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Integumentary Disorders Nursing Test Banks With 100% Rationale answers |80 Questions and answers
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Integumentary Disorders Nursing Test Banks With 100% Rationale answers 1. integumentary Disorders NCLEX Practice Exam 2. Integumentary Disorders NCLEX Practice Exam 3. Integumentary Disorders NCLEX Practice Exam 4. Integumentary Disorders NCLEX Practice Exam 1 Integumentary Disorders NCLEX Practice Exam 1. 1. Question 1 point(s) When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority? o A. Ineffective airway clearance related to edema of the respiratory passages o B. Impaired physical mobility related to the disease process o C. Disturbed sleep pattern related to facility environment o D. Risk for infection related to breaks in the skin Correct Correct Answer: A. Ineffective airway clearance related to edema of the respiratory passages When caring for a client with upper torso burns, the nurse’s primar y goal is to maintain respiratory integrity. Therefore, option A should take the highest priority. Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal ha irs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. Option B: This nursing diagnosis isn’t appropriate because burns aren’t a disease. Note circulation, motion, and sensation of digits frequently. Edema may compromise circulation to extremities, potentiating tissue necrosis and the development of contractures. Option C: Disturbed sleep pattern may be appropriate, but don’t command a higher priority than the ineffective airway clearance because they don’t reflect immediately life -threatening problems. Initially, the patient may use denial and repression to reduce and filte r information that might be overwhelming. Some patients display a calm manner and alert mental status, representing a dissociation from reality, which is also a protective mechanism. Option D: Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage. Indicators of sepsis (often occurs with full -thickness burn) requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies. 2. 2. Question 1 point(s) In a female client with burns on the legs, which nursing intervention helps prevent contractures? A. Applying knee splints. B. Elevating the foot of the bed. C. Hyperextending the client’s palms. D. Performing shoulder range -of-motion exercises. Correct Correct Answer: A. Applying knee splints. Applying knee splints prevents leg contractures by holding the joints in a position of function. Maintain proper body alignment with supports or splints, especi ally for burns over joints. Promotes functional positioning of extremities and prevents contractures, which are more likely over joints. Option B: Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a pos ition of function. Medicate for pain before activity or exercise. Reduces muscle and tissue stiffness and tension, enabling the patient to be more active and facilitating participation. Option C: Hyperextending a body part for an extended time is inappropr iate because it can cause contractures. Incorporate ADLs with physical therapy, hydrotherapy, and nursing care. Combining activities produces improved results by enhancing the effects of each. Option D: Performing shoulder range -of-motion exercises can pre vent contractures in the shoulders, but not in the legs. Perform ROM exercises consistently, initially passive, then active. Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces lo ss of calcium from the bone. 3. 3. Question 1 point(s) 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? 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? B. “Use sunscreen with a sun protection factor of 6 or higher.” C. “Apply sunscreen even o n overcast days.” D. “When at the beach, sit in the shade to prevent sunburn.” Correct Correct Answer: C. “Apply sunscreen even on overcast days.” Sunscreen should be applied even on overcast days because the sun’s rays are as damaging then as on sunny days. Apply sunscreen to dry skin 15 minutes before going outside. Use at least 1 oz (2 tablespoons or enough to fill a shot glass) to cover the expos ed areas of the body. Don’t overlook often -forgotten places like the scalp, the back of the neck, the tops of the feet, and the ears. Reapply the sunscreen every 2 hours and after swimming, sweating, or towel -drying. Use a lip balm with an SPF of at least 15 too. Option A: The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. Wear protective clothing such as loose shirts with long sleeves, long pants, a wide -brimmed hat, and shoes. Keep in mind that clothes don’t protect the skin completely from the sun’s rays, so wear sunscreen too. Option B: The nurse should recommend sunscreen with a sun protection factor of at least 15. Choose a sunscreen with a sun protection factor (SPF) of 15 or more that’s waterproof or water -resistant. Never seek out the sun to get a tan. Like sunburn, a suntan damages the skin. Option D: Sitting in the shade when at the beach doesn’t guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun’s rays onto the skin. Head indoors right away if the skin starts to ache or tingle. 4. 4. Question 1 point(s) 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? A. 18% B. 27% C. 30% D. 36% Correct Correct Answer: D. 36% The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this clien t’s burns cover 36% of the body surface area. Option A: The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by trauma and emergency medicine providers to assess the total body surface area (TBSA) involved in burn patients. Measuremen t of the initial burn surface area is important in estimating fluid resuscitation requirements since patients with severe burns will have massive fluid losses due to the removal of the skin barrier.
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