NURS 618 Saunders Med Surg Skin
Integumentary Revised
Saunders Med- Surg Skin Integumentary
1. A client calls the emergency department and tells the nurse that he came directly into
contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the
skin and asks the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rinsing several times."
4. "It is not necessary to do anything if you cannot see anything on your skin."
Answer: 3. "Take a shower immediately, lathering and rinsing several times."
Rationale:
When an individual comes in contact with a poison ivy plant, the sap from the plant forms an
invisible film on the human skin. The client should be instructed to cleanse the area by
showering immediately and to lather the skin several times and rinse each time in running
water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion
may be one product recommended for use if dermatitis develops. The client does not need to
be seen in the emergency department at this time.
2. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left
leg. During the admission assessment, the nurse expects to note which finding?
1. An inflammation of the epidermis only
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. An epidermal and lymphatic infection caused by Staphylococcus
Answer: 2. A skin infection of the dermis and underlying hypodermis
Rationale:
Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red
erythema without sharp borders and spreads widely throughout tissue spaces. The skin is
erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial,
rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial
and extends deeper than the epidermis.
3. The clinic nurse assesses the skin of a client with psoriasis after the client has used a new
topical treatment for 2 months. The nurse identifies which characteristics as improvement in
the manifestations of psoriasis?
Select all that apply.
1. Presence of striae
2. Palpable radial pulses
3. Absence of any ecchymosis on the extremities
4. Thinner and decrease in number of reddish papules
5. Scarce amount of silvery-white scaly patches on the arms
Answer: 4. Thinner and decrease in number of reddish papules
5. Scarce amount of silvery-white scaly patches on the arms
Rationale:
Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white
patches. A decrease in the severity of these skin lesions is noted as an improvement. The
presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to
psoriasis.
4. The clinic nurse notes that the health care provider has documented a diagnosis of herpes
zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder,
the nurse determines that this definitive diagnosis was made by which diagnostic test?
1. Positive patch test
2. Positive culture results
3. Abnormal biopsy results
4. Wood's light examination indicative of infection
Answer: 2. Positive culture results
Rationale:
With the classic presentation of herpes zoster, the clinical examination is diagnostic.
However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster
(shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes
chickenpox. A patch test is a skin test that involves the administration of an allergen to the
surface of the skin to identify specific allergies. A biopsy would provide a cytological
examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet
light to identify superficial infections of the skin.
5. A client returns to the clinic for follow-up treatment following a skin biopsy of a
suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a
melanoma. The nurse understands that melanoma has which characteristics? Select all that
apply.
1. Lesion is painful to touch.
2. Lesion is highly metastatic.
3. Lesion is a nevus that has changes in color.
4. Skin under the lesion is reddened and warm to touch.
5. Lesion occurs in body area exposed to outdoor sunlight.
Answer: 2. Lesion is highly metastatic.
3. Lesion is a nevus that has changes in color.
Rationale:
Melanomas are pigmented malignant lesions originating in the melanin- producing cells of
the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This
skin cancer is highly metastatic, and a person's survival depends on early diagnosis and
treatment.
Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure
increases the risk of melanoma, lesions are most commonly found on the upper back and legs
and on the soles and palms of persons with dark skin.
6. A client arriving at the emergency department has experienced frostbite to the right hand.
Which finding would the nurse note on assessment of the client's hand?
1. A pink, edematous hand
2. Fiery red skin with edema in the nail beds
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch
Answer: 4. A white color to the skin, which is insensitive to touch
Rationale:
Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and
insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or
blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.
7. The evening nurse reviews the nursing documentation in a client's chart and notes that the
day nurse has documented that the client has a stage II pressure ulcer in the sacral area.
Which finding would the nurse expect to note on assessment of the client's sacral area?
1. Intact skin
2. Full-thickness skin loss
3. Exposed bone, tendon, or muscle
4. Partial-thickness skin loss of the dermis
Answer: 4. Partial-thickness skin loss of the dermis
Rationale:
In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has
occurred. It presents as a shallow open ulcer with a red- pink wound bed, without slough. It
may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage
I. Full- thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in
stage IV.
8. An adult client was burned in an explosion. The burn initially affected the client's entire
face (anterior half of the head) and the upper half of the anterior torso, and there were
circumferential burns to the lower half of both arms. The client's clothes caught on fire, and
the client ran, causing subsequent burn injuries to the posterior surface of the head and the
upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn
injury?
1. 18%
2. 24%
3. 36%
4. 48%
Answer: 3. 36%
Rationale:
According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%,
the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The
subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of
posterior torso, equaling 9%. This totals 36%.
9. The nurse is preparing to care for a burn client scheduled for an escharotomy procedure
being performed for a third-degree circumferential arm burn. The nurse understands that
which finding is the anticipated therapeutic outcome of the escharotomy?
1. Return of distal pulses
2. Brisk bleeding from the site
3. Decreasing edema formation
4. Formation of granulation tissue
Answer: 1. Return of distal pulses
Rationale:
Escharotomies are performed to relieve the compartment syndrome that can occur when
edema forms under nondistensible eschar in a circumferential third-degree burn. The
escharotomy releases the tourniquet-like compression around the arm. Escharotomies are
performed through avascular eschar to subcutaneous fat. Although bleeding may occur from
the site, it is considered a complication rather than an anticipated therapeutic outcome.
Usually, direct pressure with a bulky dressing and elevation control the bleeding, but
occasionally an artery is damaged and may require ligation. Escharotomy does not affect the
formation of edema.
Formation of granulation tissue is not the intent of an escharotomy.
10. The nurse is caring for a client who sustained superficial partial- thickness burns on the
anterior lower legs and anterior thorax. Which finding does the nurse expect to note during
the resuscitation/emergent phase of the burn injury?
1. Decreased heart rate
2. Increased urinary output
3. Increased blood pressure
4. Elevated hematocrit levels
Answer: 4. Elevated hematocrit levels
Rationale:
The resuscitation/emergent phase begins at the time of injury and ends with the restoration of
capillary permeability, usually at 48 to 72 hours following the injury. During the
resuscitation/emergent phase, the hematocrit level increases to above normal because of
hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to
0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours
after injury. Initially, blood is shunted away from the kidneys and renal perfusion and
glomerular filtration are decreased, resulting in low urine output. The burn client is prone to
hypovolemia and the body attempts to compensate by increased pulse rate and lowered blood
pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as
a result of the large fluid shifts.
11. The nurse is administering fluids intravenously as prescribed to a client who sustained
superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of
fluid resuscitation, the nurse understands that which assessment would provide the most
reliable indicator for determining the adequacy?
1. Vital signs
2. Urine output
3. Mental status
4. Peripheral pulses
Answer: 2. Urine output
Rationale:
Successful or adequate fluid resuscitation in the client is signaled by stable vital signs,
adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most
reliable indicator for determining adequacy of fluid resuscitation, especially in a client with
burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.
12. The nurse is caring for a client following an autograft and grafting to a burn wound on the
right knee. What would the nurse anticipate to be prescribed for the client?
1. Out-of-bed activities
2. Bathroom privileges
3. Immobilization of the affected leg
4. Placing the affected leg in a dependent position
Answer: 3. Immobilization of the affected leg
Rationale:
Autografts placed over joints or on the lower extremities after surgery often are elevated and
immobilized for 3 to 7 days. This period of immobilization allows the autograft time to
adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted
leg dependent would put stress on the grafted wound.
13. The health education nurse provides instructions to a group of clients regarding measures
that will assist in preventing skin cancer. Which instructions should the nurse provide? Select
all that apply.
1. Sunscreen should be applied every 8 hours.
2. Use sunscreen when participating in outdoor activities.
3. Wear a hat, opaque clothing, and sunglasses when in the sun.
4. Avoid sun exposure in the late afternoon and early evening hours.
5. Examine your body monthly for any lesions that may be suspicious.
Answer: 2. Use sunscreen when participating in outdoor activities.
3. Wear a hat, opaque clothing, and sunglasses when in the sun.
5. Examine your body monthly for any lesions that may be suspicious.
Rationale:
The client should be instructed to avoid sun exposure between the hours of brightest sunlight:
10 a.m. and 4 p.m. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for
outdoor activities. The client should be instructed to examine the body monthly for the
appearance of any cancerous or any precancerous lesions. Sunscreen should be reapplied
every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is
reduced.
14. The community health nurse is visiting a homeless shelter and is assessing the clients in
the shelter for the presence of scabies. Which assessment finding should the nurse expect to
note if scabies is present?
1. Brown-red macules with scales
2. Pustules on the trunk of the body
3. White patches noted on the elbows and knees
4. Multiple straight or wavy threadlike lines underneath the skin
Answer: 4. Multiple straight or wavy threadlike lines underneath the skin
Rationale:
Scabies can be identified by the multiple straight or wavy threadlike lines beneath the skin.
The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs.
The eggs hatch in a few days, and the baby mites find their way to the skin surface, where
they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.
15. The nurse is concerned about potential skin integrity problems for an unconscious client.
Which interventions would be most appropriate to include in the plan of care for this client?
Select all that apply.
1. Reposition every 2 hours.
2. Use a bed cradle as indicated.
3. Apply protective pads to heels and elbows.
4. Add a small amount of alcohol to the daily bath water.
5. Provide perineal care every 8 hours and after incontinence.
Answer: 1. Reposition every 2 hours.
2. Use a bed cradle as indicated.
3. Apply protective pads to heels and elbows.
5. Provide perineal care every 8 hours and after incontinence.
Rationale:
Unconscious clients are completely immobile, having lost the protective reflexes to shift
body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause
skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours.
Use of a bed cradle can protect the client's toes from breakdown due to weight from linens.
Protective pads can be applied to the heels and elbows to reduce friction and shear.
Appropriate perineal care is essential to keep waste products from excoriating the skin. The
nurse can reduce skin dryness and irritation by adding a superfatty solution (such as baby oil
or castile soap) to the daily bath water. Drying agents such as alcohol are avoided because
dry skin can crack and break down.
16. The emergency department nurse is caring for a client who has sustained chemical burns
to the esophagus after ingestion of lye. The nurse reviews the health care provider's
prescriptions and should plan to question which prescription?
1. Gastric lavage
2. Intravenous (IV) fluid therapy
3. Nothing by mouth (NPO) status
4. Preparation for laboratory studies
Answer: 1. Gastric lavage
Rationale:
The client who has sustained chemical burns to the esophagus is placed on NPO status, is
given IV fluids for replacement and treatment of possible shock, and is prepared for
esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies
also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are
avoided to prevent further erosion of the mucosa by the irritating substances that these
treatments involve.
17. The nurse is conducting a screening program to identify clients at risk for an
integumentary disorder. Which client seen at the screening would most likely be at risk for
development of an integumentary disorder?
1. An athlete
2. An adolescent
3. An older client
4. A client who tans in an indoor tanning bed
Answer: 4. A client who tans in an indoor tanning bed
Rationale:
Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme
conditions can damage the skin, posing the highest risk for skin disorders. An athlete would
be at low risk of developing an integumentary problem. An adolescent may be prone to the
development of acne, but this does not occur in all adolescents. An older client may be at a
higher risk than a younger person.
18. The nurse is providing information to a client scheduled for a skin biopsy. The client asks
the nurse how painful the procedure is. The nurse should make which response to the client?
1. "The procedure is painless."
2. "A preoperative medication will put you to sleep."
3. "An analgesic will be prescribed after the procedure."
4. "The local anesthetic may cause a stinging sensation."
Answer: 4. "The local anesthetic may cause a stinging sensation."
Rationale:
A skin biopsy is not painless. The most common source of pain during a skin biopsy is the
initial local anesthetic, which can produce a burning or stinging sensation. A preoperative
medication that puts the client to sleep is not a component of this procedure. Analgesics may
be prescribed after the procedure, but this option does not address the issue related to the
amount or type of pain associated with the procedure itself.
19. The nurse is reviewing the discharge instructions for the client who had a skin biopsy.
Which statement, if made by the client, would indicate a need for further instruction?
1. "I will keep the dressing dry."
2. "I will watch for any drainage from the wound."
3. "I will use the antibiotic ointment as prescribed."
4. "I will return tomorrow to have the sutures removed."
Answer: 4. "I will return tomorrow to have the sutures removed."
Rationale:
Sutures usually are removed 7 to 10 days after a skin biopsy, depending on health care
provider (HCP) preference. After a skin biopsy, the nurse instructs the client to keep the
dressing dry and in place for a minimum of 8 hours as prescribed. After the dressing is
removed, the site is cleaned once a day with tap water or saline to remove any dry blood or
crusts. The HCP may prescribe an antibiotic ointment to minimize local bacterial
colonization. The nurse instructs the client to report any redness or excessive drainage at the
site. The site may be closed with sutures or may be allowed to heal without suturing.
20. The nurse prepares to assist the health care provider to examine the client's skin with a
Wood's lamp. Which should be included in the preprocedure plan of care?
1. Shave the skin site.
2. Prepare a local anesthetic.
3. Obtain an informed consent.
4. Tell the client that the procedure is painless.
Answer: 4. Tell the client that the procedure is painless.
Rationale:
A Wood's light examination is a painless procedure. The skin does not need to be shaved, and
a local anesthetic is not necessary. Examination of the skin under a Wood's lamp is always
carried out in a darkened room. This is a noninvasive examination; therefore, an informed
consent is not required. A hand-held long-wavelength ultraviolet light source or Wood's lamp
is used. Areas of blue-green or red fluorescence are associated with certain skin infections.
21. The home care nurse visits an older client who was discharged from the hospital after
diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which
measure should the nurse recommend for the client to alleviate this discomfort?
1. Run a dehumidifier in the home.
2. Apply astringents to the skin twice daily.
3. Apply emollients to the skin after bathing.
4. Take baths twice daily using a dilute solution of alcohol and water.
Answer: 3. Apply emollients to the skin after bathing.
Rationale:
One bath or one shower per day for 15 to 20 minutes with warm water and a mild soap
should be followed immediately by the application of an emollient to prevent evaporation of
water from the hydrated epidermis. The client should avoid using a dehumidifier because this
will further dry room air. The client should be instructed to avoid applying rubbing alcohol,
astringents, or other drying agents to the skin. A bath using a dilute alcohol solution will
cause further drying of the skin.
22. The nurse is providing an educational session to community members regarding Lyme
disease. The nurse should provide what information regarding this disease?
1. It is caused by a tick bite.
2. It can be contagious by skin contact with an infected person.
3. It can be caused by the inhalation of spores from bird droppings.
4. It is caused by contamination from cat feces or the consumption of rare or raw meat.
Answer: 1. It is caused by a tick bite.
Rationale:
Lyme disease is a multisystem infection that results from a bite by a tick that is usually
carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the
spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from 1 person to
another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.
Toxoplasmosis is caused from the inhalation of cysts from contaminated cat feces or the
consumption of rare or raw meat.
23. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left
leg, and a nursing student is assigned to provide care for the client. The nursing instructor
asks the student to describe this diagnosis. Which answer demonstrates the student's
understanding of the diagnosis?
1. "It is an acute superficial infection."
2. "It is an inflammation of the epidermis."
3. "Staphylococcus is the cause of this epidermal infection."
4. "This skin infection involves the deep dermis and subcutaneous fat."
Answer: 4. "This skin infection involves the deep dermis and subcutaneous
fat."
Rationale:
Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red
erythema without sharp borders and spreads widely through tissue spaces. The skin is
erythematous, edematous, tender, and sometimes nodular. Options 1, 2, and 3 are incorrect
descriptions.
24. The nurse expects to note which prescription for a client with a skin infection that extends
into the dermis?
1. Applying warm compresses to the affected area
2. Placing iced compresses to the affected area every 4 hours
3. Alternating the application of hot and iced compresses every 2 hours
4. Placing antibiotic ointment on the affected site followed by continuous heat lamp
application
Answer: 1. Applying warm compresses to the affected area
Rationale:
Warm compresses may be prescribed to decrease the discomfort, erythema, and edema
associated with a skin infection that is characteristic of cellulitis. The nurse should also
provide supportive care as prescribed to manage associated symptoms such as fever or chills.
After tissue and blood are obtained for culture, antibiotics are initiated. Heat lamps can cause
more disruption to already inflamed tissue. Iced compresses are not prescribed because they
can damage tissue.
25. The nurse is performing an assessment on a client suspected of having herpes zoster. The
nurse would expect to note which types of lesions on inspection of the client's skin?
1. Clustered skin vesicles
2. A generalized body rash
3. Small blue-white spots with a red base
4. A fiery-red edematous rash on the cheeks
Answer: 1. Clustered skin vesicles
Rationale:
The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles
on an erythematous base along a dermatome. Because they follow nerve pathways, the
lesions do not cross the body's midline. Options 2, 3, and 4 are incorrect descriptions.
26. The nurse is providing instructions regarding skin care to a client after removal of a leg
cast. The nurse should instruct the client to take which measure?
1. Avoid the use of sunscreen on the skin for at least 2 years.
2. Apply an emollient lotion to the skin to enhance softening.
3. Scrub the skin vigorously with soap and water to remove the dead skin.
4. Soak the skin for 1 hour 6 times daily to assist in removing any dry scales.
Answer: 2. Apply an emollient lotion to the skin to enhance softening.
Rationale:
The skin under a casted area may be discolored and crusted with dead skin layers. The client
should gently soak and wash the skin for the first few days; however, soaking for 1 hour 6
times daily is excessive and could lead to skin breakdown. The skin should not be scrubbed
vigorously because this action also could lead to skin breakdown. The skin should be patted
dry, and a lubricating lotion should be applied. The client should avoid overexposing the skin
to the sunlight.
27. A client sustains a burn injury to the entire right and left arms, the right leg, and the
anterior thorax. According to the rule of nines, the nurse would assess that this injury
constitutes which body percentage? Fill in the blank.
Answer: 54%
Rationale:
According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%.
The right leg is equal to 18% and the left leg is equal to 18%.
The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is
equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right
and left arms were burned, according to the rule of nines, the total area involved would be
54%.
28. The nurse has applied a hypothermia blanket to a client with a fever. A priority for the
nurse is to inspect the skin frequently to detect which complication of hypothermia blanket
use?
1. Frostbite
2. Skin breakdown
3. Venous insufficiency
4. Arterial insufficiency
Answer: 2. Skin breakdown
Rationale:
When a hypothermia blanket is used, the skin is inspected frequently for pressure points,
which over time could lead to skin breakdown. Options 1, 3, and 4 are not complications.
29. A client with severe psoriasis has a problem of chronic low self-esteem. The nurse should
incorporate which nursing action when working with this client?
1. Listening attentively
2. Keeping communications brief
3. Approaching the client in a formal manner
4. Avoiding looking at the affected skin areas
Answer: 1. Listening attentively
Rationale:
Clients with chronic skin disorders may experience chronic low self-esteem because of the
disorder itself and possible rejection by others. The nurse demonstrates acceptance of the
client by using a quiet, unhurried manner and by using appropriate visual contact, facial
expression, and therapeutic touch. Communications that seem brief and formal may reinforce
the feelings of rejection, as may avoidance of looking at the affected skin areas.
30. A client is admitted to the hospital emergency department after receiving a burn injury in
a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very
painful. The nurse determines that this client's burn should be classified as which type?
1. Superficial
2. Full-thickness
3. Deep partial-thickness
4. Partial-thickness superficial
Answer: 2. Full-thickness
Rationale:
Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat
layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic.
Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar
formation. Some nerve endings have been damaged, and the area may be insensitive to touch,
with little or no pain.
31. A client who is being evaluated for thermal burn injuries to the arms and legs complains
of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?
1. Allow the client to have full liquids.
2. Give the client small glasses of clear liquids.
3. Order the client a full meal tray with extra liquids.
4. Keep the client on NPO (nothing by mouth) status.
Answer: 4. Keep the client on NPO (nothing by mouth) status.
Rationale:
The client should be maintained on NPO status because burn injuries frequently result in
paralytic ileus. The client also should be told that fluids could cause vomiting because of the
effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as
appropriate to alleviate the sensation of thirst.
32. A client has sustained a superficial skin tear to the arm. The nurse should apply which
dressing as the best type of bandage for this wound?
1. Dry sterile dressing
2. Wet to dry dressing
3. Gelfoam sponge dressing
4. Semipermeable film dressing
Answer: 4. Semipermeable film dressing
Rationale:
Semipermeable film dressings are used on superficial wounds, on ulcers, and occasionally on
some deep, draining, or necrotic ulcers. These dressings have the advantage of staying in
place for several days, allowing tissues to heal underneath. Dry sterile dressings would stick
to the wound and are inappropriate. Wet to dry dressings are unnecessary because the tissue
does not need debridement. Gelfoam sponge dressings are a type of enzyme dressing used in
the treatment of necrotic tissue.
33. A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place
after suffering bilateral burns to the legs. The nurse determines that the client's
gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment?
1. Gastric pH of 3
2. Absence of abdominal discomfort
3. GI drainage that is guaiac negative
4. Presence of hypoactive bowel sounds
Answer: 1. Gastric pH of 3
Rationale:
The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and
histamine 2 (H2) receptor–blocking agents. Lowered pH (to the acidic range) in the absence
of food or tube feedings can lead to erosion of the gastric lining and ulcer development.
Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The
client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube
intake.
34. The nurse has a prescription to get a client who is paraplegic out of bed and into a chair.
The nurse determines which item would be best to put in the chair under the client?
1. Pillow
2. Foam pad
3. Folded blankets
4. Plastic-lined absorbent pad
Answer: 2. Foam pad
Rationale:
The client who cannot shift weight unassisted should have a pressure relief pad in place under
the buttocks to prevent skin breakdown. The best products for this purpose are those that have
a tendency to equalize the client's weight on the pad. These include foam, water, gel, and
alternating air products. A pillow provides cushion but does not distribute weight equally. A
plastic-lined pad and folded blankets provide no pressure relief.
35. A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse
should tell the client to take which measure?
1. Maintain room humidity at less than 40%.
2. Use very hot or very cold water for bathing.
3. Apply emollients once the skin is thoroughly dry.
4. Avoid bathing in the shower or tub more than once daily.
Answer: 4. Avoid bathing in the shower or tub more than once daily.
Rationale:
Several things may be done to promote hydration of the skin. The client should limit tub or
shower bathing to once daily or every other day and should sponge bathe on the other days.
Room humidity should be maintained at greater than 40%. Bath water should be between
95°F and 100°F (35°C to 37.8°C) (tepid) and not very hot or very cold. Harsh soaps should
be avoided, and emollients should be applied generously to skin while it is still damp.
36. A client has undergone laser surgery to remove 2 nevi. The nurse determines that the
client has understood discharge instructions if the client makes which statement?
1. "I can expect significant discomfort after the procedure."
2. "I need to cleanse the operated areas daily using scrubbing motions."
3. "I need to protect the operated areas from direct sunlight for at least
3 months."
4. "I need to report any signs of swelling or redness immediately to the health care provider."
Answer: 3. "I need to protect the operated areas from direct sunlight for at least 3 months."
Rationale:
After laser surgery to remove any type of skin lesion, the skin should be protected from direct
sunlight for a minimum of 3 months. There should be minimal or no discomfort after the
procedure, and, if present, the discomfort should be relieved easily with acetaminophen. The
operated area should be cleansed gently with half-strength hydrogen peroxide twice a day
after the dressing is removed (24 hours after the procedure). Redness and swelling are
expected after this procedure.
37. A client is seen in the ambulatory care clinic for a superficial burn to the arm. On
assessing the skin at the burn injury, what will the nurse observe?
1. White color
2. Pink or red color
3. Weeping blisters
4. Insensitivity to pain and cold
Answer: 2. Pink or red color
Rationale:
Superficial burns are pink or red without any blistering. The skin blanches to touch, may be
edematous and painful, and heals on its own, usually within 1 week. A white color
characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness
superficial burns. Deep full- thickness burns are associated with insensitivity to pain and
cold.
38. The nurse provides home care instructions to a client diagnosed with impetigo. Which
statement by the client indicates the need for further instruction?
1. "I need to continue with the antibiotics as prescribed."
2. "I need to wash my hands thoroughly and frequently throughout the day."
3. "I should wash my dishes separately from those of other household members."
4. "It is not necessary to separate my linens and towels from those of other household
members."
Answer: 4. "It is not necessary to separate my linens and towels from those of other
household members."
Rationale:
The client needs to separate his or her linens and towels from those of other household
members. Thorough hand washing, separating linens and towels, and separate washing of the
client's dishes are required because the infection is contagious so long as skin lesions are
present. Antibiotics are administered and should be continued as prescribed.
39. The nurse has been working with the client diagnosed with candidiasis (thrush). What
should the nurse assess for in this client?
1. The presence of blisters
2. The presence of white patches
3. The presence of purple patches
4. The presence of numerous small, red, pinpoint lesions
Answer: 2. The presence of white patches
Rationale:
Assessment of the client with candidiasis (thrush) will reveal white patches on the tongue,
palate, and buccal mucosa. The lesions adhere firmly to the tissues and are difficult to
remove. The lesions often are referred to as "milk curds" because of their appearance. Clients
often describe the lesions as dry and hot. Options 1, 3, and 4 are not characteristics of thrush.
40. The nurse has provided instructions to a client with pruritus regarding measures to relieve
the discomfort. Which statement, if made by the client, indicates a need for further
instruction?
1. "I should use tepid water for bathing."
2. "I need to keep my skin lubricated and cool."
3. "After bathing, I should pat my skin dry rather than rubbing it."
4. "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."
Answer: 4. "I should apply a lubricant to my skin after bathing when my skin is thoroughly
dry."
Rationale:
The client should be instructed that a lubricant is applied immediately after the bath, while
the skin is still damp, to help increase hydration of the stratum corneum. Options 1, 2, and 3
are appropriate home care measures to control the symptoms associated with pruritus.
41. The nurse is preparing to perform an assessment on a client being seen in the clinic. On
review of the client's record, the nurse notes that the client has psoriasis. The nurse would
expect to observe which characteristics on assessment of the client's psoriatic lesions? Select
all that apply.
1. Red, raised papules
2. Large plaques covered by silvery scales
3. Tiny red vesicles that weep serous material
4. Erythema noted mostly under the breast area
5. Pink to dark red, patchy eruptions on the skin
Answer: 1. Red, raised papules
2. Large plaques covered by silvery scales
Rationale:
Psoriasis lesions appear as red, raised papules that may coalesce into large plaques covered
by silvery scales. Eczema can manifest as tiny red vesicles that weep serous or purulent
material. Erythema noted mostly under the breast area is characteristic of seborrheic
dermatitis. Pink to dark red, patchy eruptions on the skin may be indicative of exfoliative
dermatitis.
42. The nurse is caring for a client who was admitted to the burn unit after sustaining a burn
injury covering 30% of the body. What is the most appropriate time frame for the emergent
phase?
1. The entire period of time during which rehabilitation occurs
2. The period from the time the client is stable to the time when all burns are covered with
skin
3. The period from the time the burn was incurred to the time when the client is admitted to
the hospital
4. The period from the time the burn was incurred to the time when the client is considered
physiologically stable
Answer: 4. The period from the time the burn was incurred to the time when the client is
considered physiologically stable
Rationale:
The emergent phase of burn care generally extends from the time the burn injury is incurred
until the time when the client is considered physiologically stable. The acute phase lasts until
all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5
years for an adult and includes reintegration into society.
43. Respiratory Question: The nurse in the post-anesthesia care unit is monitoring a client for
signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding
may be occurring?
1. Frequent swallowing
2. Client complaints of discomfort
3. Ecchymosis around the client's eyes
4. Blood on the external nasal dressing
Answer: 1. Frequent swallowing
Rationale:
The client should be assessed for frequent swallowing, which may be the only sign of
bleeding. Bleeding may not always be externally visible after rhinoplasty because blood may
run down the back of the client's throat. The surgical procedure and the packing may be
uncomfortable, so discomfort is expected, and analgesics would be prescribed. The area
around the client's eyes is expected to be edematous and ecchymotic, and ice compresses are
applied. Some blood on the external nasal dressing is expected.
44. Respiratory Question: The nurse is providing home care instructions to a client after
rhinoplasty. Which statement by the client indicates a need for further instruction?
1. "I should sleep on 2 pillows to elevate my head."
2. "I should avoid any activities such as bending over."
3. "I should be sure to run a dehumidifier in my home."
4. "I need to sneeze through the mouth and not blow through the nose."
Answer: 3. "I should be sure to run a dehumidifier in my home."
Rationale:
After rhinoplasty, the client is taught to sleep on at least 2 pillows; this elevates the head and
reduces edema. The client also is told to avoid any activities, such as bending over, that
would increase intracranial pressure and cause nasal bleeding. A humidifier (not a
dehumidifier) decreases the dry throat associated with mouth breathing. The client should be
instructed to sneeze through the mouth and not blow through the nose.
45. Respiratory Question: A client is seen in the health care clinic 2 weeks after rhinoplasty.
The client tells the nurse that the upper lip is numb. Which nursing response would be
appropriate?
1. "The numbness is normal and is likely to be permanent."
2. "In many cases the nose and upper lip are numb for up to 6 months."
3. "Numbness usually indicates nerve damage that occurred during the procedure."
4. "You will need to see the health care provider because this may indicate a complication of
the procedure."
Answer: 2. "In many cases the nose and upper lip are numb for up to 6 months."
Rationale:
The nurse should instruct the client that after this procedure ecchymosis will last
approximately 2 weeks, and the nose and upper lip may be numb for approximately 6
months. Options 1, 3, and 4 are inappropriate and inaccurate nursing responses.
46. A client is admitted to the hospital with a partial-thickness skin loss and blister on the
sacrum. The nurse should develop a plan of care for which stage of pressure ulcer? Refer to
Figure.
View Figure
1. Stage I ulcer
2. Stage II ulcer
3. Stage III ulcer
4. Stage IV ulcer
Answer: 2. Stage II ulcer
Rationale:
A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as
an abrasion, a shallow crater, or a blister. A stage I ulcer is characterized by a reddened area
and intact skin. Stage III ulcers are full-thickness lesions of the skin. Stage IV ulcers also are
full-thickness lesions, with exposed muscle, bone, or supportive tissue.
47. A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What
should the nurse include in client teaching to maximize the effects of the treatment?
1. Rub the application into the skin.
2. Place the area under a heat lamp for 20 minutes.
3. Apply a dry sterile dressing over the affected area.
4. Cover the application with a warm, moist dressing and an occlusive outer wrap.
Answer: 4. Cover the application with a warm, moist dressing and an occlusive outer wrap.
Rationale:
Penetration of topical corticosteroid therapy can be enhanced by applying warm, moist heat
and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or similar
item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12
hours per day to minimize local and systemic adverse effects. The medication is applied but
not rubbed into the skin. Dry sterile dressings are not used. A heat lamp can cause a burn
injury.
IMPORTANT Note: Please note that the nurse would be concerned about the potential for
systemic absorption of the topical corticosteroid if it’s being applied to a reddened, itchy area
underneath an occlusive dressing.
48. The nurse performs an assessment on a client admitted with contact dermatitis. Which
signs and symptoms should the nurse look for?
1. Lichenification with scaling and excoriation
2. Lesions with well-defined geometric margins
3. Bright red erythematous macules and papules
4. Evolution of lesions from vesicles to weeping papules and plaques
Answer: 2. Lesions with well-defined geometric margins
Rationale:
Contact dermatitis findings include skin lesions with well-defined geometric margins. Option
1 describes a medication eruption. Option 3 describes nonspecific eczematous dermatitis.
Option 4 describes atopic dermatitis.
49. The nurse is teaching the client about risk factors for skin cancer. Which statements by
the client indicate that teaching was successful? Select all that apply.
1. "I have to avoid excessive exposure to sunlight."
2. "My dark skin color predisposes me to skin cancer."
3. "I am at higher risk for skin cancer because my mother had one."
4. "I am at higher risk for skin cancer because I am 20 years old."
5. "I am immune to skin cancer because I work as a pest control exterminator."
Answer: 1. "I have to avoid excessive exposure to sunlight.
3. "I am at higher risk for skin cancer because my mother had one."
Rationale:
Options 1 and 3 describe risk factors for skin cancer. Additional risk factors for skin cancer
include age greater than 60 years, light-colored skin, and occupation exposure to arsenic,
which is commonly used in pest control.
50. The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus
the assessment on which structures? Select all that apply.
1. Lips
2. Tongue
3. Earlobes
4. Conjunctiva
5. Mucous membranes
Answer: 1. Lips
4. Conjunctiva
5. Mucous membranes
Rationale:
Changes in skin color can be difficult to assess in the dark-skinned client. Color changes are
most easily seen in areas of the body where the epidermis is thin and in areas where
pigmentation is not influenced by exposure to sunlight. The nurse should assess the lips,
conjunctiva, and oral mucous membranes for signs of anemia in the dark-skinned client.
Signs of anemia are less easily observed in the tongue and earlobes.
51. The nurse is providing teaching to a client who will undergo chemotherapy for cancer,
and alopecia is expected from the chemotherapeutic agent. Which statement made by the
client indicates a need for further teaching?
1. "Excessive hair brushing should be avoided."
2. "I can't believe my hair loss will be permanent."
3. "I guess I'll have to stop using my electric hair dryer and curling rod."
4. "I will have my hair stylist cut my hair short just before I start my treatments."
Answer: 2. "I can't believe my hair loss will be permanent."
Rationale:
Alopecia refers to loss of hair and is a temporary side effect of many chemotherapeutic
agents. Excessive brushing and use of electric appliances on the hair may hasten hair loss
once chemotherapy is started. Cutting the hair short before starting the chemotherapy helps
the client to gradually adapt to the loss.
52. The nurse is caring for a client with full-thickness circumferential burns of the entire
trunk of the body. Which finding suggests that an escharotomy may be necessary?
1. Pallor of all extremities
2. Pulse oximetry reading of 93%
3. Peripheral pulses are diminished
4. High pressure alarm keeps sounding on the ventilator
Answer: 4. High pressure alarm keeps sounding on the ventilator
Rationale:
A client with a circumferential burn of the entire trunk likely will be on a ventilator because
of the potential for breathing to be affected by this injury. The high pressure alarm will sound
on the ventilator when there is any kind of obstruction. If the chest cannot expand due to
restriction by eschar and increasing edema, this results in obstruction.
53. The nurse is planning care for a client who suffered a burn injury and has a negative selfimage related to keloid formation at the burn site. The keloid formation is indicative of which
condition?
1. Nerve damage
2. Hypertrophy of collagen fibers
3. Compromised circulation at the burn site
4. Increase in subcutaneous tissue at the burn site
Answer: 2. Hypertrophy of collagen fibers
Rationale:
Keloids are visible as excessive scar formation and result from hypertrophy of collagen
fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides
blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides
for heat insulation, mechanical shock absorption, and caloric reserve.
54. The nurse observes the client's sacrum and notes the following. How will the nurse
document this in the client's medical record? Refer to figure.
View Figure
1. Deep tissue injury
2. Stage II pressure ulcer
3. Stage III pressure ulcer
4. Stage IV pressure ulcer
Answer: 4. Stage IV pressure ulcer
Rationale:
In a stage IV pressure ulcer there is full-thickness tissue loss with exposed bone, tendon, or
muscle. Eschar or slough may be present in some parts of the wound. In a stage II pressure
ulcer there is partial-thickness loss of the dermis manifesting as a shallow open ulcer with a
pink/red wound bed and no slough. In a stage III pressure ulcer there is full-thickness tissue
loss with subcutaneous fat visible but no exposure of tendon or muscle, and slough may be
present. Deep tissue injury appears as localized areas of purple or maroon discolored intact
skin or a blood-filled blister.
55. A client exhibits erythema of the skin. The nurse plans care, knowing that which factors
are responsible for this finding? Select all that apply.
1. Fever
2. Vasodilation
3. Inflammation
4. Deoxygenated hemoglobin
5. Excessively high environmental temperature
Answer: 1. Fever
2. Vasodilation
3. Inflammation
5. Excessively high environmental temperature
Rationale:
Erythema (or redness) of the skin can be caused by vasodilation from high environmental
temperatures, fever, or inflammation. The presence of deoxygenated hemoglobin is
responsible for cyanosis of the skin.
56. An older client is lying in a supine position. The nurse understands that the client is at
least risk for skin breakdown in which body area?
1. Heels
2. Sacrum
3. Back of the head
4. Greater trochanter
Answer: 4. Greater trochanter
Rationale:
The greater trochanter is at greater risk of skin breakdown from excessive pressure when the
client is in the side-lying position. When the client is lying supine, the heels, sacrum, and
back of the head all are at risk, as are the elbows and scapulae.
57. In planning care for the client with psoriasis, the nurse understands that which represents
a priority client problem?
1. Fatigue
2. Constipation
3. Impaired safety
4. Altered body image
Answer: 4. Altered body image
Rationale:
Psoriasis is an autoimmune dermatitis that is expressed as silvery scales on reddish-colored
skin on areas such as scalp, elbows, hands, and knees. Onset of the disease generally occurs
before age 40, with symptoms varying in intensity from mild to severe. Skin disorders,
particularly when experienced by young persons and particularly when visible on exposed
body parts, can cause significant psychosocial distress. Altered body image is a priority client
problem that should be considered when planning care for a client with psoriasis. The
remaining options are not priority client problems associated with psoriasis.
58. A client exhibits a purplish bruise to the skin after a fall. The nurse would document this
finding in the health record most accurately using which term?
1. Purpura
2. Petechiae
3. Erythema
4. Ecchymosis
Answer: 4. Ecchymosis
Rationale:
Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term
that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are
another form of purpura. Erythema is an area of redness on the skin.
59. A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be
used for final coverage of the client's burn wound?
1. Biobrane
2. Autograft
3. Homograft
4. Xenograft
Answer: 2. Autograft
Rationale:
A full-thickness burn will require terminal coverage with an autograft–the client's own skin.
Biobrane is porcine collagen bonded to a silicone membrane, which is temporary and lasts
anywhere from 10 to 21 days. Homografts (cadaveric skin) and xenografts (pigskin) provide
temporary coverage of the wound by acting as a dressing for up to 3 weeks before rejecting.
60. The nurse is providing instructions to a client with psoriasis who will be receiving
ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to
include in the client's instructions?
1. "Each treatment will last at least 30 minutes."
2. "Your entire body will be exposed to the light treatment."
3. "You will need to wear cotton clothes during the treatment."
4. "You will need to wear dark eye goggles during the treatment."
Answer: 4. "You will need to wear dark eye goggles during the treatment."
Rationale:
Safety precautions are required during UV light therapy. Protective dark eye goggles are
required to prevent exposure of the eyes to the UV light; it may be necessary to wear the
goggles for the remainder of the day following treatment. The face also is shielded with a
loosely applied cloth if it is unaffected by the psoriasis. Most UV light therapies require the
client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client
will not wear clothing on the body parts to be exposed and will expose only those areas
requiring treatment to the UV light. Direct contact with the lightbulbs used for the treatment
should be avoided to prevent burning of the skin.
61. The nurse in the surgical care center will be assisting the health care provider to perform a
punch biopsy of a client's skin lesion. Which interventions should be included in the
preprocedure plan of care? Select all that apply.
1. Obtain an informed consent.
2. Clean the area of the lesion with water.
3. Prepare to apply direct pressure to the biopsy site after the procedure.
4. Tell the client that a small piece of tissue will be removed for examination.
5. Teach the client about the need to cleanse the site post procedure with hydrogen peroxide
and a topical corticosteroid every 4 hours.
Answer: 1. Obtain an informed consent.
3. Prepare to apply direct pressure to the biopsy site after the procedure.
4. Tell the client that a small piece of tissue will be removed for examination.
Rationale:
The nurse would obtain an informed consent from the client because the procedure is
invasive. The nurse would cleanse the biopsy site with an antibacterial solution (not water)
before the biopsy. The client is informed that a small piece of tissue will be removed for
examination. Direct pressure is applied to the area to stop bleeding after the procedure. In the
postprocedure period, the client is usually directed to keep the site clean and dry; antibiotic
ointment may be prescribed, but normally a topical corticosteroid is not necessary.
62. The nurse is reviewing the health care records of clients scheduled to be seen at a health
care clinic. The nurse determines that which client is at the greatest risk for development of
an integumentary disorder?
1. An adolescent
2. An older woman
3. A physical education teacher
4. An outdoor construction worker
Answer: 4. An outdoor construction worker
Rationale:
Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. The
outdoor construction worker would fit into a high-risk category for the development of an
integumentary disorder {An outdoor construction is at very high risk to develop SKIN
CANCER secondary to prolonged exposure to sunlight}. An adolescent may be prone to the
development of acne, but this does not occur in all adolescents. Immobility and lack of
nutrition would increase the older client's risk, but the older client is not at as high a risk as
the outdoor construction worker. The physical education teacher is at low or no risk of
developing an integumentary problem.
63. A client scheduled for a skin biopsy is concerned and asks the nurse how painful the
procedure is. Which statement is the appropriate response by the nurse?
1. "There is no pain associated with this procedure."
2. "The local anesthetic may cause a burning or stinging sensation."
3. "A preoperative medication will be given so you will be sleeping and will not feel any
pain."
4. "There is some pain, but the health care provider will prescribe an opioid analgesic after
the procedure."
Answer: 2. "The local anesthetic may cause a burning or stinging sensation."
Rationale:
Depending on the size and location of the lesion, a biopsy is usually a quick and almost
painless procedure. The most common source of pain is the administration of the initial local
anesthetic, which can produce a burning or stinging sensation. Preoperative medication is not
necessary with this procedure. Opioid analgesics are not necessary following the procedure.
64. The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for
this procedure?
1. Ensure that the consent form has been signed.
2. Ensure that a Foley catheter has been inserted.
3. Provide chlorhexidine wipes to be used before the procedure.
4. Verify the blood bank has 1 unit of packed red blood cells available if needed.
Answer: 1. Ensure that the consent form has been signed.
Rationale:
A punch biopsy involves use of a punch instrument that punctures the skin and is rotated to
obtain some of the dermis and fat. It is used for diagnostic purposes. A signed consent form is
required for this procedure. A Foley catheter is not indicated and should be avoided if
possible for any condition or procedure due to the risk for catheter-associated urinary tract
infection. Chlorhexidine wipes are not specifically indicated for this procedure; usually an
antibacterial such as povidone-iodine is used. There is not typically a lot of bleeding with this
procedure; therefore, units of blood are not typically made available for the client undergoing
punch biopsy.
65. The nurse prepares to assist a health care provider who is examining a client's skin with a
Wood's light. Which step should the nurse include in the plan for this procedure?
1. Prepare a local anesthetic.
2. Obtain an informed consent.
3. Darken the room for the examination.
4. Shave the skin and scrub with povidone-iodine solution.
Answer: 3. Darken the room for the examination.
Rationale:
Examination of the skin under a Wood's light is always carried out in a darkened room. The
procedure is painless. This is a noninvasive examination; therefore, an informed consent is
not required. A hand-held, long-wavelength ultraviolet light or Wood's light is used. The skin
does not need to be shaved and a local anesthetic is not necessary. Areas of blue- green or red
fluorescence are associated with certain skin infections.
66. The nurse prepares to treat a client with frostbite of the toes. Which action should the
nurse anticipate will be prescribed for this condition?
1. Rapid and continuous rewarming of the toes after flushing returns
2. Rapid and continuous rewarming of the toes in cold water for 45 minutes
3. Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes
4. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin
occurs
Answer: 4. Rapid and continuous rewarming of the toes in a warm water bath until flushing
of the skin occurs
Rationale:
Acute frostbite is treated ideally with rapid and continuous rewarming of the tissue in a warm
water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or
interrupted periods of warmth are avoided because they can contribute to increased cellular
damage. Cold or hot water is not used. Thawing can cause considerable pain, and the nurse
administers analgesics as prescribed.
67. The presence of which finding leads the home health nurse to suspect infestation of a
client with scabies?
1. Patchy hair loss and round red macules with scales
2. The presence of white patches scattered about the trunk
3. Multiple straight or wavy, threadlike lines beneath the skin
4. The appearance of vesicles or pustules with a thick honey-colored crust
Answer: 3. Multiple straight or wavy, threadlike lines beneath the skin
Rationale:
Scabies can be identified by the presence of multiple straight or wavy, threadlike lines
beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the
skin and lays its eggs. The eggs hatch in a few days, and the baby mites find their way to the
skin surface, where they mate and complete the life cycle. Options 1, 2, and 4 are not
characteristics of scabies.
68. The nurse suspects herpes zoster (shingles) when which assessment finding is noted?
1. Clustered skin vesicles
2. A generalized body rash
3. Small blue-white spots with a red base
4. A fiery red, edematous rash on the cheeks
Answer: 1. Clustered skin vesicles
Rationale:
The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles
on an erythematous base along a dermatome. Because the lesions follow nerve pathways,
they do not cross the midline of the body. Options 2, 3, and 4 are incorrect descriptions of
herpes zoster.
69. Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a
client with psoriasis, and the nurse provides instructions to the client regarding the treatment.
Which statement by the client indicates a need for further instruction?
1. "Treatments are limited to 2 or 3 times a week."
2. "The UV light treatments are given on consecutive days."
3. "Eye goggles need to be worn to prevent exposure to UV light."
4. "Just the area requiring treatment should be exposed to the UV light."
Answer: 2. "The UV light treatments are given on consecutive days."
Rationale:
UV light treatments are limited to 2 or 3 times a week and are not given on consecutive days.
Safety precautions are required during UV light therapy. It is best to expose only those areas
requiring treatment to the UV light. Protective wraparound goggles prevent exposure of the
eyes to UV light. The face should be shielded with a loosely applied pillowcase if it is
unaffected. Direct contact with the lightbulbs of the treatment unit should be avoided to
prevent burning of the skin.
70. The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse
anticipates that which interventions will be prescribed for the client? Select all that apply.
1. Antibiotic therapy
2. Cold compresses to the affected area
3. Warm compresses to the affected area
4. Intermittent heat lamp treatments 4 times daily
5. Alternating hot and cold compresses continuously
Answer: 1. Antibiotic therapy
3. Warm compresses to the affected area
Rationale:
Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep
red erythema without sharp borders and spreads widely throughout tissue spaces. Warm
compresses may be used to decrease the discomfort, erythema, and edema. After tissue and
blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive
care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia.
Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and
alternating cold and hot compresses are not the best measures.
71. Which individuals are most likely to be at risk for development of psoriasis? Select all
that apply.
1. A 32-year-old African American
2. A woman experiencing menopause
3. A client with a family history of the disorder
4. An individual who has experienced a significant amount of emotional distress
5. A female client with a thin body frame who adheres to a regular exercise program
Answer: 2. A woman experiencing menopause
3. A client with a family history of the disorder
4. An individual who has experienced a significant amount of emotional distress
Rationale:
Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results
in psoriatic patches. Various forms exist, with psoriasis vulgaris being the most common
type. Possible causes of the disorder include stress, trauma, infection, hormonal changes,
obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a
cause. The disorder also may be exacerbated by the use of certain medications. Psoriasis
occurs equally among women and men, although the incidence is lower in darker-skinned
races and ethnic groups.
72. A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland
(Baxter) formula, the minimum fluid requirements are which during the first 24 hours after
the burn?
1. 1200 mL of 5% dextrose in water solution
2. 2400 mL of 0.45% normal saline solution
3. 4800 mL of 0.9% normal saline solution
4. 9600 mL of lactated Ringer's solution
Answer: 4. 9600 mL of lactated Ringer's solution
Rationale:
The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight ×
percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL.
73. The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding
indicates adequate fluid resuscitation?
1. Disorientation to time only
2. Heart rate of 95 beats/minute
3. +1 palpable peripheral pulses
4. Urine output of 30 mL over the past 2 hours
Answer: 2. Heart rate of 95 beats/minute
Rationale:
When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as
indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by
determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the
client is oriented to client, place, and time.
74. The nurse is assessing a dark-skinned client for the presence of petechiae. Which body
area is the best for the nurse to check in this client?
1. Sclera
2. Oral mucosa
3. Soles of the foot
4. Palms of the hand
Answer: 2. Oral mucosa
Rationale:
In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa and
in areas of lighter melanization such as the abdomen and buttocks. Jaundice would best be
noted in the sclera of the eye.
Cyanosis is best noted on the palms of the hands and soles of the feet.
75. The nurse is performing assessment of the client who is admitted with left leg cellulitis.
What does the nurse anticipate finding on the assessment of the left lower extremity?
1. Pallor
2. Cyanosis
3. Erythema
4. Jaundice
Answer: 3. Erythema
Rationale:
Cellulitis presents with erythema (redness), which is localized inflammation. Options 1, 2,
and 4 are not signs or symptoms of cellulitis.
76. A client complains of chronic pruritus. Which diagnosis should the nurse expect to note
documented in the client's medical record that would support this client's complaint?
1. Anemia
2. Hypothyroidism
3. Diabetes mellitus
4. Chronic kidney disease
Answer: 4. Chronic kidney disease
Rationale:
Clients with chronic kidney disease often have pruritus, or itchy skin. This is because of
impaired clearance of waste products by the kidneys. The client who is markedly anemic is
likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with
diabetes mellitus are at risk for skin infections and skin breakdown.
77. A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash
noted across the nose. The nurse interprets that this finding is consistent with early
manifestations of which disorder?
1. Hyperthyroidism
2. Pernicious anemia
3. Cardiopulmonary disorders
4. Systemic lupus erythematosus (SLE)
Answer: 4. Systemic lupus erythematosus (SLE)
Rationale:
An early sign of SLE is the appearance of a butterfly rash across the nose.
Hyperthyroidism often leads to moist skin and increased perspiration. Pernicious anemia is
exhibited by pale skin. Severe cardiopulmonary disorders may lead to clubbing of the fingers.
78. The nurse is teaching a client about changes in body image related to chronic obstructive
pulmonary disease (COPD). Which statement by the client would indicate that teaching was
successful?
1. "My nails may become clubbed."
2. "My nails may have multiple small pits."
3. "I may develop flattening of the nail plate."
4. "I may develop horizontal depressions on my nails."
Answer: 1. "My nails may become clubbed."
Rationale:
A client with COPD will have clubbing of the nails, described as an angle between the nail
plate and the proximal nail fold exceeding 180 degrees. Psoriasis is represented by multiple
small pits in the nail bed. Flattening of the nail plate is caused by several conditions, such as
iron deficiency anemia and poorly controlled diabetes for greater than 15 years. Horizontal
depression across the nail beds is caused by medical problems, such as acute, severe illness
and isolated periods of severe malnutrition.
79. The nurse is teaching a client who is preparing for discharge from the hospital after
having a stroke about prevention of pressure ulcers while the client has limited mobility.
Which statement by the client indicates the need for further teaching?
1. "I will inspect my skin daily."
2. "I can sit in my favorite chair all day."
3. "I need to drink at least 2 liters of fluid daily."
4. "I will make sure that my skin is clean and well moisturized."
Answer: 2. "I can sit in my favorite chair all day."
Rationale:
Sitting in one position all day can be a risk factor for pressure ulcer development. Options 1,
3, and 4 are preventative measures for pressure ulcer development.
80. The nurse is caring for a client with a diabetic ulcer. What discharge instructions should
the nurse provide to the client? Select all that apply.
1. Wash feet with hot water daily.
2. Use a mild soap when washing the feet.
3. Use lanolin on the feet to prevent dryness.
4. Wear open-toed shoes to allow air flow to the feet.
5. Exercise the feet daily by walking and flexing at the ankle.
Answer: 2. Use a mild soap when washing the feet.
3. Use lanolin on the feet to prevent dryness.
5. Exercise the feet daily by walking and flexing at the ankle.
Rationale:
The client with a diabetic ulcer needs to take strict precautions and implement very specific
measures to allow for wound healing. Interventions include washing the feet with warm (not
hot) water daily with a mild soap, using lanolin to prevent drying and cracking, wearing
closed-toed shoes that are well fitting and avoiding high-heel and open-toed shoes, and
exercising the feet daily by walking and flexing at the ankle to promote circulation.
81. An older client has been lying in a supine position for the past 3 hours. The nurse who is
repositioning this client would be most concerned with examining which bony prominences
of the client? Select all that apply.
1. Heels
2. Ankles
3. Elbows
4. Sacrum
5. Back of the head
6. Greater trochanter
Answer: 1. Heels
3. Elbows
4. Sacrum
5. Back of the head
Rationale:
When the client is lying supine, the heels, sacrum, and back of the head are all at risk, as are
the elbows and scapulae. The greater trochanter and ankles are at greater risk of skin
breakdown from excessive pressure when the client is in the side-lying position.
82. An adult client trapped in a burning house has suffered burns to the back of the head, the
upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what
percentage does the nurse determine the extent of the burn injury to be? Fill in the blank.
Answer: 22.5%
Rationale:
According to the rule of nines, the posterior side of the head equals 4.5%, the back of both
arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%.
83. The nurse is planning care for a client returning from the operating room after having an
autograft applied to the right lower extremity. Which nursing intervention is focused on
promoting graft "take"?
1. Monitor temperature every 4 hours.
2. Leave the dressing intact for 3 to 5 days.
3. Maintain the right lower extremity in a dependent position.
4. Apply an ice pack to the site to decrease edema formation.
Answer: 2. Leave the dressing intact for 3 to 5 days.
Rationale:
After surgery, graft sites are immobilized with bulky cotton pressure dressing for 3 to 5 days
to allow vascularization, or "take," of the newly grafted skin. Dressings should not be
disturbed. Elevation and complete rest of the grafted area is required to allow blood vessels to
connect the graft with the wound bed. Any activity that might cause movement of the
dressing against the body and separation of the graft from the wound is prohibited, such as
application of an ice pack. Additionally, cold promotes vasoconstriction.
