RN Integumentary System EAQ EXAM Latest Version

What could be the possible cause of a scald injury? Contact with grease Contact with hot liquids or steam Contact with alkali in oven cleaners Contact with open flame in house fires Which complication may be caused by sepsis in burns? Diarrhea Constipation Paralytic ileus Curling’s ulcer What is a clinical manifestation of hypernatremia in burns? Fatigue Seizures Paresthesias Cardiac dysrhythmias The nurse is teaching the client about wound healing. Which feature is associated with the "maturation phase" of normal wound healing? The scar is firm and inelastic on palpation. Fibrin strands form a scaffold or framework. White blood cells migrate into the wound. Epithelial cells are grown over the granulation tissue bed. which key feature does the nurse associate with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage to the subcutaneous tissues Appearance of a reddened area over a bony prominence Which type of biopsy would the nurse identify as required for removal of entire lesions on the skin? Punch biopsy Shave biopsy Incisional biopsy Excisional biopsy Which test would the client undergo to receive a diagnosis of systemic lupus erythematosus? Patch test Photo patch test Direct immunofluorescence test Indirect immunofluorescence test Which benign condition of the client’s skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells? Nevi Psoriasis Acne vulgaris Plantar warts Which type of allergic skin condition in a client is associated with immunological irregularity, asthma, and allergic rhinitis? Urticaria Psoriasis Acne vulgaris Atopic dermatitis Which does the nurse understand related to negative pressure wound therapy? Select all that apply. Using a suction pump Treating necrotizing infections Administering oxygen under high pressure Application of a low-voltage current to a wound area Reducing chronic ulcers by removing fluids from the wound Which clinical manifestation is associated with cellulitis? Lymphadenopathy Occasional papules Vesicles that evolve into pustules Isolated erythematous pustules Which surgery is used to treat excessive wrinkling or sagging of facial skin? Rhinoplasty Rhytidectomy Dermabrasion Blepharoplasty Which skin infection would cause facial paralysis? Herpes zoster Herpes simplex Dermatophytosis Which secondary skin lesion may include athlete’s foot as an example? Scar Scale Ulcer Fissure Which component of skin maintains optimal barrier function? Keratin Melanin Collagen Adipose tissue A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client? Highly contagious Caused by a fungus Chronic with exacerbations Associated with other allergies Which drug is a newer treatment option for treating metastatic melanoma? Lomustin Ipilimumab Carmustine Temozolomide A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. Which is the nurse’s best response? "This type of schedule gives noncancerous cells time to recover." "The department only operates from Monday through Friday." "Your energy level will be increased greatly by a 5-day schedule." "Side effects are eliminated when treatment is administered for 5 rather than 7 days." Which clinical finding occurs due to thinning of the subcutaneous layer? Decreased tone and elasticity Decreased sensory perception Increased risk for hypothermia Increased susceptibility to dry skin The nurse is caring for a client who has been bitten by a raccoon. The client states, "Where I live, there seems to be raccoons and wild animals everywhere." Which information should the nurse consider about rabies when planning care for this client? Rabies is a bacterial infection characterized by encephalopathy and opisthotonos. Rabies is an acute bacterial septicemia that results in convulsions and a morbid fear of water. Rabies is a nonspecific immune response to organisms deposited under the skin by an animal bite. Rabies is an acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system. A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers? Avoiding leg massages Frequent repositioning of client Increasing fiber content in food Encouraging weight-bearing exercises What is an example of third spacing in a burn injury? Blister formation Edema formation Fluid mobilization Fluid accumulation A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse’s priority concern? Loss of skin integrity caused by the burns Potential infection as a result of the burn injury Inadequate gas exchange caused by smoke inhalation Decreased fluid volume because of the depth of the burns Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins? Drug eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatit Which drug can cause chemical burns? Anthralin Prednisone Tazarotene Calcipotriene Which infection is caused due to fungus? Furuncle Folliculitis Herpes zoster Dermatophytosis Which condition is an example of a bacterial infection? Impetigo Candidiasis Plantar warts Verucca vulgaris During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? Hypokalemia and hyponatremia Hyperkalemia and hyponatremia Hypokalemia and hypernatremia Hyperkalemia and hypernatremia How would the nurse describe the exudate characteristic of a serosanguineous wound? Greenish-blue pus Creamy yellow pus Blood-tinged amber fluid Beige pus with a fishy odor The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? Fluid volume Skin integrity Physical mobility Urinary elimination Which type of laser is used in the treatment of vascular and other pigmented lesions? Argon Gold vapors Neodymium Carbon dioxide What are the side effects of oral psoralen in phototherapy? Select all that apply. Atrophy Sunburn Mucositis Occular damage Persistent pruritus A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse’s conclusion? Decreased rate of glomerular filtration Excessive blood loss through the burned tissues Plasma proteins moving out of the intravascular compartment Sodium retention occurring as a result of the aldosterone mechanism Which benign condition shows silver scaly plaques on the skin? Nevi Psoriasis Urticaria Acne vulgaris The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches the most effective method for putting out the flames. Which information from the group members indicates successful learning? Wrap hand with towel and slap at the flames. Instruct the victim to roll on the ground. Pour cold liquid over the flames. Remove the victim’s burning clothes. What is the mechanism of action for wet-to-damp saline-moistened gauze for wound debridement? Promoting the dilution of viscous exudate Removing the necrotic tissue mechanically Causing a breakdown of the denatured protein of eschar Promoting the spontaneous separation of necrotic tissue Which skin color alteration may be observed in a client diagnosed with methemoglobinemia? Red Blue White Yellow-orange Which characteristic does the nurse associate with a punch biopsy? It is usually indicated for superficial or raised lesions. It is more uncomfortable than other biopsies while healing. It is performed using a circular cutting instrument 2 to 6 mm in diameter. It removes only the portion of the skin that rises above the surrounding tissue. Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor? Proteus Bacteroides Pseudomonas Staphylococcus The nurse is caring for two clients with a below-the-knee amputation. The first client was in a motor vehicle collision. The second client had chronically decreased arterial perfusion. Which information has caused the nurse to conclude that the postoperative courses of these two clients may differ? The first client probably will adjust more quickly. The second client’s incision will take longer to heal. These clients are likely to have very different occupations. The first client is more likely to have phantom limb sensations. Which description is associated with fissures? Deep erosions that extend beneath the epidermis Thinning of the skin surface with a loss of skin markings Linear cracks in the epidermis that extend into the dermis Thickened areas of epidermis with accentuated skin markings Which description describes a coalesced type of skin lesion configuration? Lesions are well defined with sharp borders. Lesions merge together and appear confluent. Lesions are ringlike around flat centers of skin. Lesions have wavy borders that resemble a snake. The nurse is caring for a client with burns and reviews the client’s laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? Azotemia Hypokalemia Metabolic alkalosis Respiratory alkalosis Which statement by the nurse is true regarding dandruff? "It is a problem of excessive oil production." "It can occur as a side effect of drug therapy." "It is associated with tenderness of the scalp." "It is a manifestation of hormonal imbalance." A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client? This decreases catabolism to promote healing at the site of injury. This lowers the metabolic rate in an attempt to help reduce the fever. This reduces the energy demands on the body in the presence of infection. This limits muscle contractions that may force causative organisms into the bloodstream. A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client’s burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? Equal Unrelated Inversely related Directly proportional Which dermatologic problem is treated by using intralesional corticosteroids? Psoriasis Cellulitis Erysipelas Carbuncles What would the nurse state is a cause of systemic altered inflammatory response in impaired wound healing? Uremia Cirrhosis Leukemia Hypovolemia What is the source of an Integra graft? Porcine skin Cadaveric skin Glycosaminoglycan bonded to silicone membrane Porcine collagen bonded to silicone membrane What would the nurse state is a serious side effect of x-rays? Vesicles Papular Desquamation Plaque-like lesions Which fungal infection does the client refer to as jock itch? Tinea pedis Tinea cruris Tinea corporis Tinea unguium Which predisposing condition may be present in a client with pitting edema? Shock Kidney disease Hypothyroidism Severe dehydration A nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond? Instruct the client to take a friend along for safety. Encourage participation in this activity, because it provides excellent range-ofmotion exercise. Explain that the incision should not be immersed in water until it has healed. Let the client know that swimming can substitute for the prescribed physical therapy. A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan? "Rinse the mouth three times a day with lemon juice and water." "Brush the teeth once daily and use dental floss after each meal." "Clean the mouth with a soft toothbrush or a gentle spray." "Gently clean the mouth with commercial mouthwash." A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client asks what to do about itchy dry skin? What is the best response by the nurse? Wear plenty of warm clothes to keep moisture in the skin. Use a moisturizer on the skin daily to help reduce itching. Take hot tub baths only twice a week to reduce drying of the skin. Expose the skin to the air to help reduce the sensation of itching. A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. What could be the possible condition in the client? Tinea pedis Tinea cruris Tinea corporis Tinea unguium A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up? "I will leave the skin markings intact." "I will protect the skin from sources of heat." "I will wear soft clothing over the upper body." "I will use an oatmeal-based lotion after each treatment." A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? Bathing will not be permitted. Dressings will be changed daily. Personal protective equipment will be worn by staff. Room temperature will be kept below 72° F (22.2° C). What is the color of a client’s wound caused by skin tears? Red Gray Black Yellow While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent the development of pneumonia. Which other complication can be prevented through this nursing intervention? Renal calculi Disorientation Pressure ulcers Urinary infection A 23-year-old client has white hair. Which change in the hair is responsible for this condition? Decreased oils Decreased density Decreased estrogen levels Decreased melanocytes While assessing the skin of a client, the nurse observes a lesion that has a wavy border. Which type of lesion is present in the client? Annular Circinate Coalesced Serpiginous A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? Trimming toenails so that they are short and rounded Checking bathwater temperature by putting the toes in first Using alcohol to rub hands, feet, legs, and arms at least two times a day Seeking professional treatment for any minor injuries to the extremities A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client’s admission and identifies the client’s potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client’s diet? Milk Tea Orange juice Tomato juice Which complications does the nurse anticipate in the client who has blue-colored nail beds? Thrombocytopenia Polycythemia vera Methemoglobinemia Cardiopulmonary disease Which physical changes may cause longitudinal nail ridges? Decreased rate of growth Decreased cell division Decreased blood flow Decreased vitamin D production Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? Utricaria A drug reaction Atopic dermatitis Allergic contact dermatitis A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? Readiness to discuss the client’s deformities Indication of a change in family relations Need for more time to think about the future Beginning realization of implications for the future Which fungal infection in a client is commonly referred to as athlete’s foot? Tinea pedis Tinea cruris Tinea corporis Tinea unguium Which technique would the nurse describe as promoting autolysis in the spontaneous separation of necrotic tissue? Continuous wet gauze Moisture-retentive dressing Topical enzyme preparations -Wet-to-dry damp saline moistened gauz A client sustained minor skin injuries following an accident. Which event occurs close to the time of injury? Thinning of the scar tissue Formation of granulation tissue Migration of leukocytes to the site of injury Arrival of fibroblasts to the site of infection A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care? Use a consistent approach to care and encourage participation. Prepare equipment while doing the procedure and explain the treatment to the client. Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature. Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done. A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? Provide low-sodium milk. Provide high-protein drinks. Provide foods that are low in potassium. Provide 10% more calories in the form of fats. Which condition will the nurse monitor for in a client with interruption of venous return? Tenting Varicosity Petechiae Ecchymosis Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply. Dryness Photoaging Vascular lesions Wrinkling of skin Benign neoplasm A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? 20 25 30 36 A dark-skinned client has a gray-colored tongue and lips. Which complication does the nurse suspect? Cyanosis Jaundice Bleeding Inflammation Which physiologic activity is associated with the "proliferative phase" of normal wound healing? White blood cells migrate into the wound Epithelial cells grow over the granulation tissue bed Scar tissue gradually becomes thinner and pale in color Vasodilation occurs with increased capillary permeability Which practice would be suitable in the prevention of a pressure ulcer? Positioning a client directly on the trochanter Keeping the client’s skin directly off plastic surfaces Keeping the head of the bed elevated above 30 degrees Placing a rubber ring or donut under the client’s sacral area The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance? T-tube movement increases. Pain at the incision site increases. The nasogastric tube gets irritating. The bandage on the abdomen is constricting. Which integumentary change is associated with delayed wound healing in a client? Decreased cell division Decreased epidermal thickness Decreased immune system cells Increased epidermal permeability Which drug is prescribed for the client to treat severe nodulocystic acne? Imiquimod Isotretinoin Clindamycin Corticosteroids What is the function of the dermis? Provides cells for wound healing Assists in retention of body heat Acts as mechanical shock absorber Inhibits proliferation of microorganisms A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve? Increasing mobility Preventing contractures Limiting orthostatic hypotension Preventing pressure on peripheral blood vessels A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. Which initial response by the nurse is best? "Why did you sign the consent?" "Can you tell me why you decided to refuse the procedure?" "You are obviously afraid about something concerning the procedure." "Although the procedure is very important, I understand why you changed your mind." A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. Which condition will the nurse most closely assess the client for during the return visit to the radiology department? Ataxia Hypoxia Arthralgia Dysphagia A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? Client with shock Client with anemia Client with epilepsy Client with peripheral vascular disease Which nursing assessment finding is associated with chronic eczema? Localized edema Rough and thick skin Decreased skin turgor Increased skin temperature A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia (CREST syndrome). Which clinical indicators should the nurse expect to identify upon assessment? Select all that apply. Joint pain Masklike facies Esophageal dysmotility Spiderlike hemangiomas Episodic blanching of the fingers A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? Neurologic Wound Pain Skin Which gastrointestinal (GI) change may be found in the client with burn injuries? Abdominal distention Increased peristalsis Activation of GI motility Increased blood flow to the GI area The nurse is providing care for a client diagnosed with invasive pancreatic cancer. The client has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action should the nurse take postoperatively? Maintain intermittent low suction to limit trauma. Cleanse the area around the insertion site to prevent skin breakdown. Attach the tube to a negative-pressure drainage system to promote drainage. Reposition the client frequently to increase the flow of bile through the tube. Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? Tenting Angioma Varicosity Telangiectasia Which description is associated with a hematoma? The occurrence of redness in patches of variable size and shape The thickening of the skin with accentuated normal skin markings The visible swelling due to extravasation of blood of sufficient size The pinpoint, discrete deposits of blood in the extravascular tissues The client reports crumbly, discolored, and thickened toenails. What could be the possible reason for this condition? Allergy Insect bite Fungal infection Bacterial infection In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. Which statement from the client indicates a correct understanding of the nurse’s instructions? "I will sit in a chair for several hours every day." "I will inspect the incision for healing when I change the dressing." "I will check to see whether the staples have dissolved within a few days." "I will call the health care clinic if I see any clear drainage coming from the incision." A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey-colored crust and surrounded by erythema. Which infection is suspected by the primary healthcare provider? Shingles Impetigo Folliculitis Verruca vulgaris What should the nurse teach a client about how to care for the skin around a colostomy stoma? "Wash with soap and water." "Rinse the area with peroxide." "Apply a thick coat of an emollient." "Rub vigorously to remove hardened feces." Which changes to the client’s skin are caused by the atrophy of eccrine sweat glands? Bruises Dry skin Wrinkles Skin shearing A client visited the nurse with a complaint of chalk white patches on the skin. What could be the condition of the client? Vitiligo Jaundice Cyanosis Erythema A client arrives at the emergency department after being bitten by a dog. The bite involved tearing of skin and deep soft tissue injury. Which action should the nurse take first? Inform the owner of the dog about the client’s injury. Assess the