Integumentary

100問 • 1年前

問題一覧

When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

In a female client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

A male client comes to the physician’s office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which instruction would best prevent skin damage?

“Apply sunscreen even on overcast days.”

A female client is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

Which nursing intervention can help a client maintain healthy skin?

Keep the client well hydrated.

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?

Related to percutaneous absorption of the topical corticosteroid

A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.

A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to this drug?

Ototoxicity

A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

“Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days.”

Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?

In long, even, outward, and downward strokes in the direction of hair growth

Nurse Meredith is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it’s meant to protect?

Ring or donut

Nurse Rudolf documents the presence of a scab on a client’s deep wound. The nurse identifies this as which phase of wound healing?

Migratory

In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?

A urine output consistently above 100 ml/hour

A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause:

diarrhea

A female client sees a dermatologist for a skin problem. Later, the nurse reviews the client’s chart and notes that the chief complaint was intertrigo. This term refers to which condition?

Irritation of opposing skin surfaces caused by friction

A male client visits the physician’s office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribe:

a topical agent.

While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate response from the nurse is:

“All family members will need to be treated.”

When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care?

Administering systemic antibiotics as prescribed

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

dislodge the autografts.

Nurse Troy discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:

isolate the client’s bed linens until the client is no longer infectious.

Dr. Smith prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?

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

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

range of motion.

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

pain management.

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

protect the graft from direct sunlight.

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

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

A female client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse teaches the client about the importance of protecting the skin from ultraviolet light before drug administration and for 8 hours afterward and stresses the need to protect the eyes. After administering medication for photochemotherapy, the client must protect the eyes for:

48 hours.

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

cancer of the cervix.

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

Direct pressure

Nurse Jay is performing wound care. Which of the following practices violates surgical asepsis?

Pouring solution onto a sterile field cloth

During the acute phase of a burn, the nurse in-charge should assess which of the following?

Circulatory status

Nurse Kate is changing a dressing and providing wound care. Which activity should she perform first?

Wash hands thoroughly.

Nurse May is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?

Post a turning schedule at the client’s bedside.

Nurse Jane formulates a nursing diagnosis of Impaired physical mobility for a client with third-degree burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?

Related to circumferential eschar

The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment?

Lips

Which of the following clients would least likely be at risk of developing skin breakdown?

A client with decreased sensory perception

The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse anticipates that which of the following will be prescribed for the client?

Warm compress to the affected area

The clinic nurse notes that the physician has documented a diagnosis of herpes zoster (shingles) in the male client’s chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made following which diagnostic test?

Culture of the lesion

The nurse is assigned to care for a female client with herpes zoster (Shingles). Which of the following characteristics would the nurse expect to note when assessing the lesions of this infection?

Clustered skin vesicles

When assessing a lesion diagnosed as malignant melanoma, the nurse in-charge most likely expects to note which of the following?

An irregular shaped lesion

The nurse prepares discharge instructions for a male client following cryosurgery for the treatment of a malignant skin lesion. Which of the following should the nurse include in the instruction?

Clean the site with hydrogen peroxide to prevent infection

Nurse Carl reviews the client’s chart and notes that the physician has documented a diagnosis of paronychia. Based on this diagnosis, which of the following would the nurse expect to note during the assessment?

Red shiny skin around the nail bed

A male client arrives at the emergency room and has experienced frostbites to the right hand. Which of the following would the nurse note on assessment of the client’s hand?

A white color to the skin, which is insensitive to touch

The evening nurse reviews the nursing documentation in the male 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 of the following would the nurse expect to note on assessment of the client’s sacral area?

Partial-thickness skin loss of the dermis

Nurse Ivy is implementing a teaching plan to a group of adolescents regarding the causes of acne. Which of the following is an appropriate nursing statement regarding the cause of this disorder?

“The actual cause is not known”

A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is. The appropriate response by the nurse is:

“The local anesthetic may cause a burning or stinging sensation”

The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching?

“I’ll eat plenty of fruits and vegetables.”

Following a small-bowel resection, a male client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:

pressurelike pain.

The nurse is assessing a male client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour

A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms?

Ecchymosis

An older client’s physical examination reveals the presence of a number of bright red-colored lesions scattered on the trunk and tights. The nurse interprets that this indicates which of the following lesions due to alterations in blood vessels of the skin?

Cherry angioma

A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions. The nurse expects that these lesions will appear to be

Net-like appearance

A male client seen in an ambulatory clinic has a butterfly rash across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders?

Systemic lupus erythematosus (SLE)

A female client with cellulites of the lower leg has had cultures done on the affected area. The nurse reading the culture report understands that which of the following organisms is not part of the normal flora of the skin?

Escherichia coli (E. coli)

Nurse Davis is documenting her observations of a patient who has experienced an allergic reaction, noting diffuse swelling involving the deeper skin layers. In her records, Nurse Davis identifies this finding as:

Angioneurotic edema

Nurse Martin is assessing a 29-year-old colleague who reports itching and a rash on both hands, suspecting contact dermatitis. To confirm the diagnosis of contact dermatitis, Nurse Martin understands that the rash should present as:

Linear streaks or patterns corresponding to the contact area.

Nurse Evans is reviewing the contraindications for the use of topical corticosteroids in a male patient with atopic dermatitis (eczema). She notes that one particular type of infection is a contraindication for the use of these medications. Which infection is it?

Viral infection.

Nurse Green is explaining different skin conditions to her patient. She describes a condition that occurs due to exposure to an allergen or direct chemical or mechanical irritation of the skin, followed by a rash upon subsequent exposure. Nurse Green is referring to:

Contact dermatitis.

Nurse Patel is developing a care plan for a 5-month-old infant diagnosed with atopic dermatitis. Her primary focus in managing the condition will be on which of the following nursing interventions?

Taking measures to protect the infant from infection.

Nurse Garcia is instructing a female client with atopic dermatitis who is about to undergo photochemotherapy. She emphasizes the importance of skin protection and informs the client about the necessary precautions to take before and after the treatment. According to Nurse Garcia, what specific precaution should the client take to protect her eyes during and after photochemotherapy?

Wear UV-blocking sunglasses during the treatment and for 24 hours post-treatment.

Nurse Miller is advising the parent of a nine-month-old infant on how to manage and prevent diaper dermatitis. Which of the following measures should Nurse Miller include in her teaching?

Stop giving the infant a new food that was introduced just before the rash appeared.

The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?

Auscultate breath sounds over the trachea and mainstem bronchi

When should ambulation be initiated in the client who has sustained a major burn?

As soon as possible after resolution of the fluid shift

Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

The client’s oxygen saturation is 97%.

Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?

Vitamin D

The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action?

Notify the burn emergency team.

Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment?

“My facial scars should be less severe with the use of this mask.”

A client is admitted to the hospital following a burn injury to the left hand and arm. The client’s burn is described as white and leathery with no blisters. Which degree of severity is this burn?

third-degree burn

Which of the following statements reflect the nursing management of the patient with a white phosphorus chemical burn?

Do not apply water to the burn.

Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?

Increased urine output, decreased urine specific gravity

What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

Cherry red color to the mucous membranes

During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

Increased serum creatinine level

A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned?

31%

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27%

The burned client’s family ask at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?

“When the burn wounds are closed.”

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?

Document the finding as the only action.

The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

Superficial

The nurse is caring for client with a new donor site that was harvested to treat a new burn. The nurse position the client to:

avoid pressure on the site

All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?

Serum potassium 7.5 mmol/L (mEq/L)

Which client factors should alert the nurse to potential increased complications with a burn injury?

The burned areas include the hands and perineum.

The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint?

Hip at zero flexion with leg flat

Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?

Handwashing on entering the client’s room

Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?

Document the finding as the only action.

Related to circumferential eschar

When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately?

Hoarseness of the voice

On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?

Fluid shift

The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action?

Loosen the dressing

The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?

Have the client turn the head from side to side 90 degrees every hour while awake.

The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response?

“To decrease hydrochloric acid production in the stomach and prevent ulcers.”

The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

Myocardial infarction 1 year ago

The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?

The danger of an overdose during fluid remobilization is reduced.

In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?

“In what exact place or space were you when you were burned?”

Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by:

Fluid shift from intravascular space to the interstitial space

The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?

Partial-thickness superficial

The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission?

Heart rate and rhythm

Which statement by the client indicates correct understanding of rehabilitation after burn injury?

“I will be fully recovered when I achieve the highest possible level of functioning that I can.”

If a client has severe bums on the upper torso, which item would be a primary concern?

Frequently observing for hoarseness, stridor, and dyspnea

Contractures are among the most serious long-term complications of severe burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures?

Helping the client to rest in the position of maximal comfort

Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

Changing gloves between wound care on different parts of the client’s body.

100

Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?

Crystalloids

Astignars random QS

Kyla Angelique Son · 19問 · 1年前

Astignars random QS