Integumentary System: Saunders NCLEX Review

The nurse is conducting a session about the princi- ples of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occur- rence is which action?

1. Immobilize the affected extremity.

2. Remove jewelry and constricting clothing from the victim.

3. Place the extremity in a position so that it is below the level of the heart.

4. Move the victim to a safe area away from the snake and encourage the victim to rest.

4

Rationale: In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encour- age the victim to rest to decrease venom circulation. Next, jew- elry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity at the heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible.

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?

1. "Come to the emergency department."

2. "Apply calamine lotion immediately to the exposed skin areas."

3. "Take a shower immediately, lathering and rins- ing several times."

4. "It is not necessary to do anything if you cannot see anything on your skin."

3

Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.

A client is being admitted to the hospital for treat- ment 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

2

Rationale: Cellulitis is an infection of the dermis and underly- ing hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis. Test-Taking Strategy: Eliminate options 3 and 4 because they are comparable or alike and address the lymphatics. Eliminate option 1 because of the closed-ended word only.

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 manifesta- tions 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

4, 5

Rationale: Psoriasis skin lesions include thick reddened pap- ules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.Test-Taking Strategy: Focus on the subject, manifestations of psoriasis. Use knowledge regarding the pathophysiology and signs and symptoms associated with psoriasis. This will direct you to the correct options detailing a decrease in the psoriatic signs.

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shin- gles) in the client's chart. Based on an understand- ing 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

2

Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. Apatch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. Abiopsy would provide a cytological examination of tissue. In a Wood's light examina- tion, the skin is viewed under ultraviolet light to identify super- ficial infections of the skin.

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 under- stands 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 in body area exposed to out-

door sunlight.

2, 3

Rationale: Melanomas are pigmented malignant lesions orig- inating in the melanin-producing cells of the epidermis. Mela- nomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions are most commonly found on the upper back and legs and on the soles and palms of persons with dark skin.

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

4, 5

Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adher- ent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.

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 erythematous rash

4. A white color to the skin, which is insensitive

4

Rationale: Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.

The evening nurse reviews the nursing documenta- tion in a client's chart and notes that the day nurse has documented that the client has a stage II pres- sure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the cli- en t's sacral area?

1. Intactskin

2. Full-thickness skin loss

3. Exposed bone, tendon, or muscle

4. Partial-thickness skin loss of the dermis

4

Rationale: In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It pre- sents as a shallow open ulcer with a red-pink wound bed, with- out slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

An adult client was burned in an explosion. The burn initially affected the client's entire face (ante- rior half of the head) and the upper half of the ante- rior 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 subse- quent 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%

3

Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.

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?

1. Return of distal pulses

2. Brisk bleeding from the site

3. Decreasing edema formation

4. Formation of granulation tissue

1

Rationale: Escharotomies are performed to relieve the com- partment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascu- lar eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occa- sionally an artery is damaged and may require ligation. Eschar- otomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mm Hg, a pulse rate of 110 beats/minute, and a urine out- put of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?

1. Transfusing 1 unit of packed red blood cells

2. Administering a diuretic to increase urine output

3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour

4. Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

3

Rationale: Fluid management during the first 24 hours follow- ing a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Lactated Ringer's solution is an iso- tonic solution that contains electrolytes that will maintain fluid volume in the circulation. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/ hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate per- fusion of the brain, heart, kidneys, and other body organs. Therefore, the HCP would prescribe an increase in the amount of IVlactated Ringer's solution administered per hour. There is nothing in the situation that calls for blood resplacement, which is not used for fluid therapy for burn injuries. Adminis- tering a diuretic would not correct the problem because fluid replacement is needed. Diuretics promote the removal of the circulating volume, thereby further compromising the inade- quate tissue perfusion. Intravenous 5% dextrose solution is iso- tonic before administered but is hypotonic once the dextrose is metabolized. Hypotonic solutions are not appropriate for fluid resuscitation of a client with significant burn injuries.

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.

1. Restrict fluids.

2. Assess for airway patency.

3. Administer oxygen as prescribed.

4. Place a cooling blanket on the client.

5. Elevate extremities if no fractures are present.

6. Prepare to give oral pain medication as prescribed.

2, 3, 5

Rationale: The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IVline should be obtained and fluid resuscita- tion started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm since the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.

The nurse is caring for a client who sustained super- ficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emer- gent phase of the burn injury?

1. Decreased heart rate

2. Increased urinary output

3. Increased blood pressure

4. Elevated hematocrit levels

4

Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glo- merular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

The nurse manager is planning the clinical assign- ments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply.

1. The nurse who never had roseola

2. The nurse who never had mumps

3. The nurse who never had chickenpox

4. The nurse who never had German measles

5. The nurse who never received the varicella-zoster vaccine

3, 5

Rationale:The nurses who have not had chicken pox or did not receive the varicella-zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are sus- ceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.

A client arrives at the emergency department fol- lowing a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?

1. 100% oxygen via an aerosol mask

2. Oxygen via nasal cannula at 6 L/minute

3. Oxygen via nasal cannula at 15 L/minute

4. 100% oxygen via a tight-fitting, nonrebreather face mask

4

Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

1. Vital signs

2. Urine output

3. Mental status

4. Peripheral pulses

2

Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine out- put. For an adult, the hourly urine volume should be 30 to 50mL.

The nurse manager is observing a new nursing grad- uate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe com- ponent of protective isolation technique?

1. Using sterile sheets and linens

2. Performing strict hand-washing technique

3. Wearing gloves and a gown only when giving direct care to the client

4. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

3

Rationale: In protective isolation, the nurse needs to protect the client at all times from any potential infectious contact. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protec- tive garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client.

The nurse is caring for a client following an auto- graft and grafting to a burn wound on the right knee. What would the nurse anticipate to be pre- scribed for the client?

1. Out-of-bed activities

2. Bathroom privileges

3. Immobilization of the affected leg

4. Placing the affected leg in a dependent position

3

Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the auto- graft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate not- ing which sign in the client?

1. Coma

2. Flushing

3. Dizziness

4. Tachycardia

2

Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tin- nitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.