is positioned on his or her side, direct positioning on the trochanter should be avoided. The head of the bed should not be kept elevated above 30 degrees. This is to prevent shearing. A rubber ring or donut under the client’s sacral area should be avoided.

A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report?

A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? 1 20 2 25 3 30 Correct4 36 Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% total for both arms) and 18% for the anterior trunk; thus the total body surface area burned is 36%. The choices 20%, 25%, and 30% are too low.

Which type of allergic skin condition in a client is associated with immunological irregularity, asthma, and allergic rhinitis?

1 Urticaria 2 Psoriasis 3 Acne vulgaris Correct4 Atopic dermatitis Atopic dermatitis is an allergic skin condition that is a genetically influenced, chronic, relapsing disease. It is associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma. Urticaria is an allergic skin condition that results in a local increase in permeability of capillaries, causing erythema and edema in the upper dermis. Psoriasis is an autoimmune chronic dermatitis but not an allergic skin condition. Acne vulgaris is an inflammatory disorder of sebaceous glands.

Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply.

Correct1 Burns Incorrect2 Skin cancer Correct3 Osteomyelitis Correct4 Diabetic ulcers 5 Myocardial infarction Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue’s oxygen concentration. Burns, osteomyelitis, and diabetic ulcers are treated by hyperbaric oxygen therapy. Skin cancer and myocardial infarctions are not treated using hyperbaric oxygen therapy.

nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client says, "What should I do about my dry skin? It is so itchy." What is the best response by the nurse?

Incorrect1 "Wear warm clothes to keep moisture in the skin." Correct2 "Use a moisturizer on the skin daily to help reduce itching." 3 "Take hot tub baths only twice a week to reduce drying of the skin." 4 "Expose the skin to the air to help reduce the sensation of itching." Lubricating the skin with a moisturizer effectively relieves dryness and thus the pruritus. Wearing warm clothing will do nothing to lubricate the skin or relieve the pruritus. Warm or cool, not hot, tub baths will decrease itching. Exposing the skin to the air causes further drying and will not relieve pruritus.

The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." Which information should the nurse consider about rabies when planning care for this client?

1 Rabies is a bacterial infection characterized by encephalopathy and opisthotonos. 2 Rabies is an acute bacterial septicemia that results in convulsions and a morbid fear of water. Incorrect3 Rabies is a nonspecific immune response to organisms deposited under the skin by an animal bite. Correct4 Rabies is an acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system. Rabies is a viral infection that enters the body through a break in the skin and is characterized by convulsions and choking. Rabies is not caused by a bacteria; its outstanding symptoms are convulsions and choking. Rabies is not associated with a bacterial septicemia; it is caused by a virus. The virus specifically attacks nervous tissue and is carried in the saliva of infected animals.

Which skin infection would cause facial paralysis?

1 Candidiasis Correct2 Herpes zoster 3 Herpes simplex 4 Dermatophytosis Facial paralysis is the clinical sign of Bell’s palsy, a complication of the herpes zoster infection. This is seen when the trigeminal nerve is infected by the varicella-zoster virus. Candidiasis is a fungal infection not associated with Bell’s palsy. Herpes simplex is a viral infection and may not cause Bell’s palsy. Dermatophytosis is also a fungal infection not associated with Bell’s palsy.

A client is admitted to the hospital for the medical management of burns over 18% of the body’s surface. What should the nurse teach the client to help manage pain during dressing changes?

Correct1 Deep breathing exercises 2 Progressive muscle relaxation 3 Active range-of-motion exercises 4 Important elements of wound care Deep breathing exercises are an effective intervention in controlling pain; this is a positive coping skill. Muscle relaxation techniques generally include muscle contraction and then relaxation, which may increase the pain. Active range-of-motion exercises may increase the pain. Understanding important aspects of wound care will not reduce pain; health teaching should be initiated before, not during, a procedure.

Which secondary skin lesion may include athlete’s foot as an example?

1 Scar Incorrect2 Scale 3 Ulcer Correct4 Fissure An example of a fissure-type secondary lesion is athlete’s foot. Surgical incisions and healed wounds are examples of scar-type secondary lesions. A scale-type secondary lesion would include flaking of the skin following a drug reaction or sunburn. Ulcer-type lesions may include pressure ulcers or chancres.

Which dermatologic problem is treated by using intralesional corticosteroids?

Correct1 Psoriasis 2 Cellulitis 3 Erysipelas 4 Carbuncles Psoriasis is a dermatologic problem treated by using intralesional corticosteroids. Cellulitis, erysipelas, and carbuncles are treated by using systemic antibiotics such as synthetic sulfur.

What is a clinical manifestation of hypernatremia in burns?

1 Fatigue Correct2 Seizures Incorrect3 Paresthesias 4 Cardiac dysrhythmias Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

The client reports crumbly, discolored, and thickened toenails. What could be the possible reason for this condition?

fungal infection

Which type of laser is used in the treatment of vascular and other pigmented lesions?

Correct1 Argon 2 Gold vapors Incorrect3 Neodymium 4 Carbon dioxide An argon laser is used in the treatment of vascular and other pigmented lesions. Gold vapors and neodymium are type of lasers used in the treatment of skin disorders. A carbon dioxide laser is also a type of laser used in the treatment of skin disorders; it has numerous applications as a vaporizing and cutting tool for most tissues.

Which description could be related to zosteriform-type lesions?

1 Wide distribution 2 Diffuse distribution 3 Bilateral distribution Correct4 Band-like distribution Band-like distribution of lesions would be termed as zosteriform-type lesions. Diffuse-type lesions are described as the wide distribution of the lesions. Generalized-type lesions are identified by the diffused distribution of the lesions. Symmetric-type lesions are the bilateral distribution of the lesions.

After assessing the color of a client’s nail beds, the primary healthcare provider concludes that the client has trauma to the nail beds. Which variations in nail color might the client have?

Correct1 Red color 2 Blue color Incorrect3 White color 4 Yellow-brown color A red color is an indication of trauma to the nail bed. A blue color is an indication of respiratory failure. A white color is an indication of anemia, chronic liver, or kidney disease. A yellow-brown color is an indication of jaundice or cardiac failure.

What is the source of an Integra graft?

1 Porcine skin 2 Cadaveric skin Correct3 Glycosaminoglycan bonded to silicone membrane Incorrect4 Porcine collagen bonded to silicone membrane Glycosaminoglycan bonded to silicone membrane is the source of an Integra artificial skin graft. Porcine skin is the source of a xenograft. Cadaveric skin is the source of an allograft. Porcine collagen bonded to silicone membrane is the source of a biobrane graft.

Which change in the epidermis causes increased risk of sunburn?

1 Decreased cell division Correct2 Decreased melanocyte activity 3 Decreased vitamin D production 4 Decreased immune system cells Decreased melanocyte activity in the epidermis leads to increased risk of sunburn. Decreased cell division causes delayed wound healing. Decreased vitamin D production leads to increased risk for osteomalacia. Decreased immune system cells results in a decreased skin inflammatory response.

Which physical changes may cause longitudinal nail ridges?

1 Decreased rate of growth 2 Decreased cell division Correct3 Decreased blood flow 4 Decreased vitamin D production Longitudinal ridges may be due to decreased blood flow to the nail beds. Decreased cell division in the skin may cause a delay in wound healing. Increased risk of fungal infections is due to decreased rate of growth. Increased risk of osteomalacia is due to a decrease in vitamin D levels.

A client has bright-red erythematosus macules and papules on the skin. What could be the diagnosis?

Correct1 Drug eruption 2 Atopic dermatitis Incorrect3 Contact dermatitis 4 Nonspecific eczematous dermatitis Drug eruptions are characterized by bright-red erythematosus macules and papules on the skin, which occur because of an adverse reaction to a drug. Atopic dermatitis is characterized by scaling and excoriation, which occurs due to food allergies, chemicals, or stress. Contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens. Nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques.

A client’s wound is healing. Which event occurs in the proliferative phase of wound healing?

1 Thinning of scar tissue 2 Strengthening of collagen Correct3 Formation of "granulation" tissue 4 Increase in capillary permeability "Granulation" tissue is formed in the proliferative tissue. Thinning of scar tissue and strengthening of collagen fibers is seen in the maturation phase of wound healing. The increase in capillary permeability occurs in the inflammatory phase of wound healing.

Which benign tumor forms on the surface of the client’s epithelium?

1 Fibroma 2 Adenoma Correct3 Papilloma 4 Chondroma A papilloma is a benign tumor that forms on the surface of the epithelium. A fibroma forms on the fibrous tissue. An adenoma forms on the glandular epithelium. A chondroma forms on the cartilage.

Which infection is caused due to fungus?

1 Furuncle 2 Folliculitis 3 Herpes zoster Correct4 Dermatophytosis Dermatophytosis is a fungal infection in which single or multiple patches appear on the skin. Furuncle is a bacterial infection in which small, tender, erythematous nodules filled with pus appear on the skin. Folliculitis is a bacterial infection in which erythematous pustules appear singly or in groups on the skin. Herpes zoster is a viral infection in which lesions are present on an erythematous base.

The nurse is providing care for a client diagnosed with invasive pancreatic cancer. The client has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action should the nurse take postoperatively?

1 Maintain intermittent low suction to limit trauma. Correct2 Cleanse the area around the insertion site to prevent skin breakdown. 3 Attach the tube to a negative-pressure drainage system to promote drainage. 4 Reposition the client frequently to increase the flow of bile through the tube. Bile is irritating to the skin; cleansing the area around the T-tube to prevent skin breakdown is a priority. Suction is contraindicated; drainage is via gravity. The T-tube is attached to a bag for straight drainage via gravity, not suction that uses negative pressure. Repositioning the client is vital to prevent venous and pulmonary stasis, not for facilitating the drainage of bile.

A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve?

1 Increasing mobility 2 Preventing contractures 3 Limiting orthostatic hypotension Correct4 Preventing pressure on peripheral blood vessels The circulating air bed disperses body weight over a larger surface, which reduces pressure against the capillary beds, allowing for tissue perfusion. These beds are used for clients who are immobile; they do not increase mobility. Limiting orthostatic hypotension is achieved by dangling, not by this type of bed. Range-of-motion exercises, not the type of bed, will help prevent contracture.

The nurse is caring for a client with burns and reviews the client’s laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings?

Correct1 Azotemia 2 Hypokalemia Incorrect3 Metabolic alkalosis 4 Respiratory alkalosis The BUN is greater than the expected value of 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Urea nitrogen is the major nitrogenous end product of protein and amino acid catabolism; azotemia is the accumulation of excessive nitrogenous compounds, such as BUN and creatinine, in the blood. The client has hyperkalemia; the expected value for potassium is 3.5 to 5.5 mEq/L (3.5 to 5.5 mmol/L). Although the client does have a metabolic acid-base imbalance, it is acidosis, not alkalosis, because the pH is less than the expected range of 7.35 to 7.45. The PO2 is within the expected range of 80 to 100 mm Hg, which indicates that the problem is metabolic, not respiratory.

A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client?

1 Bathing will not be permitted. 2 Dressings will be changed daily. Correct3 Personal protective equipment will be worn by staff. 4 Room temperature will be kept below 72° F (22.2° C). Personal protective equipment (disposable hats, masks, gowns, and gloves) are essential for the prevention of infection in clients with the open method of treatment. Hydrotherapy in a large tank tub may be used to clean burn wounds. Dressings are not used with the open method. Clients are more comfortable with a room temperature of 85° F (29.4° C).

Which statement by the nurse is true regarding dandruff?

Correct1 "It is a problem of excessive oil production." 2 "It can occur as a side effect of drug therapy." 3 "It is associated with tenderness of the scalp." 4 "It is a manifestation of hormonal imbalance." Dandruff is associated with excessive oil production. Hirsutism may occur as a side effect of a drug therapy. Tenderness of the scalp is associated with lice and nits. Hirsutism is a manifestation of a hormonal imbalance.

A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan?

A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan? 1 "Rinse the mouth three times a day with lemon juice and water." 2 "Brush the teeth once daily and use dental floss after each meal." Correct3 "Clean the mouth with a soft toothbrush or a gentle spray." 4 "Gently clean the mouth with commercial mouthwash." Chemotherapy destroys the rapidly dividing cells of the oral mucosa; frequent gentle oral hygiene limits additional trauma. Although it is recommended to rinse the mouth every 2 hours, the client does not need to brush teeth and clean the mouth as often. Lemon juice is too caustic to the compromised mucosa. Flossing can disrupt and traumatize the gum surfaces; oral hygiene is needed more than once a day. Commercial mouthwashes contain alcohol, which is irritating to the mucosa.

Which client has a primary lesion?

Incorrect1 One with scales 2 One with ulcers 3 One with fissures Correct4 One with erosions Erosions are considered primary lesions. Scales, ulcers, and fissures are secondary lesions, which are modifications of primary lesions.

Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs?

1 Tenting 2 Angioma 3 Varicosity Correct4 Telangiectasia Telangiectasia is a permanent condition characterized by cutaneous blood vessels that are superficial and visibly dilated. Tenting is the failure of the skin to immediately return to the normal position after a gentle pinch. Angioma is a tumor that consists of blood and lymph vessels. Varicosity is the increased prominence of superficial veins. Topics

A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. What could be the possible condition in the client?

Correct1 Tinea pedis 2 Tinea cruris Incorrect3 Tinea corporis 4 Tinea unguium Tinea pedis is a fungal infection with an itching sensation associated with pain. It is clinically manifested as interdigital scaling and maceration and a scaly plantar surface, sometimes with erythema and blistering. Tinea cruris is a fungal infection that is clinically manifested with well-defined scaly plaque in the groin area. Tinea corporis is clinically manifested as an erythematous, annular, ring-like scaly appearance with well-defined margins. Tinea unguium or onychomycosis is manifested with scaliness under the distal nail plate.

A registered nurse teaches a client about the self-care measures to be taken to prevent dry skin. Which statement made by the client indicates the nurse needs to follow up?

1 "I will decrease intake of caffeine and alcohol." 2 "I will avoid wearing tight outfits and tight belts." Correct3 "I will use deodorant soap in place of alkaline soap." 4 "I will wear splints at night to prevent scratching in deep sleep." Use of deodorant soap will make the skin dry further so the nurse needs to follow up to correct this misconception. Deodorant soap should be avoided in clients having dry skin. All of the other statements are correct and need no follow up. Avoiding caffeine and alcohol will prevent dry skin. Avoiding tight outfits will prevent the drying of skin. Wearing splints will prevent damage to dry skin caused by scratching during deep sleep due to pruritus.

Which organism infestation is diagnosed with the help of the mineral oil test?

Incorrect1 Lice 2 Ticks Correct3 Mites 4 Fungus Mites are the causative organism of scabies. Examination using mineral oil is a diagnostic measure for the scabies infection. To check for infestations, scrapings are placed on a slide with mineral oil and viewed microscopically. Lice leave excrement and eggs on skin and hair, live in seams of clothing (if body lice), and in hair as nits. A diagnosis of Lyme disease caused by ticks is often based on clinical manifestations, in particular the erythema migrans lesion, and a history of exposure in an endemic area. If the enzyme immunoassays is positive or inconclusive, a Western blot test is done to confirm the infection. The microscopic examination of skin lesions in 10% to 20% potassium hydroxide is a diagnostic measure to determine the presence of a fungus.

Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply.

Incorrect1 Dryness Correct2 Photoaging 3 Vascular lesions Correct4 Wrinkling of skin Incorrect5 Benign neoplasm The skin damage that happens from chronic exposure to ultraviolet rays are photoaging and skin wrinkling. Dryness, vascular lesions, and benign neoplasm are changes related to aging.

What is an example of third spacing in a burn injury?

Correct1 Blister formation 2 Edema formation 3 Fluid mobilization 4 Fluid accumulation Blister formation is an example of third spacing in burn injuries. Edema formation and fluid mobilization generally happen in every burn injury. Fluid accumulation is formed in second spacing in a burn injury.

nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client?

Correct1 Highly contagious 2 Caused by a fungus 3 Chronic with exacerbations 4 Associated with other allergies Scabies is caused by the itch mite (Sarcoptes scabiei), the female of which burrows under the skin to deposit eggs. It is intensely pruritic and is transmitted by direct contact or in a limited way by soiled sheets or undergarments. It is not caused by a fungus. Scabies is an acute infestation; there are no remissions and exacerbations. It is a disease unrelated to allergies.

Which clinical manifestation is associated with cellulitis?

Correct1 Lymphadenopathy Incorrect2 Occasional papules 3 Vesicles that evolve into pustules 4 Isolated erythematous pustules Cellulitis is accompanied by lymphadenopathy. Occasional papules are present in folliculitis. Herpes simplex viral infections evolve the vesicles into pustules. Isolated erythematous pustules occur in folliculitis bacterial infections.

A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care?

Correct1 Use a consistent approach to care and encourage participation. Incorrect2 Prepare equipment while doing the procedure and explain the treatment to the client. 3 Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature. 4 Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done. Client participation provides for a sense of control, and a consistent approach provides a routine with no surprises; these approaches may limit pain and promote adherence to the regimen. Preparation of the equipment and explanation of the procedure should be performed before the procedure; when performed during the procedure, it wastes time, which can prolong pain and increase anxiety. Water temperature of 105° F (40.6° C) is too hot; the rinse water should be room temperature. Changing staff disrupts the client’s routine and sense of trust.

Which does the nurse understand related to negative pressure wound therapy? Select all that apply.

Correct1 Using a suction pump Incorrect2 Treating necrotizing infections 3 Administering oxygen under high pressure 4 Application of a low-voltage current to a wound area Correct5 Reducing chronic ulcers by removing fluids from the wound In negative pressure wound therapy, a suction pump is used to treat the wounds. This therapy can reduce chronic ulcers by removing fluids from the wound. Necrotizing infections are treated by hyperbaric oxygen therapy. Hyperbaric oxygen therapy is the administration of oxygen under high pressure. Electrical stimulation is the application of a low-voltage current to a wound area.

Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins?

1 Drug eruption 2 Atopic dermatitis Correct3 Contact dermatitis 4 Nonspecific eczematous dermatitis In contact dermatitis, localized eczematous eruptions are seen with well-defined geometric margins. In drug eruption, bright-red erythematosus macules and papules are seen. In atopic dermatitis, lichenification with scaling and excoriation is observed. Lichenification with weeping papules and macules is seen in nonspecific eczematous dermatitis.

A client is diagnosed with psoriasis, and the nurse is providing health teaching concerning skin care at home. Which recommendation does the nurse include in the teaching?

1 "Shower twice a day." 2 "Soak the affected areas in hot water." Correct3 "Apply moisturizing lotion several times a day." 4 "Cover affected areas when in contact with others." Moisturizing lotions provide an occlusive film on the skin surface so that usual water loss through the skin is limited, allowing the trapped water to hydrate the stratum corneum. Excessive exposure to water, particularly hot water, increases irritation and scaling. Psoriasis is not a communicable disease, and affected areas do not need to be covered when in contact with others.

What would the nurse state is a serious side effect of x-rays?

1 Vesicles 2 Papular Correct3 Desquamation 4 Plaque-like lesions X-ray is one of the radiologic diagnostic tests also used as therapy in some disease conditions. Desquamation is a serious side effect caused by x-rays. Vesicles, papules, and plaque-like lesions are serious effects caused by drug-induced photosensivity.

What would the nurse state is a cause of systemic altered inflammatory response in impaired wound healing?

1 Uremia 2 Cirrhosis Correct3 Leukemia 4 Hypovolemia Leukemia is a cause of systemic altered inflammatory response in impaired wound healing. Uremia, cirrhosis, and hypovolemia are systemic impaired cellular proliferation responses in impaired wound healing.

A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client’s admission and identifies the client’s potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client’s diet?

1 Milk Correct2 Tea 3 Orange juice 4 Tomato juice The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.

Which nursing assessment finding is associated with chronic eczema?

1 Localized edema Correct2 Rough and thick skin 3 Decreased skin turgor 4 Increased skin temperature Rough and thick skin may indicate chronic eczema. Localized edema is associated with trauma/inflammation. A decrease in skin turgor may indicate severe dehydration. An increase in skin temperature may be a sign of fever.

What would the nurse state is a cause of systemic altered inflammatory response in impaired wound healing?

1 Uremia 2 Cirrhosis Correct3 Leukemia 4 Hypovolemia Leukemia is a cause of systemic altered inflammatory response in impaired wound healing. Uremia, cirrhosis, and hypovolemia are systemic impaired cellular proliferation responses in impaired wound healing.

A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia (CREST syndrome). Which clinical indicators should the nurse expect to identify upon assessment? Select all that apply.

1 Joint pain 2 Masklike facies Correct3 Esophageal dysmotility Correct4 Spiderlike hemangiomas Correct5 Episodic blanching of the fingers Esophageal dysmotility is associated with CREST syndrome; it results in dysphagia and esophageal reflux. Spiderlike hemangiomas (telangiectasia) is associated with CREST syndrome. Episodic blanching of the fingers (Raynaud phenomenon), caused by vasospasms of the arterioles, is a sign associated with CREST syndrome. Joint pain, caused by inflammation, is a symptom associated with scleroderma, not CREST syndrome. Masklike facies is a sign associated with scleroderma, not CREST syndrome; it is caused by fibrotic tissue changes.

A client with a skin infection in the axilla reports a small, red lesion filled with pus. Upon assessment, the nurse notices the area to be erythematous and tender on palpation with noticeable lymphadenopathy. What could be the possible diagnosis?

Incorrect1 Shingles 2 Cellulitis Correct3 Furuncle 4 Folliculitis A furuncle is a skin infection seen in the axilla. It is characterized by a small erythematous lesion filled with pus and is tender on percussion. Lymphadenopathy in the axilla is called regional lymphadenopathy. This is also associated with a furuncle. Shingles do not have small, red, pus-filled lesions. Cellulitis is a local inflammatory reaction associated with skin trauma and does not have small, red, pus-filled lesions. Folliculitis presents with hair in the center of the lesion.

A client with third-degree burns asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse’s best response?

1 "It helps debride necrotic tissue." Correct2 "It promotes rapid healing of the wound." 3 "When sutured in place, it provides better adherence." 4 "Topical lotions can be used concurrently with the graft." The graft provides a framework for granulation and speeds healing. The graft promotes epithelialization; enzymatic preparations or surgery may be used to debride the burned tissue. Pigskin grafts are not sutured. Using topical lotions on burn wounds can increase the likelihood of infections.

The primary healthcare provider prescribed imiquimod to a client with a skin infection. What could be the possible condition of the client?

1 Shingles 2 Erysipelas Correct3 Plantar warts 4 Verucca vulgaris Imiquimod is a topical immunomodulator that stimulates the production of α interferon and other cytokines to enhance cell-mediated immunity. This medication is used for warts, actinic keratoses, and superficial basal cell carcinoma. Topical imiquimod may be used in the treatment of plantar warts, which are caused by a viral infection called the human papilloma virus. Shingles, caused by activation of varicella-zoster virus, is treated with antiviral agents such as acyclovir and famciclovir. Erysipelas is a bacterial infection treated with systemic antibiotics such as penicillin. Verucca vulgaris, also a viral infection, is treated with blistering agents such as cantharidin, keratolytic agents such as salicylic acid, and CO2 laser destruction.

A client sustains full-thickness and deep partial-thickness burns. The client asks, "What is the difference between my full-thickness and deep partial-thickness burns?" Which information will the nurse share with the client?

Correct4 Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis. The response that full-thickness burns extend into the subcutaneous tissue and deep partial-thickness burns extend through the epidermis and involve only part of the dermis correctly describes the difference between full-thickness and deep partial-thickness burns. Whereas full-thickness burns extend into the subcutaneous tissue, deep partial-thickness burns affect both the epidermis and dermis. Deep partial-thickness burns not only extend through the epidermis but also involve part of the dermis; superficial partial-thickness, not full-thickness, burns affect the superficial layers of the epidermis.

he nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice?

Incorrect1 Thinning subcutaneous layer 2 Degeneration of elastic fibers Correct3 Decreased dermal blood flow 4 Benign proliferation of capillaries With decreased dermal blood flow the client is susceptible to dry skin; the nurse should advise the client to apply moisturizer when the skin is moist. If a client is found to have a thinning subcutaneous layer, the nurse should teach the client to dress warmly in cold weather. If a client presents with degenerated elastic fibers, the nurse should check the skin turgor on the forehead or chest of the client. If a client has benign proliferation of the capillaries, this indicates cherry hemangiomas; the nurse should teach the client that these are benign.

The nurse is caring for a client who returns from surgery with a catheter that is attached to a portable wound drainage system exiting from the surgical site. Which principle underlying the function of a portable drainage system will the nurse consider when planning care for this client?

1 Gravity 2 Osmosis 3 Active transport Correct4 Negative pressure The negative pressure of a portable wound drainage system exerts a sucking force that pulls fluid toward the collection chamber. An indwelling urinary catheter uses the principle of gravity to draw fluid from the bladder to the collection bag held below the level of the bladder. Osmosis occurs when a solvent moves from a solution of lesser concentration to one of greater solute concentration when the two solutions are separated by a semipermeable membrane; fluid moving from the interstitial compartment into the intracellular compartment uses osmosis. Active transport occurs when ions move across a cell membrane against a concentration gradient with the assistance of metabolic energy; sodium and potassium ions move into and out of cells via active transport (sodium-potassium pump).

A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take?

1 Cover the cast with plastic wrap until dry. 2 Assist with weight bearing when the client ambulates. Correct3 Elevate the affected leg above the level of the heart. 4 Insert a finger inside the edges of the cast to check for skin abrasions. Elevating the affected leg will help reduce the formation of edema via the principle of gravity. Plastic wrap holds moisture and will interfere with drying of the cast. Full weight bearing should not start until prescribed by the primary healthcare provider. Nothing should be inserted under the cast; this can cause tissue injury.

A client is diagnosed with a dysfunction of the eccrine gland. Which physiologic abnormality might occur in the client? Select all that apply.

1 Drying of hair Correct2 Drying of surface cells 3 Decreased synthesis of vitamin D Correct4 Decreased efficiency to cool the body Correct5 Decreased excretion of waste products through the skin The eccrine gland is a sweat gland, the main functions of which are to moisturize the surface cells, cool the body by evaporation, and excrete waste products through the pores of the skin. Therefore dysfunction of the eccrine gland may result in drying of surface cells, decreased efficiency to cool the body, and decreased excretion of waste products through the skin. The sebaceous gland secretes sebum, which prevents drying of hair and skin. Therefore dysfunction of the sebaceous gland may lead to drying of hair and skin. Endogenous synthesis of vitamin D occurs by the action of UV light on vitamin D precursors in epidermal cells. Therefore dysfunction of the eccrine gland may not be associated with decreased vitamin D synthesis.

The primary healthcare provider instructs the nurse to monitor serum creatinine and blood urea nitrogen in a client who is on therapy for burn wounds. Which medication most likely has been prescribed to the client?

1 Nitrofurantoin 2 Mafenide acetate Incorrect3 Silver sulfadiazine Correct4 Gentamicin sulfate Gentamicin sulfate may cause nephrotoxicity in the client; therefore the client who is prescribed this drug should be carefully monitored for serum creatinine and blood urea nitrogen. The client on nitrofurantoin should be closely observed for signs of allergic reactions. Blood gas and serum electrolyte levels should be monitored in clients on mafenide acetate. In clients who are on silver sulfadiazine, wounds should be monitored for infections.

The registered nurse is teaching a community event about health promotion activities appropriate for good skin health. Which instructions given by the nurse would be beneficial? Select all that apply.

Correct1 "Eat foods rich in vitamin B." Correct2 "Sleep for longer periods of time." 3 "Use alkaline soaps for better hygiene." Incorrect4 "Use sunscreen of sun protection factor (SPF) 30 daily." Correct5 "Avoid exposure to sun after administering ketoconazole." Deficiency of vitamin B4 (niacin) and B6 (pyridoxine) are manifested as erythema, bullae, and seborrhea-like lesions. Deficiency of biotin, a B-complex vitamin, may cause rashes and alopecia. Adequate rest increases tolerance to itching, thereby decreasing skin damage from scratching in pruritic skin diseases. Some medications potentiate the effect of the sun causing sunburns. Acidic activity of the skin protects against bacterial overgrowth. Alkaline soaps neutralize the skin thereby decreasing the protection. Sunscreen of SPF 15 should be used daily by everybody. People with history of skin cancer or problems with photosensitivity may use sunscreen with SPF of at least 30.

The nurse is caring for a client who underwent intestinal surgery 3 days ago and notices brownish pus with a fecal odor draining from the incision. What should the nurse infer from this finding?

1 Colonization with Proteus 2 Colonization with Pseudomonas 3 Colonization with Staphylococcus Correct4 Colonization with aerobic coliform and Bacteroides A client who underwent intestinal surgery is more susceptible to developing colonization of aerobic coliform and Bacteroides, which results in brown pus with a fecal odor. Beige pus that has a fishy odor is formed due to colonization with Proteus. Greenish-blue pus that has a fruity smell is formed due to colonization with Pseudomonas. Creamy-yellow pus indicates a colonization of Staphylococcus.