SKIN / BURN / ULCERS
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
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
The clinic nurse notes that the primary 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
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 only in body area exposed to outdoor sunlight
, When assessing a lesion diagnosed as basal cell carcinoma, the nurse most
likely expects to note which findings? Select all that apply.
1. An irregularly shaped lesion
2. A small papule with a dry, rough scale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a central crater and a waxy border
5. Location in the bald spot atop the head that is exposed to outdoor
sunlight
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
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
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%
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?
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
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
The clinic nurse notes that the primary 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
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 only in body area exposed to outdoor sunlight
, When assessing a lesion diagnosed as basal cell carcinoma, the nurse most
likely expects to note which findings? Select all that apply.
1. An irregularly shaped lesion
2. A small papule with a dry, rough scale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a central crater and a waxy border
5. Location in the bald spot atop the head that is exposed to outdoor
sunlight
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
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
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%
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?
