Integumentary and Burns- NCLEX

Integumentary and Burns- NCLEX ScienceMedicineDermatology Clmims87 Save Chapter 25 Burns NCLEX style quest...22 terms Amanda_Washingto... Preview Davis Edge Upper GI 46 terms bridget_liles-kellum Preview pediatrics 97 terms ebonyclarkePreview Integum 61 terms Clm An adult client was burned as a result if an explosion. The burn initially affected the client's entire face (the anterior half of his head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The clients clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury?36% The nurse, employed in a long-term care facility, is planning the clinical assignments for the day.The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

• A staff member who has never has roseola
• A staff member who has never had mumps

3, An unlicensed assistive personnel who has never had chickenpox

• An unlicensed assistive personnel who has never had German measles

3, An unlicensed assistive personnel who has never had chickenpox A client returns to the clinic for follow up treatment for a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of lesion? SELECT ALL THAT APPLY

• Metastasis is rare
• It is encapsulated
• It is highly metastatic
• It is characterized by local invasion
• Lesions in a nevus that has changed in color
• It is highly metastatic
• Lesions in a nevus that has changed in color

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? SELECT ALL THAT APPLY

• Lesions have a waxy border

2.An irregularly shaped lesion

• Papule, with a red, central crater
• A small papule with a dry, rough scale
• A firm nodular lesion topped with a crust

. 1.Lesions have a waxy border 2.An irregularly shaped lesion The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for FURTHER teaching?

• " I need to wear sunscreen when participating in outdoor activities
• " I need to avoid sun exposure before 10:00 am and after 4:00 pm"

3." I need to wear a hat,. opaque clothing, and sunglasses when in the sun"

• " I need to examine my body monthly for any lesions that may be suspicious"
• " I need to avoid sun exposure before 10:00 am and after 4:00 pm"

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand?

• A pink, endematous hand
• Fiery red skin with edema in the nail beds
• Black fingertips surrounded by an erythematous rash
• A white color of the skin which is insensitive to touch
• A white color of the skin which is insensitive to touch

The evening nurse reviews the evening documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the clients sacral area?

• intact skin
• the pressure of tunneling
• a deep crater like appearance
• partial-thickness skin loss of the epidermis
• partial-thickness skin loss of the epidermis

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is suspected?

• oily skin
• silvery-white scaly lesions
• patchy hair loss and round, red mascules with scales
• the presence of wheal patches scattered about the trunk
• silvery-white scaly lesions

The nurse is told that an assigned client is suspected of having methicillin- resistant Staphylococcus aures (MRSA). Which precautions should the nurse institute during the care of the client?

• wear gloves
• wear mask and gloves

3.wear a gown and gloves

• avoid touching the client's clothes

3.wear a gown and gloves The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected.Which should the nurse anticipate as being prescribed for the client?

• oxygen via nasal cannula at 10 L
• oxygen via nasal cannula at 15 L
• 100% oxygen via an aerosol mask
• 100% oxygen via a tight fitting, nonrebreather face mask
• 100% oxygen via a tight fitting, nonrebreather face mask

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky.Based on this data, which interpretation should the nurse make?

• the client is hypotensive
• pain is present from the burn injury

3.the burn has probably caused laryngeal edema, which has occluded the airway.

• the client is afraid and is having a panic attack as a result of the unfamiliar surroundings

3.the burn has probably caused laryngeal edema, which has occluded the airway.Which should be anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

• the return of distal pulses
• decreasing edema formation
• brisk bleeding from the injury site
• the formation of granulation tissue
• the return of distal pulses

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of burn?

• a dependent position
• elevation of the knees
• flat, without elevation
• elevation above the level of the heart
• elevation above the level of the heart

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the MOST reliable indicator for determining the adequacy of the fluid resuscitation?

• vital signs
• urine output
• mental status
• peripheral pulses
• urine output

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

• positive patch test
• positive culture results
• abnormal biopsy results
• wood's light examination indicative of infection
• positive culture results

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication ?

• Tinnitus
• Diarrhea
• Constipation
• Decreased respirations
• Tinnitus

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide? SELECT ALL THAT APPLY

• sunscreen should be applied every 8 hours
• use sunscreen when participating in out door activities
• wear a hat, opaque clothing, and sunglasses when in the sun
• avoid sun exposure in the late afternoon and early evening hours
• examine your body monthly for any lesions that may be suspicious
• use sunscreen when participating in out door activities
• wear a hat, opaque clothing, and sunglasses when in the sun
• examine your body monthly for any lesions that may be suspicious

silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse?

• glucose level of 99 mg/dL (5.5mmol/L)
• platelet level of 300,000 mm3 (300x10/L)
• magnesium level of 1.5mEq/L (0.75mmol/L)
• white blood cell count of 3000mm3 (3.0x10/L)
• white blood cell count of 3000mm3 (3.0x10/L)

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates the occurrence if a systemic effect?

1.hyperventilation

• elevated blood pressure
• local rash at the burn site
• local pain at the burn site

1.hyperventilation