Integumentary and Other Maps

Question 1

Malignant Melanoma

Answer 1

Skin cancer occurs when cells in the skin turn cancerous.

Question 2

What is skin cancer?

Answer 2

It occurs when cells in the epidermis turn into cancerous cells.

Question 3

Melanoma

Answer 3

occurs when the melanocytes become cancerous…hence why most lesions of melanoma are dark in color.

Question 4

ABCDE Melanoma

Answer 4

Asymmetrical: if you draw a line in the middle of it, it should look the same on each side…abnormal would be that it doesn’t look the same (asymmetrical)

Border are uneven

Color: watch out for dark black or multiple colors

Diameter: greater than 6mm

Evolution: changes in size, shape, and color

Question 5

Skin Cancer Prevention

Answer 5

Avoid direct sun exposure between 10 am – 4 pm (sun rays are the strongest during these times)

Wear long-sleeves, sun glasses, and a hat to avoid unnecessary sun exposure.

Use a sunscreen that is broad-spectrum with a SPF of 15 or higher for exposed areas when outside.

Avoid tanning beds and toxic chemical on the skin.

Question 6

Skin Cancer Treatment

Answer 6

radiation
Chemotherrapy

Question 7

Risk Factors for Skin Cancer

Answer 7

Too much sun exposure (using tanning beds)

Predisposition due to genetics (melanoma can be more common in certain families)

Light skin, blonde, red hair, green or blue eyes

Exposure to toxic chemicals
History of frequent sunburns as a child

Question 8

Nonmelanoma

Answer 8

these are types of skin cancer that do NOT originate from melanocytes so they’re not considered melanoma:

Question 9

Basal Cell Carcinoma:

Answer 9

most common form of skin cancer…appearance: “pearly” glossy, shiny, waxy, small raised bump with a depressed center and slightly elevated border.
It’s slow growing and metastasis (meaning the cancer spreads to other organs) is very rare….it originates from the basal cells in epidermis.

Question 10

Squamous Cell Carcinoma:

Answer 10

appearance: “crusty” hard-covering, scaly, pink or reddish and raised. It’s faster growing that basal cell and can metastasize…it originates from keratinocytes found in the squamous layer.

Question 11

Actinic Keratosis (solar keratosis)

Answer 11

appearance: scaly reddened patches
It’s precancerous and can develop into squamous cell carcinoma, if not removed.
It tends to affect older white adults and forms in areas exposed to the sun like the top of the head, face, arms etc.

Question 12

Burns

Answer 12

Injuries caused by direct tissue damage from exposure to the sun, chemicals, thermal and even electricity

Question 13

First degree burn

Answer 13

Superficial, damage too epidermis
Dry with blanch able redness

Question 14

Second degree burn

Answer 14

Partial thickness
Affects epidermis and dermis
Painful blisters
Red, moist, shiny fluid fileld vesicles
Can be treated outpatient with wound care and dressing changes

Question 15

Third Degree Burn

Answer 15

Full thickness
Affects the epidermis, dermis and possible subcutaneous tissue
Dry waxy white, leathery or charred black colour, non-blanchable
Deadly

Question 16

Fourth Degree Burn

Answer 16

Full thickness
Goes through all layer of skin, down to the muscles and bones
Lack of pain - nerves are damaged
May look similar to 3rd degree but are much worse because they are much deeper
Deadly requiring intensive care

Question 17

Care for minor burns

Answer 17

Cool water: briefly soak area, no ice, no creams, no antibiotic ointment to open skin (scan lad to additional damage)
Cover the area “clean dry cloth” prevent infection and more damage
Clothing + removal not adhered to the burnt skin, only the HPC should remove anything adhering to the burn

Question 18

The nurse instructs firefighters that in the event of a tar burn which is the immediate action?

Answer 18

Cooling the injury with water

Question 19

Chemical burn injury… the nurse instruct the employees that which is the first consideration in immediate care?

Answer 19

Removing all clothing including gloves, s hoes and any undergarments

Question 20

Discharge teaching to a client with partial thickness burns (second-degree burns) on the hand:

Answer 20

Wrap fingers with individual dressings

Question 21

Major Burns Pathophysiology

Answer 21

Can cause massive tissue damage and cellular destruction, resulting in widespread systemic inflammation
causes leaky blood vessels that fill up the body like a water balloon
Fluid, electrolytes, proteins and other contents spill over into the interstitial spaces (third spaces)
Severely low fluid volume = Hypovolemic shock

Question 22

1 intervention for major burns in the first 24 hours

Answer 22

IV lactated ringers
IV normal Saline
ONLY Isotonic fluids - stay inside veins longer than any other solution and mimics the composition of human blood - increased the fluid volume inside the blood vessels = increases blood pressure

*NOT 5% dextrose, NOT 0.45% saline

Question 23

The nurse if caring for a client with full thickness burns covering 20% of their body. What is the priority of care after ensuring a patent airway

Answer 23

IV fluids

Question 24

Extensive Burn injury… 45% of total body surface area. Planning for fluid resuscitation the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period?

Answer 24

Between 18 and 24 hours after the injury

Question 25

Major Burns signs and symptoms First 24 hours

Answer 25

High Potassium over 5.0
potassium, priority, pumps heart
High Potassium = High Pumps of the heat
High Potassium = tall peaked T waves on ECG
Hyponatremia, Low sodium below 135

Elevated hemoglobin (12-18 Normal) and Hematocrit (36-54% normal) due to low blood volume, makes remaining blood thick and concentrated

Question 26

Severe burn injury that covers 35% of the total body surface area. the nurse iim most likely to note which finding on the laboratory report?

Answer 26

Hematocrit 60%

Question 27

Rule of Nines

Answer 27

Head/Neck: 4.5% on each side = total 9%
Upper Back: 9%, lower back: 9% = 18% total
Chest 9%, abdomen 9% = 18% total
Arms 4.5 on each side = 9% total for each arm
legs: 9% each side = 18% for each leg
genitals: 1%

Question 28

A client has a full thickness burn to all posterior body surfaces
Using the rule of nines, calculate the % of total body surface area affected

Answer 28

49.5%

Question 29

Client has partial thickness burns to the anterior legs and perineum
using the rule of nines, calculate the % of the total body surface area affected

Answer 29

19% TBSA

Question 30

Parkland Formula

Answer 30

4ml x kg of body weight x TBSA%

Client weighed 100kg with 19% TBSA calculate the faceted ringers fluid resuscitation needed?
4ml x 100kg x 19
7,600ml (within the first 24 hours)
We give first 1/2 off fluid in the first 8 hours = 3,800ml
rest 3,800 in the last 16 hours

Question 31

Major Burn Treatments

Answer 31

Fluid in the first 24 hours
Assessment of fluid resuscitation:
1. Urine output 30ml/hr or MORE
30ml or less mens kidneys are in distress
2. Blood pressure greater than 90 systolic
3. HR less than 120/min
*Electrolyte imbalance is not the best indicator of fluid resuscitation

Question 32

Kawasaki Disease

Answer 32

causes swelling (inflammation) in children in the walls of small to medium-sized blood vessels that carry blood throughout the body.
Kawasaki disease commonly leads to inflammation of the coronary arteries, which supply oxygen-rich blood to the heart.

Also causes swelling in glands (lymph nodes) and mucous membranes inside the mouth, nose, eyes and throat.

Question 33

Kawasaki Disease Symptoms

Answer 33

fever greater than 102.2 F (39 C) for five or more days the following signs and symptoms.

A rash on the main part of the body or in the genital area

An enlarged lymph node in the neck
Extremely red eyes without a thick discharge

Red, dry, cracked lips and an extremely red, swollen tongue

Swollen, red skin on the palms of the hands and the soles of the feet, with later peeling of skin on fingers and toes

Question 34

Kawasaki disease Risk Factors

Answer 34

Age. Children under 5 years old are at highest risk of Kawasaki disease.

Sex. Boys are slightly more likely than girls to develop Kawasaki disease.

Ethnicity. Children of Asian or Pacific Island descent, such as Japanese or Korean, have higher rates of Kawasaki disease.

Question 35

A 42-year-old client is diagnosed with shingles. Which findings confirm this diagnosis? Select all that apply

Answer 35

severe, deep pain around the thorax
red, nodular skin lesions around the thorax
fever
malaise

Question 36

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Answer 36

scale

Question 37

A client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN?

Answer 37

Ensure adequate caloric and protein intake.

Question 38

A client presents at the health care provider’s office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The health care provider diagnoses scabies. Which teaching points would a nurse review with the client? Select all that apply.

Answer 38

Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing
Severe itching of the affected areas, especially at night, is a common finding
All of the client’s linens and clothing should immediately be washed in hot water

Question 39

Which factor would have the least influence on the survival and effectiveness of a burn victim’s porcine grafts?

Answer 39

use of analgesics as necessary for pain relief

Question 40

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at an adult child’s home with six other people. During the client’s visit to the clinic, the client asks a staff nurse, “What should my family do?” The most accurate response from the nurse is

Answer 40

When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they’re symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

Question 41

A nurse is preparing a care plan for a client burned over 36% of their body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

Answer 41

The client’s complete blood count readings reflect a reduced hematocrit.

Question 42

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education?

Answer 42

“On the morning of the surgery, I can shave my surgical area at home to save time.”

The client shouldn’t shave the surgical area at home. Any necessary clipping of hair will be done at the surgical center. Allowing the client to shave the area with a razor could cause skin abrasions and subsequent infections.

Question 43

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.

Answer 43

Reposition the client every 2 hours.
Perform range-of-motion exercises.
Encourage the client to eat a well-balanced diet.

Question 44

The nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client’s medical record, the nurse would suspect which medication to be a probable cause of this disorder?

Answer 44

phenytoin
Antiseizure medications are often the cause of toxic epidermal necrolysis. Other common medications that may cause toxic epidermal necrolysis include antibiotics, NSAIDs (nonsteroidal anti-inflammatory drugs), and sulfa medications.

Question 45

A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. All options must be used.

Answer 45

Wash hands thoroughly.
Put on latex gloves.
Slowly remove the soiled dressing.
Assess the drainage in the dressing.

Question 46

When instructing a client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch?

Answer 46

A roast beef sandwich, milkshake, and cottage cheese would provide the client with the extra protein and calories needed for healing.

Question 47

The nurse should assess a client who is in the emergency phase of burn management for which finding?

Answer 47

hyperkalemia
Owing to the massive cellular destruction that occurs in burns, potassium is released into the extracellular fluid, which leads to hyperkalemia.

Question 48

A nurse is examining a client’s scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

Answer 48

behind the ears

Question 49

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?

Answer 49

The dressing should keep the wound moist.

Question 50

A child presents with a skin rash that resembles an allergic response, similar to atopic dermatitis, and requires differentiation by the nurse. Which communicable diseases should the nurse consider? Select all that apply.

Answer 50

rubella
rubeola
erythema infection

Rubella, rubeola, and erythema infectiosum all present with a rash that may resemble atopic dermatitis. The nurse would need to perform further assessment to determine what the child had. Mumps and pertussis are communicable diseases, but do not generally present with a rash as a symptom.

Question 51

A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

Answer 51

“Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days.”

Question 52

While caring for a client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for which finding?

Answer 52

gastrointestinal ulceration
Gastrointestinal ulceration, also known as a Curling ulcer, occurs in about half of clients with severe burns. The incidence of ulceration appears proportional to the extent of the burns and is believed to be due to hypersecretion of gastric acid and compromised gastrointestinal perfusion

Question 53

A client is experiencing intertrigo caused by friction between the inner thighs. Which action should the nurse take to help this client?

Answer 53

Apply lubricating lotion over the affected areas.

Question 54

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy?

Answer 54

client with a compromised skin graft
A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy is not used to improve the oxygenation status of a client with chronic obstructive pulmonary disease or pneumonia.

Question 55

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

Answer 55

a wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance

A wound (regardless of its size) that contains tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place

Question 56

During the emergency (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation?

Answer 56

serum creatinine level of 2.5 mg/dL (221 µmol/L)
Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would increase the serum creatinine level.

Question 57

At a health care facility, clients with major burns are transferred to a burn center. The nurse anticipates the transfer of which clients to the burn center? Select all that apply.

Answer 57

an adult with 1.5% total body surface area third-degree burns of face
an adult with an electrical burn
a child with burns of hands and feet
Major burn injuries include second-degree burns > 25% total body surface area (TBSA) in adults or > 20% TBSA in children; any electrical injuries; and any burns involving eyes, ears, face, hands, feet, perineum, and joints.

Question 58

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

Answer 58

ring or donut
The nurse should not use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client’s weight, and water beds distribute pressure over the entire surface.

Question 59

The nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do?

Answer 59

Encourage the client to ambulate in the halls on the unit.
The client has cellulitis and should elevate the affected area above heart level. Ambulation stimulates circulation and promotes the deposition of pathogens in other areas of the body. Alcohol and perfumed soaps are drying to the skin. Massaging the lower extremities could dislodge a clot.

Question 60

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Answer 60

mafenide
The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns.

Question 61

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Answer 61

Irrigate the wounds with water.

Question 62

The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home?

Answer 62

use of smoke detectors

Question 63

A client has a foot ulcer that has not shown signs of improvement over the past several months. Which medical condition is most likely causing the delay in wound healing? Select all that apply.

Answer 63

peripheral vascular disease
diabetes

Question 64

The community health nurse is working with a client who has limited mobility. Which interventions would the nurse implement for primary prevention of skin breakdown? Select all that apply.

Answer 64

encouragement of the client to walk around the home three times a day
education of the client on turning frequently in the bed if lying down
instruction on the application of lotion for dry skin on extremities

Question 65

A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering I.V. fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse?

Answer 65

Ensure a fluid volume sufficient to prevent shock.

Question 66

A client who is taking aspirin caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which action first?

Answer 66

Apply an ice pack for 20 minutes.
Aspirin has an antiplatelet effect, and bleeding time can consequently be prolonged. Intermittent use of ice packs to the site may stop the bleeding; ice causes blood vessels to vasoconstrict. Use of lukewarm water, patting the injury, and wrapping the entire forearm do not promote vasoconstriction to stop bleeding.

Question 67

When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing?

Answer 67

adequate circulatory status
Adequate circulatory status is the most important factor in the healing process of an infected decubitus ulcer. Blood flow to the area must be present to bring nutrients and prescribed antibiotics to the tissues. Rest and a balanced diet are essential to health maintenance but are not the priority for healing an infected decubitus ulcer. A fluid intake of 2000 to 3000 mL a day, if not contraindicated, is recommended to provide hydration to the client’s tissues.

Question 68

A client is brought to the emergency department having been involved in a fire while putting lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be dry and pale white with some areas that are brown and leathery. Which type of burns does the nurse determine are present?

Answer 68

third degree (full thickness)