EAQ- Integumentary Flashcards
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.
Frequently reposition the client on a scheduled basis.
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.
Lesions merge together and appear confluent.
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
Linear cracks in the epidermis that extend into the dermis
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.
It is performed using a circular cutting instrument 2 to 6 mm in diameter.
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
Glycosaminoglycan bonded to silicone membrane
Which type of biopsy is required for removal of entire lesions on the skin?
Punch biopsy
Shave biopsy
Incisional biopsy
Excisional biopsy
Excisional biopsy
Which test is used in the diagnosis of systemic lupus erythematosus?
Patch test
Photo patch test
Direct immunofluorescence test
Indirect immunofluorescence test
Direct immunofluorescence test
Which disorder is a cause of systemic altered inflammatory response in impaired wound healing?
Uremia
Cirrhosis
Leukemia
Hypovolemia
Leukemia
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
Blood-tinged amber fluid
Which infection is caused by a fungus?
Furuncle
Folliculitis
Herpes zoster
Dermatophytosis
Dermatophytosis
Which skin infection would cause facial paralysis?
Candidiasis
Herpes zoster
Herpes simplex
Dermatophytosis
Herpes zoster
Which fungal infection does the client refer to as jock itch?
Tinea pedis
Tinea cruris
Tinea corporis
Tinea unguium
Tinea cruris
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
The scar is firm and inelastic on palpation.
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
Presence of nonintact skin
Which item can cause scald injuries?
Grease
Hot liquids or steam
Alkali in oven cleaners
Open flame in house fires
Hot liquids or steam
Which secondary skin lesion may include athlete’s foot as an example?
Scar
Scale
Ulcer
Fissure
Fissure
Which disease is caused by the virus that causes chickenpox?
Athlete’s foot
Herpes zoster
German measles
Infectious hepatitis
Herpes zoster
Which component of skin maintains optimal barrier function?
Keratin
Melanin
Collagen
Adipose tissue
Keratin
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
Increased risk for hypothermia
Which clinical manifestation is characterized by eczematous eruption with well-defined geometric margins?
Medication eruption
Atopic dermatitis
Contact dermatitis
Nonspecific eczematous dermatitis
Contact dermatitis
Which condition is an example of a bacterial infection?
Impetigo
Candidiasis
Plantar warts
Verruca vulgaris
Impetigo
Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor?
Proteus
Bacteroides
Pseudomonas
Staphylococcus
Pseudomonas
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
Removing the necrotic tissue mechanically
Which clinical manifestation is associated with cellulitis?
Lymphadenopathy
Occasional papules
Vesicles that evolve into pustules
Isolated erythematous pustules
Lymphadenopathy
Which type of allergic skin condition is associated with immunological irregularity, asthma, and allergic rhinitis?
Urticaria
Psoriasis
Acne vulgaris
Atopic dermatitis
Atopic dermatitis
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
Nevi
Which type of laser is used in the treatment of vascular and other pigmented lesions?
Argon
Gold vapors
Neodymium
Carbon dioxide
Argon
Which dermatological problem is treated by using intralesional corticosteroids?
Psoriasis
Cellulitis
Erysipelas
Carbuncles
Psoriasis
Which surgery is used to treat excessive wrinkling or sagging of facial skin?
Rhinoplasty
Rhytidectomy
Dermabrasion
Blepharoplasty
Rhytidectomy
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.
Explain that the incision should not be immersed in water until it has healed.
Which benign condition shows silver scaly plaques on the skin?
Nevi
Psoriasis
Urticaria
Acne vulgaris
Psoriasis
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
All of the above
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
All of the above
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
Brown or black mole with red, white, or blue areas
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
Macule
Which skin color alteration may be observed in a client diagnosed with methemoglobinemia?
Red
Blue
White
Yellow-orange
Blue
Which is a serious side effect of x-rays?
Vesicles
Papules
Desquamation
Plaque-like lesions
Desquamation
Which clinical manifestation is associated with hypernatremia in burns?
Fatigue
Seizures
Paresthesias
Cardiac dysrhythmias
Seizures
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
Photoaging
Wrinkling of skin
Which physical changes may cause longitudinal nail ridges?
Decreased rate of growth
Decreased cell division
Decreased blood flow
Decreased vitamin D production
Decreased blood flow
Which color would the nurse anticipate when assessing a client’s skin tears?
Red
Gray
Black
Yellow
Red
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
Keeping the client’s skin directly off plastic surfaces
Which condition would a nurse suspect when a client reports crumbly, discolored, and thickened toenails?
Allergy
Insect bite
Fungal infection
Bacterial infection
Fungal infection
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
Decreased melanocytes
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
Abdominal distention
The client with burn injuries may have abdominal distention due to loss of peristalsis
Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs?
Tenting
Angioma
Varicosity
Telangiectasia
Telangiectasia
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
The visible swelling due to extravasation of blood of sufficient size
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
Seeking professional treatment for any minor injuries to the extremities
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
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.
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.”
“Wash with soap and water.”
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.”
“Tell me why you want to refuse the procedure.”
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
Impetigo
Which fungal infection is commonly referred to as athlete’s foot?
Tinea pedis
Tinea cruris
Tinea corporis
Tinea unguium
Tinea pedis
Which type of skin lesion has a wavy border?
Annular
Circinate
Coalesced
Serpiginous
Serpiginous
Which assessment finding is associated with chronic eczema?
Localized edema
Rough, thick skin
Decreased skin turgor
Increased skin temperature
Rough, thick skin
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
Tinea pedis
Which changes to the client’s skin are caused by the atrophy of eccrine sweat glands?
Ecchymosis
Dry skin
Wrinkles
Skin shearing
Dry skin
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
Pressure injuries
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
Provides cells for wound healing
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.”
“Clean the mouth with a soft toothbrush or a gentle spray.”
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].”
“Personal protective equipment will be worn by staff.”
Which term would the nurse use to document a 1 cm elevated solid lesion noted on a client’s skin?
Papule
Nodule
Vesicle
Pustule
Nodule
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
All of the above
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
Forgets home address
Which characteristic mental change occurs with delirium and differentiates it from dementia?
Daytime sleepiness
Rapid-onset confusion
Lasts over several years
Progressive deterioration
Rapid-onset confusion
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).”
“I will use deodorant soap in place of alkaline soap.”
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 lesion filled with serous fluid
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
30 degrees
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.”
“Apply an alcohol free, moisturizing lotion several times a day.”
Which type of lesion does the client with an elevated, solid lesion measuring 4 mm × 4 mm in size have?
Papule
Vesicle
Pustule
Macule
Papule
A hospital-acquired infection is also called a/an ___________ infection.
nosocomial
You know that acetaminophen should be effective in reducing Dave’s temperature because of its ____________ action.
antipyretic
anti-inflammatory
analgesic
antiinfective
antipyretic
