FUNDAMENTALS 1023 Integumentary disorders Quiz with Correct Answers

NURS 1023 Integumentary disorders When assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is: Correct response: • maintaining the client's fluid, electrolyte, and acid-base balance. A nurse is caring for a client who was admitted to the burn unit after suffering burns from a house fire. During the acute phase of a burn, the nurse should collect data on which topic? Correct response: • circulatory status A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client? Correct response: • "Cover the area when in direct sunlight." A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client? Correct response: • Wound care nurse The nurse is performing wound care on a client. Which task indicates surgical asepsis? Correct response: • Preparing sterile surgical instruments for the physician to debride the wound A client with a sacral pressure ulcer is limited to 2 hours of sitting in a chair twice per day. She is scheduled for physical therapy three times per day and dressing changes twice per day. How can a nurse best coordinate this client's care? Correct response: • Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session. A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize? Correct response: • lean meats and low-fat milk A client is prescribed methotrexate 25 mg by mouth as a single weekly dose. The pharmacy dispenses 2.5-mg scored tablets. How many tablets should the nurse instruct the client to consume to achieve the prescribed dose? Record your answer using a whole number. Correct response: • 10 A child was found unconscious at home and brought to the emergency department by the fire and rescue unit. While collecting data, the nurse observes cherry-red mucous membranes, nail beds, and skin. Which cause is the most likely explanation for the child’s condition? Correct response: • Carbon monoxide poisoning The nurse observes a ring-shaped rash that has a red raised border and a clearer center on the upper arm. The client asks the nurse what kind of rash it is. What is the best response by the nurse? Correct response: • tinea corporis A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition? Correct response: • carbon monoxide poisoning A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition? Correct response: • carbon monoxide poisoning The nurse is reading the progress notes for a client who has a pressure ulcer. Based on the nurse’s note in the chart shown, what stage pressure ulcer does this client have? Correct response: • stage II A 2-year-old child has been diagnosed with cellulitis. The health care provider has order the client to get ceftriaxone 50 mg IM. The pharmacy sends 100 mg/2 mL. The nurse will administer the medication in the vastus lateralis. How many milliliters should be administered? Record your answer using a whole number. Correct response: • 1 A 6-year-old child has had a recent diagnosis of Lyme disease. Which medication would the nurse expect the health care provider to order if the child has an allergy to penicillin? Correct response: • cefuroxime The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it is meant to protect? Correct response: • ring or donut The licensed practical nurse is collecting a wound culture from a client's gaping surgical incision. Which would the nurse consider to ensure proper culture collection? Correct response: • Gently roll a sterile swab from the center of the wound outward to collect drainage. When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include? Select all that apply. Correct response: • Monitor the skin for breakdown daily during client’s bath. • Keep skin clean and dry to prevent breakdown. • Turn and reposition the client every two hours. The nurse is working in a long-term-care facility and receives an admission to the unit. After performing the initial survey, the nurse documents a stage 2 pressure ulcer. Which graphic illustrates a stage 2 pressure ulcer? Correct response: • The nurse is reinforcing education to parents of an infant about burn prevention. Which instructions should be reinforced regarding burns from tap water? Correct response: • Before putting the infant in the tub, test the water with a hand. When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should: Correct response: • wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious. A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should monitor the client for which adverse reaction to this drug? Correct response: • Ototoxicity The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect? Correct response: • Ring or donut Which intervention has the highest priority when providing skin care to a bedridden client? Correct response: • Keeping the skin clean and dry without using harsh soaps A nurse is instructing a group of nursing assistants about client care. The nurse tells them to turn clients how often to prevent skin breakdown? Correct response: • Every 2 hours Which action by the nurse displays client advocacy during a skin assessment? Correct response: • Ensuring client privacy by pulling the curtain closed A nurse is caring for a client who is at risk for skin breakdown. To decrease the risk, the nurse must help ensure that the client remains adequately hydrated. Which action can the nurse take to help determine the client's fluid needs? Correct response: • Measure intake and output. A postoperative client has just been admitted to a unit from the postanesthesia care unit (PACU). When should the nurse change the dressing for the first time? Correct response: • after the surgeon changes the first dressing and provides the written orders The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is most important for the nurse to tell the client? Correct response: • Avoid exposure to sun. A client admitted with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take? Correct response: • Obtain oxygen saturation using pulse oximetry. A family that recently went camping brings their child to the clinic with a report of a rash after a tick bite. Which finding should the nurse expect to see in a child with Lyme disease? Correct response: • bright rash with red outer border circling the bite site The nurse is obtaining data from a child who is suspected of having a scabies infestation. What finding by the nurse would correlate with this diagnosis? Correct response: • pruritic papules, pustules, and linear burrows of the finger and toe webs The nurse is examining the back of a client and notes a rash with a discrete lesion configuration. Which graphic shows a discrete lesion configuration? Correct response: • The nurse is caring for a 15-year-old who has suffered third degree burns to 30% total burn surface area (TBSA). The health care provider has order morphine 0.5 mg by mouth every 3 to 4 hours as needed for pain. The elixir comes in 2mg/1 ml. How many milliliters would the nurse give? Record your answer using two decimal places. Correct response: • 0.25 The nurse is caring for a 4-year-old with a full-thickness burn. Before sending the child to hydrotherapy for a scheduled wound debridement, which nursing action is a priority? Correct response: • Implement pain control measures. The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce? Correct response: • Take the drug 1 hour before or 2 hours after meals with large amounts of water. The nurse is gathering data from a child that has a rash on the face, trunk, and extremities, but not on the palms of the hand. Which disorder should the nurse suspect this child may have? Correct response: • measles The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply. Correct response: • Keep cuts and scrapes clean and covered. • Wash hands with soap and water regularly. • Avoid sharing towels and razors with others. The nurse is collecting data from several clients at the clinic. Which client does the nurse determine is most likely receive the Zostavex vaccine for the prevention of shingles? Correct response: • 62-year-old client that had a mild case of shingles 4 years previously A college student living in the dormitory comes to the school health clinic stating, “I think I have ringworm on the bottom of my foot.” What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply. Correct response: • Be sure to wear shower shoes when using a public shower. • Change socks at least once a day. • Keep skin clean and dry. A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? Correct response: • Scale A 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? Correct response: • "Apply sunscreen even on overcast days." 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: Correct response: • cancer of the cervix. In the client with burns on the legs, which nursing intervention helps prevent contractures? Correct response: • Applying knee splints A nurse is reinforcing education for a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates that education has been effective? Correct response: • "I'll eat plenty of fruits and vegetables." While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members 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: Correct response: • "All family members will need to be treated." The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the: Correct response: • risk manager. A client understands what resources are available to help him perform wound care at home when he states the following: Correct response: • "Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need." Laboratory test results confirm that a client's wound is infected with methicillin- resistant staphylococcus aureus. Which type of isolation precautions should the nurse institute for this client? Correct response: • Contact A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse calculates that he has sustained burns to which percentage of his body? Correct response: • 27% A client develops wound evisceration following abdominal surgery. Which intervention should be the nurse’s priority for this client? Correct response: • covering the protruding internal organs with sterile gauze moistened with sterile saline The nurse is gathering data from a child suspected of being a victim of abuse. What observation by the nurse would lead to this suspicion? Correct response: • contusions of the back and buttocks Which statement would the nurse include when reinforcing education for a parent about salmon patches (stork bites)? Correct response: • “They’re benign and usually fade in adult life.” A licensed practical nurse is assisting a triage nurse in the emergency department admit a client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Correct response: • 36 The nurse is caring for a female client who is planning to start isotretinoin in 3 months. What should the nurse be sure to include in the instructions for the administration of this medication? Correct response: • Now is the time to begin contraceptive precautions. A nurse is caring for a 12-year-old child with a diagnosis of eczema. Which nursing interventions are appropriate for a child with eczema? Correct response: • Administer tepid baths, and use moisturizers immediately after the bath. The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing? Correct response: • wash hands thoroughly The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis? Correct response: • dry, cracked lips, strawberry tongue The nurse is gathering data from a child that has a rash on the face, trunk, and extremities, but not on the palms of the hand. Which disorder should the nurse suspect this child may have? Correct response: • measles A client arrives in the clinic dressed with long sleeves and long pants in the summer and states, “I have to cover these lesions, they look awful. I have plaque psoriasis.” What data gathered and documented by the nurse would correlate with the client’s statement? Select all that apply. Correct response: • red, raised patches on the skin • silvery white coated patches • reports of itching During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? Correct response: • Beau's line The nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp? Correct response: • Behind the ears The nurse is collecting data on a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem? Correct response: • Urine output of 20 ml/hour A client is diagnosed with primary herpes genitalis. Which instruction should the