Integumentary & Burns NCLEX

Integumentary & Burns NCLEX Leave the first rating Students also studied Terms in this set (61) James A Rhodes State College NSG 1523 Save integ 44 terms MJ-BGPreview NCLEX Integumentary System Revie...99 terms aFaw17Preview Integumentary System 50 terms sopmur1333Preview Integum 78 terms Sen 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 characteristic of this type of lesion to be documented in the client's record? SELECT ALL THAT APPLY

• lesion has waxy border
• an irregularly shaped lesion
• papule, with res, central crater
• a small papule with a dry, rough scale
• a firm nodular lesion topped with a crust
• lesion has waxy border
• 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 a.m and after
• p.m"

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 a.m and after 4 p.m"

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

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

trunk

• silvery-white scaly lesions

The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas?SELECT ALL THAT APPLY

• face
• knees
• elbows
• abdomen
• base of the spine
• knees
• elbows
• base of the spine

The client recovering from a third-degree burn asks the nurse about grafts. The nurse explains to the client that the best type of graft is which?1, allograft

• autograft
• xenograft
• biosynthetic
• autograft

The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse underdtands that moist desquamation is best described as which?

• a rash
• dermatitis
• reddened skin
• weeping of the skin
• weeping of the skin

The nurse is assigned to care for a client with partial- thickness burns to 60% of her body surfaces. On the fourth day after injury, tjr client's vital signs include an oral temperature of 102.8 F, pulse of 98 beats per minute, respiration's of 24 breaths per minute, and blood pressure of 105/64.Parental nutrition is infusing at 82mL/hr. Based on these data, the nurse plans to initially perform which action?

• recheck the vital signs in 1 hour
• monitor the client for signs of infection
• change the parenteral nutrition solution and IV tubing
• determine when the client was last medicated for pain
• monitor the client for signs of infection

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

The client returns to the clinic for follow-up treatment after a skin biopsy is a suspicious lesion that was performed 1 week ago. The biopsy report indicated that the lesion is a melanoma. The nurse understands that which characteristic describes this type of lesion?

SELECT ALL THAT APPLY

• metastasis is rare
• it is encapusulated
• it is highly metastatic
• it is characterized by local invasion
• lesion is a nevus that has changed in color
• it is highly metastatic
• lesion is a nevus that has changed in color

The nurse prepares to assist in instructing a client about lyme disease. Which should the nurse include in the instructions?

• it is caused by a tick carried by a deer
• it is caused by contamination from cat feces
• it is contagious by skin contact with an infected

individual

• it is caused by the inhalation of spores from bird

droppings

• it is caused by a tick carried by a deer

A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct 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 makes which statement to the client?

• "come to the emergency department"
• " apply calamine lotion immediately to the exposed

skin areas"

• take a shower immediately , and lather and rinse

several times"

• " it is not necessary to do anything if you cannot see

anything on your skin"

• take a shower immediately , and lather and rinse several times"

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with the early stage of cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should expect which assessment finding?

• swelling in the genital area
• swelling in the lower extremities
• large open plaques in the facial area
• appearance of reddish-blue lesions on the lower

extremities

• appearance of reddish-blue lesions on the lower extremities

The nurse is caring for a client on transmission based precautions who has herpes zoster, or shingles. Which are some of the MOST important skin issues associated with this condition?SELECT ALL THAT APPLY

• there is no pattern or segmental assignment of the

lesions

• skin eruptions occur before any discomfort or pain

appears

• lesions are very contagious when they are fluid filled

blisters

• eruptions can last several weeks , and the severe pain

(postherpetic neuralgia) often persist after the lesions have resolved

• to reduce the risk of transmitting the virus to others.

clients with lesions are separated from other clients until lesions have crusted

• lesions are very contagious when they are fluid filled blisters
• eruptions can last several weeks , and the severe pain (postherpetic neuralgia)

often persist after the lesions have resolved

• to reduce the risk of transmitting the virus to others. clients with lesions are

separated from other clients until lesions have crusted The health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equiptment?

• patch test
• skin biopsy
• culture of the lesion
• wood's light examination
• culture of the lesion

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the health care provider to prescribe which measure to maximize the effectiveness of this therapy ?

• rubbing the application into the skin
• placing the area under a heat lamp for 20 min
• applying a dry sterile dressing over the affected area
• covering the application with warm , moist dressing

and a occlusive outer wrap

• covering the application with warm , moist dressing and a occlusive outer wrap

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for FURTHER teaching about the measures that will prevent the spread of infection?

1." i need to take the full course of the antibiotics"

• " my clothes can be laundered with other household

members"

• " i must wash my hands thoroughly and frequently

throughout the day"

• " i need to wash my dishes and eating utensils separate

from other household members"

• " my clothes can be laundered with other household members"