2020 NURS618 Saunders Medical Surgical Skin Integumentary Revised Question With Answers (115 Solved Questions)

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1NURS618SaundersMedSurgSkinIntegumentaryRevisedSaundersMed-SurgSkinIntegumentary1.Aclientcallstheemergencydepartmentandtellsthenursethathecamedirectlyintocontactwithpoisonivyshrubs.Theclienttellsthenursethathecannotseeanythingontheskinandasksthenursewhattodo.Thenurseshouldmakewhichresponse?1."Cometotheemergencydepartment."2."Applycalamine lotion immediately to theexposed skin areas."3."Takeashowerimmediately,latheringandrinsingseveraltimes."4."Itisnotnecessarytodoanythingifyoucannotseeanythingonyourskin."Answer:3."Takeashowerimmediately,latheringandrinsingseveraltimes."Rationale:

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2When an individualcomesin contactwith apoisonivyplant,the sapfromtheplant formsaninvisible filmon thehuman skin.The clientshouldbeinstructedtocleansetheareabyshoweringimmediatelyandtolathertheskinseveraltimesandrinseeachtimeinrunningwater.Removingthepoisonivy sap willdecrease thelikelihood ofirritation.Calaminelotionmaybeoneproductrecommendedforuseifdermatitisdevelops.Theclientdoesnotneedtobeseenintheemergencydepartmentatthistime.2.Aclientisbeingadmittedtothehospitalfortreatmentofacutecellulitisofthelowerleftleg.Duringtheadmissionassessment,thenurseexpectstonotewhichfinding?1.Aninflammationoftheepidermisonly2.Askininfectionofthedermisandunderlyinghypodermis3.Anacutesuperficialinfectionofthedermisandlymphatics4.AnepidermalandlymphaticinfectioncausedbyStaphylococcusAnswer:2.AskininfectionofthedermisandunderlyinghypodermisRationale:Cellulitisisaninfectionofthedermisandunderlyinghypodermisthatresultsinadeeprederythemawithoutsharpbordersandspreadswidelythroughouttissuespaces.Theskiniserythematous,edematous,tender,and

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3sometimesnodular.Erysipelasisanacute,superficial,rapidlyspreadinginflammationofthedermisandlymphatics.Theinfectionisnotsuperficialandextendsdeeperthantheepidermis.3.Theclinicnurseassessestheskinofaclientwithpsoriasisaftertheclienthasusedanewtopicaltreatmentfor2months.Thenurseidentifieswhichcharacteristicsasimprovementinthemanifestationsofpsoriasis?Selectallthatapply.1.Presenceofstriae2.Palpableradialpulses3.Absenceofanyecchymosisontheextremities4.Thinneranddecreaseinnumberofreddishpapules5.Scarceamountofsilvery-whitescalypatchesonthearmsAnswers:4.Thinneranddecreaseinnumberofreddishpapules5.Scarceamountofsilvery-whitescalypatchesonthearmsRationale:Psoriasisskinlesionsincludethickreddenedpapulesorplaquescoveredbysilvery-whitepatches.Adecreaseintheseverityoftheseskinlesionsisnotedasanimprovement.Thepresenceofstriae(stretchmarks),palpablepulses,orlackofecchymosisisnotrelatedtopsoriasis.

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44.Theclinicnursenotesthatthehealthcareproviderhasdocumentedadiagnosisofherpeszoster(shingles)intheclient'schart.Basedonanunderstandingofthecauseofthisdisorder,thenursedeterminesthatthisdefinitivediagnosiswasmadebywhichdiagnostictest?1.Positivepatchtest2.Positivecultureresults3.Abnormalbiopsyresults4.Wood'slightexaminationindicativeofinfectionAnswer:2.PositivecultureresultsRationale:Withtheclassicpresentationofherpeszoster,theclinicalexaminationisdiagnostic.However,aviralcultureofthelesionprovidesthedefinitivediagnosis.Herpeszoster(shingles)iscausedbyareactivationofthevaricella-zostervirus,thevirusthatcauseschickenpox.Apatchtestisaskintestthatinvolvestheadministrationofanallergentothesurfaceoftheskintoidentifyspecificallergies.Abiopsywouldprovideacytologicalexaminationoftissue.InaWood'slightexamination,theskinisviewedunderultravioletlighttoidentifysuperficialinfectionsoftheskin.

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55.Aclientreturnstotheclinicforfollow-uptreatmentfollowingaskinbiopsyofasuspiciouslesionperformed1weekago.Thebiopsyreportindicatesthatthelesionisamelanoma.Thenurseunderstandsthatmelanomahaswhich characteristics?Selectallthatapply.1.Lesion is painful totouch.2.Lesionishighlymetastatic.3.Lesionisanevusthathaschangesincolor.4.Skinunderthelesionisreddenedandwarmtotouch.5.Lesionoccursinbodyareaexposedtooutdoorsunlight.Answers:2.Lesionishighlymetastatic.3.Lesionisanevusthathaschangesincolor.Rationale:Melanomas are pigmented malignant lesions originating in the melanin-producingcellsoftheepidermis.Melanomascausechangesinanevus(mole),includingcolorandborders.Thisskincancerishighlymetastatic,andaperson'ssurvivaldependsonearlydiagnosisandtreatment.Melanomasarenotpainfuloraccompaniedbysignofinflammation.Althoughsunexposureincreasestheriskofmelanoma,lesionsaremostcommonlyfoundontheupper backandlegsandonthesolesandpalmsofpersonswithdarkskin.

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67. A client arriving at the emergency department has experienced frostbiteto the right hand. Which finding would the nurse note on assessment of theclient'shand?1.Apink,edematoushand2.Fieryredskinwithedemainthenailbeds3.Blackfingertipssurroundedbyanerythematousrash4.Awhitecolortotheskin,whichisinsensitivetotouchAnswer:4.Awhitecolortotheskin,whichisinsensitivetotouchRationale:Assessmentfindingsinfrostbiteincludeawhiteorbluecolor;theskinwillbehard,cold,andinsensitivetotouch.Asthawingoccurs,flushingoftheskin,thedevelopmentofblistersorblebs,ortissueedemaappears.Options1,2,and3areincorrect.8.Theeveningnursereviewsthenursingdocumentationinaclient'schartandnotesthatthedaynursehasdocumentedthattheclienthasastageIIpressureulcerinthesacralarea.Whichfindingwouldthenurseexpecttonoteonassessmentoftheclient'ssacralarea?1.Intactskin

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72.Full-thicknessskinloss3.Exposedbone,tendon,or muscle4.Partial-thicknessskinlossofthedermisAnswer:4.Partial-thicknessskinlossofthedermisRationale:InastageIIpressureulcer,theskinisnotintact.Partial-thicknessskinlossofthedermishasoccurred.Itpresentsasashallowopenulcerwithared-pinkwoundbed,withoutslough.Itmayalsopresentasanintactoropen/rupturedserum-filledblister.Theskin isintact instage I.Full-thicknessskinlossoccursinstageIII.Exposedbone,tendon,ormuscleispresentinstageIV.9.An adultclient wasburnedinan explosion.The burninitiallyaffectedtheclient'sentireface(anteriorhalfofthehead)andtheupperhalfoftheanteriortorso,andtherewerecircumferentialburnstothelowerhalfofbotharms.Theclient'sclothescaughtonfire,andtheclientran,causingsubsequentburninjuriestotheposteriorsurfaceoftheheadandtheupperhalfoftheposteriortorso.Usingtheruleofnines,whatwouldbetheextentoftheburninjury?1.18%

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82.24%3.36%4.48%Answer:3.36%Rationale:Accordingtotheruleofnines,withtheinitialburn,theanteriorhalfoftheheadequals4.5%,theupperhalfoftheanteriortorsoequals9%,andthelowerhalfofbotharmsequals9%.Thesubsequentburnincludedtheposteriorhalfofthehead,equaling4.5%,andtheupperhalfofposteriortorso,equaling9%.Thistotals36%.10.Thenurseispreparingtocareforaburnclientscheduledforanescharotomyprocedurebeingperformedforathird-degreecircumferentialarmburn.Thenurseunderstandsthatwhichfindingistheanticipatedtherapeuticoutcomeoftheescharotomy?1.Returnofdistalpulses2.Briskbleedingfromthesite3.Decreasingedemaformation4.Formationofgranulationtissue

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9Answer:1.ReturnofdistalpulsesRationale:Escharotomiesareperformedtorelievethecompartmentsyndromethatcanoccurwhenedemaformsundernondistensibleescharinacircumferentialthird-degreeburn.Theescharotomyreleasesthetourniquet-likecompressionaroundthearm.Escharotomiesareperformedthroughavasculareschartosubcutaneousfat.Althoughbleedingmayoccurfromthesite,itisconsideredacomplicationratherthanananticipatedtherapeuticoutcome.Usually,directpressurewithabulkydressingandelevationcontrolthebleeding,butoccasionallyanarteryisdamagedandmayrequireligation.Escharotomydoesnotaffecttheformationofedema.Formationofgranulationtissueisnottheintentofanescharotomy.11.Thenurseiscaringforaclientwhosustainedsuperficialpartial-thicknessburnsontheanteriorlowerlegsandanteriorthorax.Whichfindingdoesthenurseexpecttonoteduringtheresuscitation/emergentphaseoftheburninjury?1.Decreasedheartrate2.Increasedurinaryoutput3.Increasedbloodpressure4.Elevatedhematocritlevels

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10Answer:4.ElevatedhematocritlevelsRationale:Theresuscitation/emergentphase beginsatthe timeofinjuryandendswiththerestorationofcapillarypermeability,usuallyat48to72hoursfollowingtheinjury.Duringtheresuscitation/emergentphase,thehematocritlevelincreasestoabovenormalbecauseofhemoconcentrationfromthelargefluidshifts.Hematocritlevelsof50%to55%(0.50to0.55)areexpectedduringthefirst24hoursafterinjury,withreturntonormalby36hoursafter injury.Initially,bloodisshuntedawayfromthekidneysandrenalperfusionandglomerularfiltrationaredecreased,resultinginlowurineoutput.Theburnclientispronetohypovolemiaandthebodyattemptstocompensate byincreasedpulserateand lowered blood pressure. Pulseratesaretypicallyhigherthannormal,andthebloodpressureisdecreasedasaresultofthelargefluidshifts.12.Thenurseisadministeringfluidsintravenouslyasprescribedtoaclientwhosustainedsuperficialpartial-thicknessburninjuriesofthebackandlegs.Inevaluatingtheadequacyoffluidresuscitation,thenurseunderstandsthatwhichassessmentwouldprovidethemostreliableindicatorfordeterminingtheadequacy?

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111.Vitalsigns2.Urineoutput3.Mentalstatus4.PeripheralpulsesAnswer:2.UrineoutputRationale:Successfuloradequatefluidresuscitationintheclientissignaledbystablevitalsigns,adequateurineoutput,palpableperipheralpulses,andclearsensorium.However, themostreliableindicatorfordeterminingadequacyoffluidresuscitation,especiallyinaclientwithburns,istheurineoutput.Foranadult,thehourlyurinevolumeshouldbe30to50mL.13.Thenurseiscaringforaclientfollowinganautograftandgraftingtoaburnwoundontherightknee.Whatwouldthenurseanticipatetobeprescribedfortheclient?1.Out-of-bedactivities2.Bathroomprivileges3.Immobilization oftheaffected leg4.PlacingtheaffectedleginadependentpositionAnswer:

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123.ImmobilizationoftheaffectedlegRationale:Autograftsplacedoverjointsoronthelowerextremitiesaftersurgeryoftenare elevated andimmobilizedfor3 to7days.This periodofimmobilizationallowstheautografttimetoadheretothewoundbed.Gettingoutofbed,goingtothebathroom,andplacingthegraftedlegdependentwouldputstressonthegraftedwound.14.Thehealtheducationnurseprovidesinstructionstoagroupofclientsregardingmeasuresthatwillassistinpreventingskincancer.Whichinstructionsshouldthenurseprovide?Selectallthatapply.1.Sunscreenshouldbeappliedevery8hours.2.Usesunscreenwhenparticipatinginoutdooractivities.3.Wearahat,opaqueclothing,andsunglasseswheninthesun.4.Avoidsunexposureinthelateafternoonandearlyeveninghours.5.Examineyourbodymonthly forany lesionsthatmaybesuspicious.Answers:2.Usesunscreenwhenparticipatinginoutdooractivities.3.Wearahat,opaqueclothing,andsunglasseswheninthesun.5.Examineyourbodymonthlyforanylesionsthatmaybesuspicious.

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13Rationale:Theclientshouldbeinstructedtoavoidsunexposurebetweenthehoursofbrightestsunlight:10a.m.and4p.m.Sunscreen,ahat,opaqueclothing,andsunglassesshouldbewornforoutdooractivities.Theclientshouldbeinstructedtoexaminethebodymonthlyfortheappearanceofanycancerousoranyprecancerouslesions.Sunscreenshouldbereappliedevery2to3hoursandafterswimmingorsweating;otherwise,thedurationofprotectionisreduced.27.Thecommunityhealthnurseisvisitingahomelessshelterandisassessingtheclientsintheshelterforthepresenceofscabies.Whichassessmentfindingshouldthenurseexpecttonoteifscabiesispresent?1.Brown-redmaculeswithscales2.Pustulesonthetrunkofthebody3.Whitepatchesnotedontheelbowsandknees4.MultiplestraightorwavythreadlikelinesunderneaththeskinAnswer:4.MultiplestraightorwavythreadlikelinesunderneaththeskinRationale:

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14Scabiescanbeidentifiedbythemultiplestraightorwavythreadlikelinesbeneaththeskin.Theskinlesionsarecausedbythefemale,whichburrowsbeneaththeskintolayitseggs.Theeggshatchinafewdays,andthebabymitesfindtheirwaytotheskinsurface,wheretheymateandcompletethelifecycle.Options1,2,and3arenotcharacteristicsofscabies.29.Thenurseisconcernedaboutpotentialskinintegrityproblemsforanunconsciousclient.Whichinterventionswouldbemostappropriatetoincludeintheplanofcareforthisclient?Selectallthatapply.1.Repositionevery2hours.2.Useabedcradleasindicated.3.Applyprotectivepadstoheelsandelbows.4.Adda smallamountof alcoholto thedailybath water.5.Provideperinealcareevery8hoursandafterincontinence.Answers:1.Repositionevery2hours.2.Useabedcradleasindicated.3.Applyprotectivepadstoheelsandelbows.5.Provideperinealcareevery8hoursandafterincontinence.Rationale:

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15Unconsciousclientsarecompletelyimmobile,havinglosttheprotectivereflexestoshiftbodyweight.Itisuptothenursetominimizetheriskofprolongedpressurethatcouldcauseskinischemiaandbreakdown.Thisisaccomplishedbyrepositioningtheclientevery2hours.Useofabedcradlecanprotecttheclient'stoesfrombreakdownduetoweightfromlinens.Protectivepadscanbeappliedtotheheelsandelbowstoreducefrictionandshear.Appropriateperinealcareisessentialtokeepwasteproductsfromexcoriatingtheskin.Thenursecanreduceskindrynessandirritationbyaddingasuperfattysolution(suchasbabyoilorcastilesoap)tothedailybathwater.Dryingagentssuchasalcoholareavoidedbecausedryskincancrackandbreakdown.30.Theemergencydepartmentnurseiscaringforaclientwhohassustainedchemicalburnstotheesophagusafteringestionoflye.Thenursereviewsthehealthcareprovider'sprescriptionsandshouldplantoquestionwhichprescription?1.Gastriclavage2.Intravenous(IV)fluidtherapy3.Nothingbymouth(NPO)status4.PreparationforlaboratorystudiesAnswer:1.Gastriclavage

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