skin

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skin
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2015-03-05 00:02:56
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  1. 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 rinsing several times." 
    4. "It is not necessary to do anything if you cannot see anything on your skin."
    3. "Take a shower immediately, lathering and rinsing several times."
  2. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg and asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that cellulitis has which characteristic? 
    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. A skin infection of the dermis and underlying hypodermis
  3. The clinic nurse assesses the skin of a client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder? 
    1. Oily skin 
    2. Clear, thin nail beds 
    3. Red-purplish scaly lesions 
    4. Silvery-white scaly patches
    4. Silvery-white scaly patches
  4. The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 
    1. Patch test 
    2. Skin biopsy 
    3. Culture of the lesion 
    4. Wood's light examination
    3. Culture of the lesion
  5. 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 understands that melanoma has which characteristic? 
    1. Metastasis is rare. 
    2. It is encapsulated. 
    3. It is highly metastatic. 
    4. It is characterized by local invasion.
    3. It is highly metastatic.
  6. When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding? 
    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
    1. An irregularly shaped lesion
  7. 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. A fiery red skin with edema in the nail beds 
    3. Black fingertips surrounded by an erythematous rash 
    4. A white color to the skin, which is insensitive to touch
    4. A white color to the skin, which is insensitive to touch
  8. The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 
    1. Intact skin 
    2. Full-thickness skin loss 
    3. Exposed bone, tendon, or muscle 
    4. Partial-thickness skin loss of the dermis
    4. Partial-thickness skin loss of the dermis
  9. An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior 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 subsequent 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. 36%
  10. 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. Return of distal pulses
  11. 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 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output 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 dextrose in water
    3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour
  12. The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 
    1. Decreased heart rate 
    2. Increased urinary output 
    3. Increased blood pressure 
    4. Elevated hematocrit levels
    4. Elevated hematocrit levels
  13. 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. Urine output
  14. The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed 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. Immobilization of the affected leg
  15. The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 
    1. Sunscreen should be applied every 8 hours. 
    2. Use sunscreen when participating in outdoor activities. 
    3. Wear a hat, opaque clothing, and sunglasses when in the sun. 
    4. Avoid sun exposure in the late afternoon and early evening hours. 
    5. Examine your body monthly for any lesions that may be suspicious.
    • 2. Use sunscreen when participating in outdoor activities. 
    • 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 
    • 5. Examine your body monthly for any lesions that may be suspicious.
  16. The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? 
    1. Brown-red macules with scales 
    2. Pustules on the trunk of the body 
    3. White patches noted on the elbows and knees 
    4. Multiple straight or wavy thread-like lines underneath the skin
    4. Multiple straight or wavy thread-like lines underneath the skin
  17. The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client? 
    1. "Apply ice to the site to prevent swelling." 
    2. "Clean the site with alcohol three times daily." 
    3. "Apply a warm, damp washcloth if discomfort occurs." 
    4. "Avoid showering or taking baths until seen by the health care provider in 1 week."
    3. "Apply a warm, damp washcloth if discomfort occurs."
  18. The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply. 
    1. Reposition every 2 hours. 
    2. Use a bed cradle as indicated. 
    3. Apply protective pads to heels and elbows. 
    4. Add a small amount of alcohol to the daily bath water. 
    5. Provide perineal care every 8 hours and after incontinence.
    • 1. Reposition every 2 hours. 
    • 2. Use a bed cradle as indicated. 
    • 3. Apply protective pads to heels and elbows. 
    • 5. Provide perineal care every 8 hours and after incontinence.
  19. The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription? 
    1. Gastric lavage 
    2. Intravenous (IV) fluid therapy 
    3. Nothing by mouth (NPO) status 
    4. Preparation for laboratory studies
    1. Gastric lavage
  20. The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would be most likely to be at risk for development of an integumentary disorder? 
    1. An athlete 
    2. An adolescent 
    3. An older client 
    4. A client who tans in an indoor tanning bed
    4. A client who tans in an indoor tanning bed
  21. The nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The nurse should make which response to the client? 
    1. "The procedure is painless." 
    2. "A preoperative medication will put you to sleep." 
    3. "An analgesic will be prescribed after the procedure." 
    4. "The local anesthetic may cause a stinging sensation, but the surgeon will numb the area so that pain will not be felt."
    4. "The local anesthetic may cause a stinging sensation, but the surgeon will numb the area so that pain will not be felt."
  22. The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction? 
    1. "I will keep the dressing dry." 
    2. "I will watch for any drainage from the wound." 
    3. "I will use the antibiotic ointment as prescribed." 
    4. "I will return tomorrow to have the sutures removed."
    4. "I will return tomorrow to have the sutures removed."
  23. The nurse prepares to assist the health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care? 
    1. Shave the skin site. 
    2. Prepare a local anesthetic. 
    3. Obtain an informed consent. 
    4. Tell the client that the procedure is painless.
    4. Tell the client that the procedure is painless.
  24. The nurse provides discharge instructions to a client after skin patch testing. Which instruction should be included on the discharge sheet for the client? 
    1. Keep the test sites dry. 
    2. All activities can be continued. 
    3. Reapply the patch if it comes off. 
    4. Return to the clinic in 2 weeks for the initial reading.
    1. Keep the test sites dry.
  25. The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? 
    1. Run a dehumidifier in the home. 
    2. Apply astringents to the skin twice daily. 
    3. Apply emollients to the skin after bathing. 
    4. Take baths twice daily using a dilute solution of alcohol and water.
    3. Apply emollients to the skin after bathing.
  26. The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease? 
    1. It is caused by a tick bite. 
    2. It can be contagious by skin contact with an infected person. 
    3. It can be caused by the inhalation of spores from bird droppings. 
    4. It is caused by contamination from cat feces or the consumption of rare or raw meat.
    1. It is caused by a tick bite.
  27. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? 
    1. "An acute superficial infection." 
    2. "An inflammation of the epidermis." 
    3. "An epidermal infection caused by staphylococci." 
    4. "A skin infection into the deep dermis and subcutaneous fat."
    4. "A skin infection into the deep dermis and subcutaneous fat."
  28. The nurse prepares a plan of care for a client with a diagnosis of acute cellulitis of the lower leg. On reviewing the plan of care, the nurse understands the treatment if the care plan includes which measure? 
    1. Cold compresses to the affected area 
    2. Heat lamp treatments four times daily 
    3. Warm compresses to the affected area 
    4. Alternating hot to cold compresses every 2 hours
    3. Warm compresses to the affected area
  29. The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which type of lesions on inspection of the client's skin? 
    1. Clustered skin vesicles 
    2. A generalized body rash 
    3. Small blue-white spots with a red base 
    4. A fiery-red edematous rash on the cheeks
    1. Clustered skin vesicles
  30. The nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client makes which statement? Select all that apply. 
    1. "I need to avoid baths or showers for 7 to 10 days." 
    2. "I need to clean the site as prescribed to prevent infection." 
    3. "I need to apply ice to the site continuously to prevent swelling." 
    4. "I need to expect some swelling and tenderness in the affected area." 
    5. "I need to apply alcohol-soaked dressings twice a day for 30 minutes each time."
    • 2. "I need to clean the site as prescribed to prevent infection." 
    • 4. "I need to expect some swelling and tenderness in the affected area."
  31. The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure? 
    1. Avoid the use of sunscreen on the skin for at least 2 years. 
    2. Apply an emollient lotion to the skin to enhance softening. 
    3. Scrub the skin vigorously with soap and water to remove the dead skin. 
    4. Soak the skin for 1 hour six times daily to assist in removing any dry scales.
    2. Apply an emollient lotion to the skin to enhance softening.
  32. A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage?
    54%
  33. The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? 
    1. Frostbite 
    2. Skin breakdown 
    3. Venous insufficiency 
    4. Arterial insufficiency
    2. Skin breakdown
  34. A client with severe psoriasis has a problem of chronic low self-esteem. The nurse should plan to incorporate which nursing action when working with this client? 
    1. Listening attentively 
    2. Keeping communications brief 
    3. Approaching the client in a formal manner 
    4. Avoiding looking at the affected skin areas
    1. Listening attentively
  35. A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? 
    1. Superficial 
    2. Full-thickness 
    3. Deep partial-thickness 
    4. Partial-thickness superficial
    2. Full-thickness
  36. A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? 
    1. Keep the client on NPO status. 
    2. Allow the client to have full liquids. 
    3. Give the client small glasses of clear liquids. 
    4. Order the client a full meal tray with extra liquids.
    1. Keep the client on NPO status.
  37. A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound? 
    1. Dry sterile dressing 
    2. Wet to dry dressing 
    3. Gelfoam sponge dressing 
    4. Semipermeable film dressing
    4. Semipermeable film dressing
  38. A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 
    1. Gastric pH of 3 
    2. Absence of abdominal discomfort 
    3. GI drainage that is guaiac negative 
    4. Presence of hypoactive bowel sounds
    1. Gastric pH of 3
  39. The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item to be best to put in the chair under the client? 
    1. Pillow 
    2. Foam pad 
    3. Folded blankets 
    4. Plastic-lined absorbent pad
    2. Foam pad
  40. A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse should tell the client to take which measure? 
    1. Maintain room humidity at less than 40%. 
    2. Use very hot or very cold water for bathing. 
    3. Apply emollients once the skin is thoroughly dry. 
    4. Avoid bathing in the shower or tub more than once daily.
    4. Avoid bathing in the shower or tub more than once daily.
  41. A client has undergone laser surgery to remove two nevi. The nurse determines that the client has understood discharge instructions if he or she makes which statement? 
    1. "I can expect significant discomfort after the procedure." 
    2. "I need to cleanse the operated areas daily using scrubbing motions." 
    3. "I need to protect the operated areas from direct sunlight for at least 3 months." 
    4. "I need to report any signs of swelling or redness immediately to the health care provider."
    3. "I need to protect the operated areas from direct sunlight for at least 3 months."
  42. A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe? 
    1. White color 
    2. Pink or red color 
    3. Weeping blisters 
    4. Insensitivity to pain and cold
    2. Pink or red color
  43. The nurse provides home care instructions to a client diagnosed with impetigo. Which statement by the client indicates the need for further instruction? 
    1. "I need to continue with the antibiotics as prescribed." 
    2. "I need to wash my hands thoroughly and frequently throughout the day." 
    3. "I should wash my dishes separately from those of other household members." 
    4. "It is not necessary to separate my linen and towels from those of other household members."
    4. "It is not necessary to separate my linen and towels from those of other household members."
  44. The nurse inspects the oral cavity of a client with candidiasis (thrush). Which finding should the nurse expect to note in this client? 
    1. The presence of blisters 
    2. The presence of white patches 
    3. The presence of purple patches 
    4. The presence of numerous small, red, pinpoint lesions
    2. The presence of white patches
  45. A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? 
    1. Eschar 
    2. Intact blisters 
    3. Liquefaction necrosis 
    4. Cherry-red, firm tissue
    3. Liquefaction necrosis
  46. The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction? 
    1. "I should use tepid water for bathing." 
    2. "I need to keep my skin lubricated and cool." 
    3. "After bathing, I should pat my skin dry rather than rubbing it." 
    4. "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."
    4. "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."
  47. The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply. 
    1. Red, raised papules 
    2.  Large plaques covered by silvery scales 
    3. Tiny red vesicles that weep serous material 
    4. Erythema noted mostly under the breast area 
    5. Pink to dark red, patchy eruptions on the skin
    • 1. Red, raised papules 
    • 2. Large plaques covered by silvery scales
  48. The nurse is performing an assessment on a client with a diagnosis of pemphigus vulgaris. How should the nurse assess for the presence of Nikolsky's sign? 
    1. Note a foul odor to the skin. 
    2. Look for blisters that are draining. 
    3. Look into the mouth for white patches. 
    4. Note skin blistering and sloughing after application of lateral finger pressure on the epidermis.
    4. Note skin blistering and sloughing after application of lateral finger pressure on the epidermis.
  49. The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? 
    1. The entire period of time during which rehabilitation occurs 
    2. The period from the time the client is stable until all burns are covered with skin 
    3. The period from the time the burn was incurred to the time when the client is admitted to the hospital 
    4. The period from the time the burn was incurred to the time when the client is considered physiologically stable
    4. The period from the time the burn was incurred to the time when the client is considered physiologically stable
  50. A nurse in the ambulatory care clinic is reviewing a plan of care for a client who will be returning from the postanesthesia care unit after a blepharoplasty. Which nursing interventions should be a component of the postoperative care plan for this client? Select all that apply. 
    1. Monitoring for swelling 
    2. Elevating the head of the bed 
    3. Applying warm gauze pads to the eyes 
    4. Instructing the client to avoid Valsalva maneuvers
    5. Assessing the function of the extraocular eye muscles
    • 1. Monitoring for swelling 
    • 2. Elevating the head of the bed 
    • 4. Instructing the client to avoid Valsalva maneuvers
    • 5. Assessing the function of the extraocular eye muscles
  51. A nurse has provided home care instructions to a client after blepharoplasty. Which statement by the client indicates a need for further instruction? 
    1. "I need to keep ice on my eyes for at least 3 days." 
    2. "I need to avoid vigorous activities for about 1 month." 
    3. "I need to sleep on my back with at least two pillows under my head." 
    4. "I need to avoid activities requiring bending over at the waist for at least 48 hours."
    1. "I need to keep ice on my eyes for at least 3 days."
  52. Which information should the nurse include while providing education for a client scheduled for a rhinoplasty? 
    1. General anesthesia is always administered. 
    2. Packing will need to be removed in 1 week. 
    3. Incisions are made around the outside of the nose. 
    4. The nasal bone is fractured, and the cartilage and bone are remolded into the desired shape.
    4. The nasal bone is fractured, and the cartilage and bone are remolded into the desired shape.
  53. A nurse in the postanesthesia care unit is monitoring a client for signs of bleeding after a rhinoplasty. Which observation indicates to the nurse that bleeding may be occurring? 
    1. Frequent swallowing 
    2. Client complaints of discomfort 
    3. Ecchymosis around the client's eyes 
    4. Blood on the external nasal dressing
    1. Frequent swallowing
  54. A nurse is providing home care instructions to a client after rhinoplasty. Which statement by the client indicates a need for further instruction? 
    1. "I should sleep on two pillows to elevate my head." 
    2. "I should avoid any activities such as bending over." 
    3. "I should be sure to run a dehumidifier in my home." 
    4. "I need to sneeze through the mouth and not blow through the nose."
    3. "I should be sure to run a dehumidifier in my home."
  55. A client is seen in the health care clinic 2 weeks after rhinoplasty. The client tells the nurse that the upper lip is numb. Which nursing response would be appropriate? 
    1. "The numbness is normal and is likely to be permanent." 
    2. "In many cases the nose and upper lip are numb for up to 6 months." 
    3. "Numbness usually indicates nerve damage that occurred during the procedure." 
    4. "You will need to see the health care provider because this may indicate a complication of the procedure."
    2. "In many cases the nose and upper lip are numb for up to 6 months."
  56. A nurse has provided home care instructions to a client after dermabrasion. Which statement by the client indicates a need for further instruction? 
    1. "I need to apply wet soaks to my skin." 
    2. "I need to apply an emollient to my skin." 
    3. "I need to keep my skin dry to allow it to heal." 
    4. "I need to use sunscreen if I plan to be outdoors."
    3. "I need to keep my skin dry to allow it to heal."
  57. A client has a pressure ulcer on the sacrum. The nurse notes that the ulcer has partial-thickness skin loss and the formation of a blister. The nurse documents that the ulcer is at which stage?

    1. Stage I ulcer 
    2. Stage II ulcer 
    3. Stage III ulcer 
    4. Stage IV ulcer
    2. Stage II ulcer
  58. A client is receiving topical corticosteroid therapy for the treatment of psoriasis. The nurse anticipates noting which health care provider's prescription in the client's medical record that will maximize the effectiveness of this therapy? 
    1. Rub the application into the skin. 
    2. Place the area under a heat lamp for 20 minutes. 
    3. Apply a dry sterile dressing over the affected area. 
    4. Cover the application with a warm, moist dressing and an occlusive outer wrap.
    4. Cover the application with a warm, moist dressing and an occlusive outer wrap.
  59. The nurse is providing skin care instructions to a female client with acne vulgaris. What should the nurse instruct the client to do? 
    1. Use oil-based cosmetics. 
    2. Vigorously rub her face when washing it. 
    3. Remove cosmetics from her face at bedtime. 
    4. Wash her face once daily with an astringent cleanser.
    3. Remove cosmetics from her face at bedtime.
  60. A nurse is performing a physical assessment on a client and notes normal skin condition and turgor. The nurse understands that which structure is responsible for the skin's toughness and resiliency? 
    1. Elastic fibers 
    2. Reticular cells 
    3. Collagen fibers 
    4. Langerhans cells
    3. Collagen fibers
  61. A client complains of being cold, and the nurse notes the presence of "goose flesh" on the client's arms. The nurse plans care, knowing that which structure is responsible for this response? 
    1. Arterioles 
    2. Sweat glands 
    3. Collagen fibers 
    4. Arrector pili muscles
    4. Arrector pili muscles
  62. The nurse plans care, knowing that the skin cells that slough off during bathing are the ones found in which skin layer? 
    1. Stratum lucidum 
    2. Stratum corneum 
    3. Stratum spinosum 
    4. Stratum granulosum
    2. Stratum corneum
  63. The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply. 
    1. Lips 
    2. Tongue 
    3. Earlobes 
    4. Conjunctiva 
    5. Mucous membranes
    • 1. Lips 
    • 4. Conjunctiva 
    • 5. Mucous membranes
  64. A nurse is assessing a client who has undergone chemotherapy for cancer and notes that the client exhibits hair loss. What should the nurse document this finding as? 
    1. Xerosis 
    2. Alopecia 
    3. Hirsutism 
    4. Hyperhidrosis
    2. Alopecia
  65. A client exhibits callus formation on the plantar areas of both feet. The nurse plans care, knowing that this finding is the result of which process? 
    1. Vitiligo 
    2. Hyperkeratosis 
    3. Melanocyte activity 
    4. Apocrine gland activity
    2. Hyperkeratosis
  66. A nurse is reviewing the medical record of a client and notes documentation of melasma. What should the nurse anticipate that the client will exhibit? 
    1. Skin that is uniformly dark 
    2. Very pale skin with little pigmentation 
    3. Patches of skin with loss of pigmentation 
    4. Blotchy brown macules across the cheeks and forehead
    4. Blotchy brown macules across the cheeks and forehead
  67. A client who previously suffered a burn injury now exhibits a keloid at the burn site. The nurse plans care, knowing that this lesion is caused by hypertrophy of which part of the dermis? 
    1. Nerves 
    2. Collagen 
    3. Vasculature 
    4. Subcutaneous tissue
    2. Collagen
  68. A client with cellulitis of the lower leg has had cultures collected from the affected area. The nurse reading the culture report understands that which organism is not part of the normal flora of the skin and is a common source of wound infections? 
    1. Candida albicans 
    2. Staphylococcus aureus 
    3. Escherichia coli (E. coli
    4. Staphylococcus epidermidis
    3. Escherichia coli (E. coli)
  69. A client complains of chronic pruritus. The nurse investigating this complaint would review the medical record for documentation of which disorder as a cause of this problem? 
    1. Anemia 
    2. Hypothyroidism 
    3. Addison's disease 
    4. Chronic kidney disease
    4. Chronic kidney disease
  70. A nurse is reviewing the medical record of a client and notes documentation of reticular skin lesions. What should the nurse expect these lesions to look like? 
    1. Linear 
    2. Ring-shaped 
    3. Shaped like an arc 
    4. Net-like in appearance
    4. Net-like in appearance
  71. A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply. 
    1. Fever 
    2. Vasodilation 
    3. Inflammation 
    4. Deoxygenated hemoglobin 
    5. Excessively high environmental temperature
    • 1. Fever 
    • 2. Vasodilation 
    • 3. Inflammation 
    • 5. Excessively high environmental temperature
  72. An older client's physical examination reveals the presence of a number of round bright red lesions scattered on the trunk and thighs. The nurse recognizes that these findings, which are caused by alterations in blood vessels of the skin, are representative of which lesions? 
    1. Purpura 
    2. Venous star 
    3. Spider angioma 
    4. Cherry angioma
    4. Cherry angioma
  73. An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? 
    1. Heels 
    2. Sacrum 
    3. Back of the head 
    4. Greater trochanter
    4. Greater trochanter
  74. In planning care for the client with psoriasis, the nurse understands that which represents a priorityclient problem? 
    1. Fatigue 
    2. Constipation 
    3. Impaired safety 
    4. Altered body image
    4. Altered body image
  75. A client has been diagnosed with paronychia. The nurse plans care, knowing that this is a disorder that affects what body area? 
    1. Nails 
    2. Hair follicles 
    3. Pilosebaceous glands 
    4. Epithelial layer of skin
    1. Nails
  76. A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding mostaccurately using which term? 
    1. Purpura 
    2. Petechiae 
    3. Erythema 
    4. Ecchymosis
    4. Ecchymosis
  77. A client is diagnosed with a full-thickness burn. The nurse plans care, knowing that which structural areas of the skin are involved? 
    1. Epidermis only 
    2. Epidermis and deeper dermis 
    3. Epidermis and upper layer of dermis 
    4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat
    4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat
  78. The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet light (UVL) therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? 
    1. "Each treatment will last at least 30 minutes." 
    2. "Your entire body will be exposed to the light treatment." 
    3. "You will need to wear cotton clothes during the treatment." 
    4. "You will need to wear dark eye goggles during the treatment."
    4. "You will need to wear dark eye goggles during the treatment."
  79. The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy of a client's skin lesion. Which is an inappropriate intervention in the preprocedure plan of care? 
    1. Obtain an informed consent. 
    2. Clean the area of the lesion with water. 
    3. Prepare to apply direct pressure to the biopsy site after the procedure. 
    4. Tell the client that a small piece of tissue will be removed for examination.
    2. Clean the area of the lesion with water.
  80. The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply. 
    1. Acne requires active treatment for control until it resolves. 
    2. Oily skin and a genetic predisposition may be contributing factors for acne. 
    3. Acne is an acute skin disorder that usually begins in puberty and is more common in females. 
    4. The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules. 
    5. The exact cause of acne is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes (and the enzymes that reduce lipids to irritating fatty acids).
    • 1. Acne requires active treatment for control until it resolves. 
    • 2. Oily skin and a genetic predisposition may be contributing factors for acne. 
    • 4. The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules. 
    • 5. The exact cause of acne is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes (and the enzymes that reduce lipids to irritating fatty acids).
  81. A nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which individual is at the greatest risk for development of an integumentary disorder? 
    1. An adolescent 
    2. An older woman 
    3. A physical education teacher 
    4. An outdoor construction worker
    4. An outdoor construction worker
  82. A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is. Which statement is the appropriate response by the nurse? 
    1. "There is no pain associated with this procedure." 
    2. "The local anesthetic may cause a burning or stinging sensation." 
    3. "A preoperative medication will be given so you will be sleeping and will not feel any pain." 
    4. "There is some pain, but the health care provider will prescribe an opioid analgesic after the procedure."
    2. "The local anesthetic may cause a burning or stinging sensation."
  83. The nurse is reviewing discharge instructions for a client who had a skin biopsy. Which statement by the client indicate a need for further instruction? 
    1. "I will use the antibiotic ointment as prescribed." 
    2. "I will return in 7 days to have the sutures removed." 
    3. "I will remove the dressing as soon as I get home and wash it with tap water." 
    4. "I will call the health care provider (HCP) if I see any drainage from the wound."
    3. "I will remove the dressing as soon as I get home and wash it with tap water."
  84. The nurse prepares to assist a health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include in the plan for this procedure? 
    1. Prepare a local anesthetic. 
    2. Obtain an informed consent. 
    3. Darken the room for the examination. 
    4. Shave the skin and scrub with povidone-iodine solution.
    3. Darken the room for the examination.
  85. The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition? 
    1. Rapid and continuous rewarming of the toes after flushing returns 
    2. Rapid and continuous rewarming of the toes in cold water for 45 minutes 
    3. Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes 
    4. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs
    4. Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs
  86. The clinic nurse inspects the skin of a client with suspected scabies. Which assessment finding will the nurse note if this disorder is present? 
    1. Patchy hair loss and round red macules with scales 
    2. The presence of white patches scattered about the trunk 
    3. Multiple straight or wavy, threadlike lines beneath the skin 
    4. The appearance of vesicles or pustules with a thick honey-colored crust
    3. Multiple straight or wavy, threadlike lines beneath the skin
  87. The nurse is assigned to care for a client with herpes zoster (shingles). Which characteristic would the nurse expect to note when assessing the lesions of this infection? 
    1. Clustered skin vesicles 
    2. A generalized body rash 
    3. Small blue-white spots with a red base 
    4. A fiery red, edematous rash on the cheeks
    1. Clustered skin vesicles
  88. Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instructions? 
    1. "Treatments are limited to two or three times a week." 
    2. "The UV light treatments are given on consecutive days." 
    3. "Eye goggles need to be worn to prevent exposure to UV light." 
    4. "Just the area requiring treatment should be exposed to the UV light."
    2. "The UV light treatments are given on consecutive days."
  89. The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. 
    1. Antibiotic therapy 
    2. Cold compresses to the affected area 
    3. Warm compresses to the affected area 
    4. Intermittent heat lamp treatments four times daily 
    5. Alternating hot and cold compresses continuously
    • 1. Antibiotic therapy 
    • 3. Warm compresses to the affected area
  90. Which individual is least likely to be at risk for development of psoriasis? 
    1. A 32-year-old African American 
    2. A woman experiencing menopause 
    3. A client with a family history of the disorder 
    4. An individual who has experienced a significant amount of emotional distress
    1. A 32-year-old African American
  91. A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 
    1. 1200 mL of 5% dextrose in water solution 
    2. 2400 mL of 0.45% normal saline solution 
    3. 4800 mL of 0.9% normal saline solution 
    4. 9600 mL of lactated Ringer's solution
    4. 9600 mL of lactated Ringer's solution
  92. Which finding indicates a burn client is adequately fluid resuscitated? 
    1. Disorientation to time only 
    2. Heart rate of 95 beats/minute 
    3. +1 palpable peripheral pulses 
    4. Urine output of 30 mL over the last 2 hours
    2. Heart rate of 95 beats/minute
  93. A nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? 
    1. Sclera 
    2. Oral mucosa 
    3. Soles of the foot 
    4. Palms of the hand
    2. Oral mucosa
  94. A nurse reviews the health record of a client with melasma. The nurse would anticipate that this client will exhibit which skin characteristic? 
    1. Skin that is uniformly dark in color 
    2. Very pale skin with little pigmentation 
    3. Patches of skin that have loss of pigmentation 
    4. Blotchy brown macules across the cheeks and forehead
    4. Blotchy brown macules across the cheeks and forehead
  95. The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report notes that which organism documented is not part of the normal flora of the skin? 
    1. Escherichia coli 
    2. Candida albicans 
    3. Staphylococcus aureus 
    4. Staphylococcus epidermidis
    1. Escherichia coli
  96. A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client' medical record that would support this client's complaint? 
    1. Anemia 
    2. Hypothyroidism 
    3. Diabetes mellitus 
    4. Chronic kidney disease
    4. Chronic kidney disease
  97. A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder? 
    1. Hyperthyroidism 
    2. Pernicious anemia 
    3. Cardiopulmonary disorders 
    4. Systemic lupus erythematosus (SLE)
    4. Systemic lupus erythematosus (SLE)
  98. The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. The nurse correctly interprets the finding as alterations in blood vessels of the skin and defines them as which type of lesions? 
    1. Purpura 
    2. Venous star 
    3. Cherry angioma 
    4. Spider angioma
    3. Cherry angioma
  99. A client has been diagnosed with paronychia. The nurse understands that this is a disorder of which anatomical area? 
    1. Nails 
    2. Hair follicles 
    3. Pilosebaceous glands 
    4. Epithelial layer of skin
    1. Nails
  100. A client is diagnosed with a full-thickness burn. The nurse understands that which structural areas of the skin are involved? 
    1. Epidermis only 
    2. Epidermis and deeper dermis 
    3. Epidermis and upper layer of dermis 
    4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat
    4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat
  101. A client is admitted to the hospital with cellulitis of the lower leg. The nurse should anticipate which therapy to be prescribed? 
    1. Intermittent heat lamp treatments 
    2. Alternating hot and cold compresses 
    3. Warm compresses to the affected area 
    4. Cold compresses to the affected area
    3. Warm compresses to the affected area
  102. An older client has been lying in a supine position for the last 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. 
    1. Heels 
    2. Ankles 
    3. Elbows 
    4. Sacrum 
    5. Back of the head 
    6. Greater trochanter
    • 1. Heels 
    • 3. Elbows 
    • 4. Sacrum 
    • 5. Back of the head
  103. An adult client trapped in a burning house has suffered burns to the back of the head, upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what does the nurse determine the extent of the burn injury to be?
    22.5%

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