50 item Integumentary Exam
1. A nurse is caring for a burn client who has sustained thoracic burns and smoke inhalation and is risk for impaired gas exchange. The nurse avoids which action in caring for this client?
a. repositioning the client from side to side every 2 hours
b. maintaining the client in a supine position with the head of the bed elevated
c. suctioning the airway as needed
d. providing humidified oxygen as prescribed
2. A client sustains a burn injury to the entire right arm, entire right leg, and anterior thorax. According to the rule of nine’s the nurse determines that what body percent was injured?
3. A nurse assesses a burn injury and determines that the client sustained a full-thickness fourth-degree burn if which of the following is noted at the site of injury?
a. a wet shiny weeping wound surface
b. a dry wound surface
c. charring at the wound site
4. A client is brought to the emergency room following a burn injury. In assessment the nurse notes that the client’s eyebrow and nasal hairs are singed. The nurse would identify this type of burn as:
5. A nurse assesses the carbon monoxide level of a client following a burn injury and notes that the level is 8%. Based on this level, which finding would the nurse expect to note during the assessment of the client?
d. impaired visual acuity
6. A nurse assesses the client’s burn injury and determines that the client sustained a partial-thickness superficial burn. Based on this determination, which finding did the nurse note?
a. a wet, shiny, weeping wound
b. a dry wound surface
c. charring at the wound site
d. absence of wound sensation
7. A nurse assesses the client’s burn injury and determines that the client sustained a partial-thickness deep burn. Based on this determination, which finding did the nurse note?
a. a wet, shiny, weeping wound surface
b. a dry wound surface
c. charring at the wound site
d. total absence of wound sensation
8. On assessment of a child, the nurse notes the presence of white patches on the child’s tongue and determines that they may be indicative of candidiasis (thrush). The nurse understands that the white patches of candidiasis (thrush):
a. adhere to the tongue even when scraped with tongue blade
b. cause the tongue to bleed continuously around the patch
c. produce a red circle in the center of the white lesion
d. will occur only in the tongue
9. On assessment, a nurse notes a flat brown circular nevi on the skin of a client that measures less than one centimeter. The client asks, “Is this cancer?” The nurse makes which response to the client?
a. “These are likely to be benign moles.”
b. “These require immediate attention because they are probably cancer.”
c. “These indicate malignancy.”
d. “These are probably verrucae.”
10. A nurse is performing a skin assessment on a client. The nurse understands that moles with variegated color, irregular borders, and/or an irregular surface should be considered:
11. A client is diagnosed with herpes zoster (shingles). Which pharmacological therapy would the nurse expect to be prescribed to treat this disorder?
a. tetracycline hydrochloride (achromycin)
b. erythromycin base (e-mycin)
c. acyclovir (zovirax)
d. indomethacin (indocin)
12. A nurse reviews the record of a client diagnosed with pemphigus and notes that the physician has documented the presence of Nikolsky’s sign. Based on this documentation, which of the following would the nurse expect to note?
a. client complains of discomfort behind the knee on forced dorsiflexion of the foot
b. a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland
c. carpal spasm elicited by compressing the upper arm
d. the epidermis of the client’s skin can be rubbed off by slight friction or injury
13. A hospitalized client is diagnosed with scabies. Which of the following would a nurse expect to note on inspection of the client’s skin?
a. the appearance of vesicles or pustules
b. the presence of white patches scattered about the trunk
c. multiple straight or wavy threadlike lines beneath the skin
d. patchy hair loss and round, red macules with scales
14. A client is seen in the health care clinic and the physician suspects herpes zoster. The nurse prepares the items needed to perform the diagnostic test to confirm this diagnosis. Which item will the nurse obtain?
a. a biopsy kit
b. a wood’s light
c. a culture swab and tube
d. a patch test kit
15. A nurse reviews the health care record of a client diagnosed with herpes zoster. Which finding would the nurse expect to note as characteristic of this disorder?
a. a generalized red body rash that causes pruritus
b. small blue-white spots with a red base noted on the extremities
c. a fiery red edematous rash on the cheeks and neck
d. clustered and grouped skin vesicles
16. A client returns to the clinic for a follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicated that the lesion is a squamous cell carcinoma. The nurse plans care knowing that which of the following describes the characteristic of this type of a lesion?
a. it is highly metastatic
b. it does not metastasize
c. it is characterized by local invasion
d. it is encapsulated
17. A nurse reviews the record of a client scheduled for removal of a skin lesion. The record indicates that the lesion is an irregularly shaped, pigmented papule with a blue-toned color. The nurse determines that this description of the lesion is characteristic of:
b. basal cell carcinoma
c. squamous cell carcinoma
d. actinic keratosis
18. A nurse is reviewing the nursing care plan for a client for whom a stage 4 decubiti ulcer has been documented. Which of the following would the nurse expect to note on assessment of the client?
a. a reddened area that returns to a normal skin color after 15 to 20 minutes of pressure relief
b. intact skin
c. an area in which the top layer of skin is missing
d. a deep ulcer that extends into muscle and bone.
19. A nurse notes documentation of a stage 3 pressure ulcer in a client’s record. Which of the following would the nurse expect to note on assessment of the client?
a. a deep ulcer that extends into muscle and bone
b. a deep ulcer that extends into the dermis and the subcutaneous tissue
c. an area in which the top layer of skin is missing
d. a reddened area that returns to normal skin color after 15 to 20 minutes of pressure relief
20. A client is in the health care clinic for complaints of pruritus. Following diagnostic studies, it has been determined that there is not a pathophysiological process causing the pruritus. The nurse prepares instructions for the client to assist in reducing the problem and tells the client to:
a. use a dehumidifier in the home
b. ensure that the temperature in the home is high, especially during the winter months
c. use a cool-mist vaporizer, especially during the winter months
d. avoid use of skin moisturizers following a bath
21. A client is seen in the health care clinic because of complaints of lesions on the elbows and the knees. The lesions are red raised papules, and large plaques covered by silvery scales are also noticed on the elbows and the knees. Psoriasis is diagnosed and the nurse provides information about treatment to the client. The nurse determines that the client needs additional information if the client states that which of the following is a component of the treatment plan?
a. tar baths
b. ultraviolet light treatments
c. topical lubricants
d. systemic corticosteroids
22. A client is seen in the health care clinic and a biopsy is performed on a skin lesion that the physician suspects malignant melanoma. The nurse prepares a plan of care for the client based on which characteristics of this type of skin cancer?
a. it is an aggressive cancer that requires aggressive therapy to control its rapid spread
b. it is a slow-growing cancer and seldom metastasizes
c. it can grow so large that an entire area, such as the nose, the lip, or the ear must be removed and reconstructed if it occurs on the face
d. it is the most common form of skin cancer
23. A nurse is caring for a client brought to the emergency room following a burn injury that occurred in the basement of the home. Which initial finding would indicate the presence of inhalation injury?
a. expectoration of sputum tinged with blood
b. the presence of singed nasal hair
c. absent breath sounds in the lower lobes bilaterally
24. A nurse is caring for a client who arrives at the emergency room with the emergency medical services team following a severe burn injury from an explosion. Once the initial assessment has been performed by the physician and life-threatening dysfunctions have been addressed, the nurse reviews the physician’s orders anticipating that which pain medication will be prescribed?
a. intravenous (IV) morphine sulfate
b. aspirin with oxycodone (percodan) via nasogastric tube
c. acetaminophen (tylenol) with codeine sulfate
d. morphine sulfate by the subcutaneous route
25. A nurse is assessing the operative site in a client who underwent a breast reconstruction. The nurse is inspecting the flap and the areola of the nipple and notes that the areola is a deep red color around the edge. The nurse takes which action first?
a. document the findings
b. elevate the breast
c. encourage nipple massage
d. notify the physician
26. A nurse performs a skin assessment on an assigned client and notes the presence of lesions that are red-tan scaly plaques. The nurse documents this findings as:
d. actinic keratoses
27. A community health nurse has provided fire safety instructions to a group of individuals who are part of a disaster response team. Which statement by a group member indicates a need for further instructions?
a. “the victim may be rolled on the ground to extinguish the flames”
b. “a blanket or another cover can be used to smother the flames”
c. “flames should be doused with water”
d. “keep the victim in standing position so flames won’t spread to other parts of the body”
28. A community health nurse is providing a teaching session to firefighters in a small community regarding care to a victim at the scene of a burn injury. The community health nurse instructs the firefighters that in the event of a tar burn the immediate action would be to:
a. cool the injury with water
b. remove all clothing immediately
c. remove the tar from the burn injury
d. leave any clothing that is saturated with tar in place
29. The client who sustained an inhalation injury arrives in the emergency department. On assessment of the client, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing:
30. The client is diagnosed with stage 1 of Lyme disease. The nurse assesses the client for the hallmark characteristic of this stage. Which assessment finding would the nurse expect to note?
a. dizziness and headaches
b. enlarged and inflamed joints
d. skin rash
31. The emergency department nurse is performing an assessment on a client who has sustained circumferential burns of both legs. Which assessment would be the priority in caring for this client?
a. assessing peripheral pulses
b. assessing neurological status
c. assessing urine output
d. assessing blood pressure
32. The nurse is reviewing the discharge instructions for a client who had skin biopsy. Which statement by the client indicates a need for further instructions?
a. “I will watch for any drainage from the wound”
b. “I will return tomorrow to have the sutures removed”
c. “I will use antibiotic ointment as prescribed”
d. “I will keep the dressing dry”
33. The nurse preparing to assist the physician to examine the client’s skin with a Wood’s light would do which of the following?
a. obtain an informed consent
b. tell the client that the procedure is painless
c. shave the skin site
d. prepare a local anesthetic
34. The nurse provides discharge instructions to a client following patch testing. Which instruction would the nurse provide to the client?
a. return to the clinic in 2 weeks for the initial reading
b. reapply the patch if it comes off
c. continue all current activities
d. keep the test sites dry
35. A nurse is preparing a client for skin grafting and notes that the physician has documented that the client is scheduled for heterograft. The nurse understands that the heterograft used for the burn client is skin from:
a. another species
b. a cadaver
c. the burned client
d. a skin bank
36. Following assessment and diagnostic evaluation, it has been determined that the client has Stage II of Lyme disease. The nurse expects to note which assessment finding that is most indicative of this stage?
a. erythematous rash
b. cardiac conduction defects
d. enlargement of joints
37. The clinic nurse reads the chart of a client that was seen by the physician and notes that the physician has documented that the client has Stage III of Lyme disease. Which clinical manifestation would the nurse expect to note in the client?
a. a generalized skin rash
b. a cardiac dysrhythmia
c. complaints of joint pain
d. paralysis in the extremity where the tick bite occurred
38. A female client arrives at the health care clinic and tells the nurse that she was bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which nursing action is appropriate?
a. refer the client for a blood test immediately
b. inform the client that the tick is needed to perform the test
c. inform the client that she will need to return in 6 weeks to be tested because testing before this time is not reliable
d. ask the client about the size and color of the tick
39. The client suspected of having Stage I of Lyme disease is seen in the health care clinic and is told that the Lyme disease test is positive. The client asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating which of the following to be part of the treatment plan?
a. no treatment unless symptoms develop
b. a 3-week course of oral antibiotic therapy
c. treatment with intravenous penicillin G
d. ultraviolet light therapy
40. The client with acquired immunodeficiency syndrome (AIDS) is suspected of having cutaneous Kaposi’s sarcoma. The nurse prepares the client for which test that will confirm the presence of this type of sarcoma?
a. sputum culture
b. liver biopsy
c. punch biopsy of the lesion
d. white blood cell count
41. The client who is newly admitted to the hospital for treatment of acute cellulitis of the lower left leg asks the nurse about the nature of the disorder. The nurse would respond that cellulitis is actually:
a. a skin infection into the deep dermis and subcutaneous fat
b. an acute superficial infection
c. an inflammation of the epidermis
d. an epidermal infection caused by Staphylococcus
42. A nurse is preparing a plan of care for a client with a diagnosis of acute cellulitis of the lower leg. The nurse anticipates which measure will be prescribed to treat this condition?
a. warm moist compresses to the affected area
b. cold compresses to the affected area
c. heat lamp treatments 4 times daily
d. alternating hot to cold compresses every 2 hours
43. A clinic nurse provides instructions to a client who will be taking isotretinoin (Accutane) for severe cystic acne. Which statement by the client indicates the need for further instructions?
a. “I need to return to the clinic for a blood test to check my triglyceride level”
b. “The medication may cause my lips to burn”
c. “The medication may cause dryness and burning in my eyes”
d. “I need to take vitamin A supplements to improve the effectiveness of this treatment”
44. A client sustained full-thickness burns to both hands from scalding water. A sheet graft was surgically applied to the wounds. The nurse tells the client that this type of graft is indicated for which of the following primary purposes?
a. better adherence to the wound bed
b. better cosmetic result
c. better donor site availability
d. easier to care for initially
45. A client sustained a major burn is beginning to take an oral diet again. The nurse plans to encourage the client to eat variety of which of the following types of foods to best help in continued wound healing and tissue repair?
a. high carbohydrate and low protein
b. high fat and low carbohydrate
c. high protein and high fat
d. high protein and high carbohydrate
46. A client with a major burn is admitted to the emergency department. The nurse anticipates that which of the following routes will be ordered for analgesics for this client?
47. A nurse is performing a skin assessment of a client who is immobile and notes the presence of partial thickness skin loss of the upper layer of the skin in the sacral area. The nurse documents these findings as a:
a. stage 1 pressure ulcer
b. stage 2 pressure ulcer
c. stage 3 pressure ulcer
d. stage 4 pressure ulcer
48. A student nurse is instructed by the registered nurse to monitor a client who has dark skin for cyanosis. The registered nurse determines that the student needs instructions regarding physical assessment techniques for the dark-skinned client if the student states that the best area to assess for cyanosis was in the:
a. nail beds
c. sclera of the eye
49. A client with severe psoriasis has a nursing diagnosis of Chronic Low Self-Esteem. The nurse uses which therapeutic strategy when working with this client?
a. listening attentively
b. pretending not to notice affected skin areas
c. keeping communications brief
d. approaching the client in a formal manner
50. A nurse caring for a client who sustained a high-voltage electrical injury analyzes the client’s test results. Which finding would the nurse interpret as increasing the client’s risk of developing acute tubular necrosis?
a. myoglobin in the urine
b. carbonaceous sputum
d. cloudy cerebrospinal fluid
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