INTEGUMENTARY Flashcards
The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action?
A/ Immobilize the affected extremity.
B/ Remove jewelry and constricting clothing from the victim.
C/ Place the extremity in a position so that it is below the level of the heart.
D/ Move the victim to a safe area away from the snake and encourage the victim to rest.
D/ Move the victim to a safe area away from the snake and encourage the victim to rest.
In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom.
The victim should be transported to an emergency facility as soon as is possible.
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?
A/ An inflammation of the epidermis only
B/ A skin infection of the dermis and underlying hypodermis
C/ An acute superficial infection of the dermis and lymphatics
D/ An epidermal and lymphatic infection caused by Staphylococcus
B/ A skin infection of the dermis and underlying hypodermis
Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics.
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?
A/ Metastasis is rare.
B/ It is encapsulated.
C/ It is highly metastatic.
D/ It is characterized by local invasion.
C/ METASTATIC
Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a person’s survival depends on early diagnosis and treatment. Options 1, 2, and 4 are not characteristics of a melanoma.
When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding?
A/ An irregularly shaped lesion
B/ A small papule with a dry, rough scale
C/ A firm, nodular lesion topped with crust
D/ A pearly papule with a central crater and a waxy border
A/ An irregularly shaped lesion
A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned colour. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Basal cell carcinoma appears as a pearly papule
with a central crater and rolled waxy border.
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?
A/ A pink, edematous hand
B/ A fiery red skin with edema in the nail beds
C/ Black fingertips surrounded by an erythematous rash
D/ A white colour to the skin, which is insensitive to touch
D/ A white colour to the skin, which is insensitive to touch
Assessment findings in frostbite include a white or blue colour; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.
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?
A/ Return of distal pulses
B/ Brisk bleeding from the site
C/ Decreasing edema formation D/ Formation of granulation tissue
A/ Return of pulses
Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.
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?
A/ Transfusing 1 unit of packed red blood cells
B/ Administering a diuretic to increase urine output
C/ Increasing the amount of intravenous (IV) lactated Ringer’s solution administered per hour
D/ Changing the IV lactated Ringer’s solution to one that contains dextrose in water
C/ Increasing the amount of intravenous (IV) lactated Ringer’s solution administered per hour
Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer’s solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hour. The client’s urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer’s solution administered per hour.
A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client?
SELECT ALL THAT APPLY
1. Assign NPO status
2. Assess for airway patency.
3. Administer oxygen as prescribed.
4. Place a cooling blanket on the client.
5. Elevate extremities if no fractures are present.
6. Prepare to give oral pain medication as prescribed.
- NPO status
- Assess for airway patency.
- Administer oxygen as prescribed.
- Elevate extremities if no fractures are present.
The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock. The client is kept warm and placed on NPO status because of the altered gastrointestinal function that occurs as a result of a burn injury.
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? A/ Decreased heart rate B/ Increased urinary output C/ Increased blood pressure D/ Elevated hematocrit levels
D/ Elevated hematocrit
The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts.
Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?
A/ 100% oxygen via an aerosol mask
B/ Oxygen via nasal cannula at 6 L/minute
C/ Oxygen via nasal cannula at 15 L/minute
D/ 100% oxygen via a tight-fitting, nonrebreather face mask
D/ 100% oxygen via a tight-fitting, nonrebreather face mask
f an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed.
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? A/ Vital signs B/ Urine output C/ Mental status D/ Peripheral pulses
B/ Urine output
Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.
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? A/ Tinnitus B/ Diarrhea C/ Constipation D/ Decreased respirations
A/ Tinnitus
Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.
Isotretinoin (Amnesteem or Claravis) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? A/ Platelet count B/ Triglyceride level C/ Complete blood count D/ White blood cell count
B/ Triglyceride level
Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment.
A client with severe acne is seen in the clinic and the health care provider (HCP) prescribes isotretinoin (Amnesteem or Claravis). The nurse reviews the client’s medication record and would contact the HCP if the client is taking which medication? A/ Vitamin A B/ Digoxin (Lanoxin) C/ Furosemide (Lasix) D/ Phenytoin (Dilantin)
A/ Vitamin A
Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. Options 2, 3, and 4 are not contraindicated with the use of isotretinoin.
The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication were being applied to which body area? A/ Back B/ Axilla C/ Soles of the feet D/ Palms of the hands
B/ Axilla
Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles).
