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Nurs 120- MCA I > EAQ- Integumentary > Flashcards

EAQ- Integumentary Flashcards

1
Q

Which nursing intervention assists in decreasing the potential occurrence of pressure ulcers when providing care for a client with quadriplegia?

Avoid massaging the client’s legs.

Frequently reposition the client on a scheduled basis.

Increase the fiber content in the client’s food.

Encourage the client to participate in weight-bearing exercises.

A

Frequently reposition the client on a scheduled basis.

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2
Q

Which description describes a coalesced type of skin lesion configuration?

Lesions are well defined with sharp borders.

Lesions merge together and appear confluent.

Lesions are ringlike around flat centers of skin.

Lesions have wavy borders that resemble a snake.

A

Lesions merge together and appear confluent.

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3
Q

Which description is associated with fissures?

Deep erosions that extend beneath the epidermis

Thinning of the skin surface with a loss of skin markings

Linear cracks in the epidermis that extend into the dermis

Thickened areas of epidermis with accentuated skin markings

A

Linear cracks in the epidermis that extend into the dermis

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4
Q

Which characteristic does the nurse associate with a punch biopsy?

It is usually indicated for superficial or raised lesions.

It is more uncomfortable than other biopsies while healing.

It is performed using a circular cutting instrument 2 to 6 mm in diameter.

It removes only the portion of the skin that rises above the surrounding tissue.

A

It is performed using a circular cutting instrument 2 to 6 mm in diameter.

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5
Q

Which form is a source of the dermal regeneration template graft?

Porcine skin

Cadaveric skin

Glycosaminoglycan bonded to silicone membrane

Porcine collagen bonded to silicone membrane

A

Glycosaminoglycan bonded to silicone membrane

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6
Q

Which type of biopsy is required for removal of entire lesions on the skin?

Punch biopsy

Shave biopsy

Incisional biopsy

Excisional biopsy

A

Excisional biopsy

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7
Q

Which test is used in the diagnosis of systemic lupus erythematosus?

Patch test

Photo patch test

Direct immunofluorescence test

Indirect immunofluorescence test

A

Direct immunofluorescence test

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8
Q

Which disorder is a cause of systemic altered inflammatory response in impaired wound healing?

Uremia

Cirrhosis

Leukemia

Hypovolemia

A

Leukemia

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9
Q

Which term would the nurse use to describe the exudate characteristic of a serosanguineous wound?

Greenish-blue pus

Creamy yellow exudate

Blood-tinged amber fluid

Beige pus with a fishy odor

A

Blood-tinged amber fluid

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10
Q

Which infection is caused by a fungus?

Furuncle

Folliculitis

Herpes zoster

Dermatophytosis

A

Dermatophytosis

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11
Q

Which skin infection would cause facial paralysis?

Candidiasis

Herpes zoster

Herpes simplex

Dermatophytosis

A

Herpes zoster

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12
Q

Which fungal infection does the client refer to as jock itch?

Tinea pedis

Tinea cruris

Tinea corporis

Tinea unguium

A

Tinea cruris

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13
Q

Which feature is associated with the “maturation phase” of normal wound healing?

The scar is firm and inelastic on palpation.

Fibrin strands form a scaffold or framework.

White blood cells migrate into the wound.

Epithelial cells are grown over the granulation tissue bed

A

The scar is firm and inelastic on palpation.

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14
Q

Which key feature is associated with a stage 2 pressure ulcer?

Presence of nonintact skin

Development of sinus tracts

Damage to the subcutaneous tissues

Appearance of a reddened area over a bony prominence

A

Presence of nonintact skin

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15
Q

Which item can cause scald injuries?

Grease

Hot liquids or steam

Alkali in oven cleaners

Open flame in house fires

A

Hot liquids or steam

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16
Q

Which secondary skin lesion may include athlete’s foot as an example?

Scar

Scale

Ulcer

Fissure

A

Fissure

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17
Q

Which disease is caused by the virus that causes chickenpox?

Athlete’s foot

Herpes zoster

German measles

Infectious hepatitis

A

Herpes zoster

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18
Q

Which component of skin maintains optimal barrier function?

Keratin

Melanin

Collagen

Adipose tissue

A

Keratin

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19
Q

Which clinical finding occurs due to thinning of the subcutaneous layer?

Decreased tone and elasticity

Decreased sensory perception

Increased risk for hypothermia

Increased susceptibility to dry skin

A

Increased risk for hypothermia

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20
Q

Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins?

Medication eruption

Atopic dermatitis

Contact dermatitis

Nonspecific eczematous dermatitis

A

Contact dermatitis

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21
Q

Which condition is an example of a bacterial infection?

Impetigo

Candidiasis

Plantar warts

Verruca vulgaris

A

Impetigo

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22
Q

Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor?

Proteus

Bacteroides

Pseudomonas

Staphylococcus

A

Pseudomonas

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23
Q

Which mechanism of action would a nurse recall when using wet-to-damp saline-moistened gauze for wound debridement?

Promoting the dilution of viscous exudate

Removing the necrotic tissue mechanically

Causing a breakdown of the denatured protein of the eschar

Promoting the spontaneous separation of necrotic tissue

A

Removing the necrotic tissue mechanically

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24
Q

Which clinical manifestation is associated with cellulitis?

Lymphadenopathy

Occasional papules

Vesicles that evolve into pustules

Isolated erythematous pustules

A

Lymphadenopathy

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25
Q

Which type of allergic skin condition is associated with immunological irregularity, asthma, and allergic rhinitis?

Urticaria

Psoriasis

Acne vulgaris

Atopic dermatitis

A

Atopic dermatitis

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26
Q

Which benign condition of the client’s skin is associated with the grouping of normal cells derived from melanocytelike precursor cells?

Nevi

Psoriasis

Acne vulgaris

Plantar warts

A

Nevi

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27
Q

Which type of laser is used in the treatment of vascular and other pigmented lesions?

Argon

Gold vapors

Neodymium

Carbon dioxide

A

Argon

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28
Q

Which dermatological problem is treated by using intralesional corticosteroids?

Psoriasis

Cellulitis

Erysipelas

Carbuncles

A

Psoriasis

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29
Q

Which surgery is used to treat excessive wrinkling or sagging of facial skin?

Rhinoplasty

Rhytidectomy

Dermabrasion

Blepharoplasty

A

Rhytidectomy

30
Q

Which action would the nurse take when a client who had a total hip replacement states that the plan is to go swimming at the community pool the day after discharge?

Tell the client to take a friend along for safety.

Encourage participation in this activity because it provides excellent range-of-motion exercise.

Explain that the incision should not be immersed in water until it has healed.

Let the client know that swimming can substitute for the prescribed physical therapy.

A

Explain that the incision should not be immersed in water until it has healed.

30
Q

Which benign condition shows silver scaly plaques on the skin?

Nevi

Psoriasis

Urticaria

Acne vulgaris

A

Psoriasis

30
Q

Which information would the nurse include in a community education session on decreasing the risk for musculoskeletal injuries? Select all that apply. One, some, or all responses may be correct.

Use of seatbelts

Obeying speed limits

Wearing safety equipment

Avoiding impaired vehicle use

Refraining from distracted driving

A

All of the above

31
Q

Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster? Select all that apply. One, some, or all responses may be correct.

Acyclovir

Silvadene

Gabapentin

Wet compresses

Contact isolation

A

All of the above

32
Q

Which physical assessment finding would the nurse expect in a client admitted with a suspected malignant melanoma on the arm?

Large area of petechiae

Red birthmark that has recently become lighter in color

Brown or black mole with red, white, or blue areas

Patchy loss of skin pigmentation

A

Brown or black mole with red, white, or blue areas

33
Q

Which type of skin lesion would be suspected when the nurse notices a minute, nonpalpable change in the skin color of a client?

Wheal

Papule

Vesicle

Macule

A

Macule

34
Q

Which skin color alteration may be observed in a client diagnosed with methemoglobinemia?

Red

Blue

White

Yellow-orange

A

Blue

35
Q

Which is a serious side effect of x-rays?

Vesicles

Papules

Desquamation

Plaque-like lesions

A

Desquamation

35
Q

Which clinical manifestation is associated with hypernatremia in burns?

Fatigue

Seizures

Paresthesias

Cardiac dysrhythmias

A

Seizures

36
Q

Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply. One, some, or all responses may be correct.

Dryness

Photoaging

Vascular lesions

Wrinkling of skin

Benign neoplasm

A

Photoaging
Wrinkling of skin

37
Q

Which physical changes may cause longitudinal nail ridges?

Decreased rate of growth

Decreased cell division

Decreased blood flow

Decreased vitamin D production

A

Decreased blood flow

38
Q

Which color would the nurse anticipate when assessing a client’s skin tears?

Red

Gray

Black

Yellow

A

Red

39
Q

Which intervention would be included in the plan of care for the prevention of a pressure injury?

Positioning a client directly on the trochanter

Keeping the client’s skin directly off plastic surfaces

Keeping the head of the bed elevated above 30 degrees

Placing a rubber ring or donut under the client’s sacral area

A

Keeping the client’s skin directly off plastic surfaces

40
Q

Which condition would a nurse suspect when a client reports crumbly, discolored, and thickened toenails?

Allergy

Insect bite

Fungal infection

Bacterial infection

A

Fungal infection

41
Q

Which changes with a client’s hair would be responsible for developing white hair at the age of 23?

Decreased oils

Decreased density

Decreased estrogen levels

Decreased melanocytes

A

Decreased melanocytes

42
Q

Which gastrointestinal (GI) change may be found in the client with burn injuries?

Abdominal distention

Increased peristalsis

Activation of GI motility

Increased blood flow to the GI area

A

Abdominal distention

The client with burn injuries may have abdominal distention due to loss of peristalsis

43
Q

Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs?

Tenting

Angioma

Varicosity

Telangiectasia

A

Telangiectasia

44
Q

Which description is associated with a hematoma?

The occurrence of redness in patches of variable size and shape

The thickening of the skin with accentuated normal skin markings

The visible swelling due to extravasation of blood of sufficient size

The pinpoint, discrete deposits of blood in the extravascular tissues

A

The visible swelling due to extravasation of blood of sufficient size

45
Q

Which direction will the nurse include in the teaching plan for a client with lower extremity arterial disease (LEAD)?

Trimming toenails so that they are short and rounded

Checking bathwater temperature by putting the toes in first

Using alcohol to rub hands, feet, legs, and arms at least two times a day

Seeking professional treatment for any minor injuries to the extremities

A

Seeking professional treatment for any minor injuries to the extremities

46
Q

Which percentage of total body surface area (TBSA) would the nurse calculate for a burn victim who has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms?

20

25

30

36

A

36

Using the rule of nines, the percentage of total body surface area burned is 9% for each arm (18% total for both arms) and 18% for the anterior trunk; thus the total body surface area burned is 36%. The choices 20%, 25%, and 30% are too low.

47
Q

Which teaching point would the nurse include when teaching a client about how to care for the skin around a colostomy stoma?

“Wash with soap and water.”

“Rinse the area with peroxide.”

“Apply a thick coat of an emollient.”

“Rub vigorously to remove hardened feces.”

A

“Wash with soap and water.”

48
Q

Which response by the nurse is therapeutic when a male client with ascites is to have a paracentesis and has signed the consent but, while the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure?

“Why did you sign the consent?”

“Tell me why you want to refuse the procedure.”

“You are obviously afraid about something concerning the procedure.”

“Although the procedure is very important, I understand why you changed your mind.”

A

“Tell me why you want to refuse the procedure.”

49
Q

Which infection is suspected by the primary health care provider when a client reports facial lesions that are surrounded by redness and cause itching with lesions that are found to be thick with a honey-colored crust and surrounded by erythema?

Shingles

Impetigo

Folliculitis

Verruca vulgaris

A

Impetigo

50
Q

Which fungal infection is commonly referred to as athlete’s foot?

Tinea pedis

Tinea cruris

Tinea corporis

Tinea unguium

A

Tinea pedis

51
Q

Which type of skin lesion has a wavy border?

Annular

Circinate

Coalesced

Serpiginous

A

Serpiginous

52
Q

Which assessment finding is associated with chronic eczema?

Localized edema

Rough, thick skin

Decreased skin turgor

Increased skin temperature

A

Rough, thick skin

53
Q

Which condition would a nurse suspect when a client with a skin infection reports an itching sensation associated with pain at the site of infection and shows erythematous blisters and interdigital scaling and maceration?

Tinea pedis

Tinea cruris

Tinea corporis

Tinea unguium

A

Tinea pedis

54
Q

Which changes to the client’s skin are caused by the atrophy of eccrine sweat glands?

Ecchymosis

Dry skin

Wrinkles

Skin shearing

A

Dry skin

55
Q

Which complication is being prevented by the nurse frequently repositioning a client with advanced muscular dystrophy who has respiratory distress?

Renal calculi

Disorientation

Pressure injuries

Urinary infection

A

Pressure injuries

56
Q

Which statement describes the function of the dermis?

Provides cells for wound healing

Assists in retention of body heat

Acts as mechanical shock absorber

Inhibits proliferation of microorganisms

A

Provides cells for wound healing

57
Q

Which information would the nurse include in the teaching plan of a client who is receiving combination chemotherapy for stage II Hodgkin disease and is at risk for stomatitis?

“Rinse the mouth 3 times a day with lemon juice and water.”

“Brush the teeth once daily and use dental floss after each meal.”

“Clean the mouth with a soft toothbrush or a gentle spray.”

“Gently clean the mouth with commercial mouthwash.”

A

“Clean the mouth with a soft toothbrush or a gentle spray.”

58
Q

Which information will the nurse explain to a burn client receiving the open method for wound treatment?

“Bathing will not be permitted.”

“Dressings will be changed daily.”

“Personal protective equipment will be worn by staff.”

“Room temperature will be kept below 72°F [22.2°C].”

A

“Personal protective equipment will be worn by staff.”

59
Q

Which term would the nurse use to document a 1 cm elevated solid lesion noted on a client’s skin?

Papule

Nodule

Vesicle

Pustule

A

Nodule

60
Q

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct.

Monitoring vital signs

Cutting off the clothing

Inserting a urinary catheter

Removing the client’s jewelry

Establishing an intravenous line

A

All of the above

61
Q

Which finding would indicate that a client needs to be evaluated by the health care provider for Alzheimer disease (AD)?

Forgets home address

Has difficulty multitasking

Unable to find food in freezer

Neglects balancing checkbook

A

Forgets home address

62
Q

Which characteristic mental change occurs with delirium and differentiates it from dementia?

Daytime sleepiness

Rapid-onset confusion

Lasts over several years

Progressive deterioration

A

Rapid-onset confusion

63
Q

Which client statement about self-care measures to prevent dry skin indicates the need for further teaching?

“I will decrease intake of caffeine and alcohol.”

“I will use deodorant soap in place of alkaline soap.”

“I will wear splints at night to prevent scratching in a deep sleep.”

” I will adjust my thermostat to remain around 74°F to 78°F (23.3°C–25.5°C).”

A

“I will use deodorant soap in place of alkaline soap.”

64
Q

Which description of a vesicle would a nurse recall when reading a report for a client that has interacted with poison ivy and has vesicles on the arms and legs?

A lesion filled with purulent drainage

An erosion into the dermis

A solid mass of fibrous tissue

A lesion filled with serous fluid

A

A lesion filled with serous fluid

65
Q

At which angle will the nurse place the head of the bed to prevent the effects of shearing force when caring for a client who has been in a coma for 2 months and is being maintained on bed rest?

30 degrees

45 degrees

60 degrees

90 degrees

A

30 degrees

66
Q

Which recommendations would the nurse include in a client’s discharge instructions regarding a home skincare program for psoriasis?

“Shower twice a day with mild soap and warm water.”

“Soak the affected areas in hot water on a daily basis.”

“Apply an alcohol free, moisturizing lotion several times a day.”

“Cover affected areas when in contact with others.”

A

“Apply an alcohol free, moisturizing lotion several times a day.”

67
Q

Which type of lesion does the client with an elevated, solid lesion measuring 4 mm × 4 mm in size have?

Papule

Vesicle

Pustule

Macule

A

Papule

68
Q

A hospital-acquired infection is also called a/an ___________ infection.

A

nosocomial

69
Q

You know that acetaminophen should be effective in reducing Dave’s temperature because of its ____________ action.

antipyretic

anti-inflammatory

analgesic

antiinfective

A

antipyretic

Nurs 120- MCA I (19 decks)

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