TEST 16: The Client with Health Problems of the Integumentary System

Question 1

The Client with Burns
1. There has been a fire in an apartment building. All residents have been evacuated, but many
are burned. Which clients should be transported to a burn center for treatment? Select all that apply.
1. An 8-year-old with third-degree burns over 10% of his body surface area (BSA).
2. A 20-year-old who inhaled the smoke of the fire.
3. A 50-year-old diabetic with first- and second-degree burns on his left forearm (about 5% of
his BSA).
4. A 30-year-old with second-degree burns on the back of his left leg.
5. A 40-year-old with second-degree burns on his right arm (about 10% of his BSA).

Answer 1

The Client with Burns
1. 1, 2, 3. Clients who should be transferred to a burn center include children under age 10 or
adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients
between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any
age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients
with chronic diseases, such as diabetes and heart or kidney disease.
CN: Management of care; CL: Analyze

Question 2

2. The nurse is assessing an 80-year-old client who has scald burns on the hands and both
   forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do
   first?
3. Clean the wounds with warm water.
4. Apply antibiotic cream.
5. Refer the client to a burn center.
6. Cover the burns with a sterile dressing.

Answer 2

2. 3. The nurse should have the client transported to a burn center. The client’s age and the extent
      of the burns require care by a burn team and the client meets triage criteria for referral to a burn
      center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn.
      Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with
      antibiotic cream at this time.
      CN: Physiological adaptation; CL: Synthesize

Question 3

3. During the emergent (resuscitative) phase of burn injury, which of the following indicates that
   the client is requiring additional volume with fluid resuscitation?
4. Serum creatinine level of 2.5 mg/dL (221 μmol/L).
5. Little fluctuation in daily weight.
6. Hourly urine output of 60 mL.
7. Serum albumin level of 3.8 (38 g/L).

Answer 3

3. 1. Fluid shifting into the interstitial space causes intravascular volume depletion and decreased
      perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be
      frequently monitored and adequately maintained with intravenous fluid resuscitation that would be
      increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid
      replacement is based on the Parkland or Brooke formula and also the client’s response by monitoring
      urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little
      fluctuation in weight suggests that there is no fluid retention and the intake is equal to output.
      Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The
      normal serum albumin is 3.5 to 5 g/dL (35 to 50 g/L).
      CN: Physiological adaptation; CL: Analyze

Question 4

4. A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and
   right leg. The shaded areas in the illustration indicate the burned areas on the client’s body. Using the
   “rule of nines,” estimate what percentage of the client’s body surface has been burned.
5. 18%.
6. 27%.
7. 45%.
8. 64%.

Answer 4

4. 3. According to the rule of nines, this client has sustained burns on about 45% of the body
      surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%,
      for a total of 45%.
      CN: Physiological adaptation; CL: Apply

Question 5

5. The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which
   of the following indicates that the client is responding to the fluid resuscitation?
6. Pulse rate of 112.
7. Blood pressure of 94/64.
8. Urine output of 30 mL/h.
9. Serum sodium level of 136 mEq/L (136 mmol/L).

Answer 5

5. 3. Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation.
      The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is
      low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid
      balance and kidney function. The sodium level is within normal limits.
      CN: Physiologic adaptation; CL: Evaluate

Question 6

6. Which of the following activities should the nurse include in the plan of care for a client with
   burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing
   change?
7. Soak the dressing.
8. Remove the dressing.
9. Administer an analgesic.
10. Slit the dressing with blunt scissors.

Answer 6

6. 3. Removing dressings from severe burns exposes sensitive nerve endings to the air, which is
      painful. The client should be given a prescribed analgesic about one-half hour before the dressing
      change to promote comfort. The other activities are done as part of the whirlpool and dressing change
      process and not one-half hour beforehand.
      CN: Reduction of risk potential; CL: Synthesize

Question 7

7. The client with a major burn injury receives total parenteral nutrition (TPN). The expected
   outcome is to:
8. Correct water and electrolyte imbalances.
9. Allow the gastrointestinal tract to rest.
10. Provide supplemental vitamins and minerals.
11. Ensure adequate caloric and protein intake.

Answer 7

7. 4. Nutritional support with sufficient calories and protein is extremely important for a client
      with severe burns because of the loss of plasma protein through injured capillaries and an increased
      metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns,
      making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by
      administration of IV fluids with electrolyte additives, although TPN typically includes all necessary
      electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides
      vitamins and minerals; however, the primary reason for starting TPN is to provide the protein
      necessary for tissue healing.
      CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 8

8. An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they:
9. Encourage the formation of tough skin.
10. Promote the growth of epithelial tissue.
11. Provide for permanent wound closure.
12. Facilitate the development of subcutaneous tissue.

Answer 8

8. 2. Biologic dressings such as porcine grafts serve many purposes for a client with severe
      burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue,
      prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They
      do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth
      of subcutaneous tissue.
      CN: Physiological adaptation; CL: Apply

Question 9

9. Which of the following factors would have the least influence on the survival and
   effectiveness of a burn victim’s porcine grafts?1. Absence of infection in the wounds.
10. Adequate vascularization in the grafted area.
11. Immobilization of the area being grafted.
12. Use of analgesics as necessary for pain relief.

Answer 9

9. 4. Analgesic administration to keep a burn victim comfortable is important but is unlikely to
      influence graft survival and effectiveness. Absence of infection, adequate vascularization, and
      immobilization of the grafted area promote an effective graft.
      CN: Physiological adaptation; CL: Evaluate

Question 10

10. The nurse should plan to begin rehabilitation efforts for the burn client:
11. Immediately after the burn has occurred.
12. After the client’s circulatory status has been stabilized.
13. After grafting of the burn wounds has occurred.
14. After the client’s pain has been eliminated.

Answer 10

10. 2. Rehabilitation efforts are implemented as soon as the client’s condition is stabilized. Early
       emphasis on rehabilitation is important to decrease complications and to help ensure that the client
       will be able to make the adjustments necessary to return to an optimal state of health and
       independence. It is not possible to completely eliminate the client’s pain; pain control is a major
       challenge in burn care.
       CN: Basic care and comfort; CL: Synthesize

Question 11

11. During the early phase of burn care, the nurse should assess the client for?
12. Hypernatremia.
13. Hyponatremia.
14. Metabolic alkalosis.
15. Hyperkalemia.

Answer 11

11. 4. Immediately after a burn, excessive potassium from cell destruction is released into the
       extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs
       within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of
       sodium bicarbonate.
       CN: Reduction of risk potential; CL: Analyze

Question 12

12. Which of the following clients with burns will most likely require an endotracheal or
    tracheostomy tube? A client who has:
13. Electrical burns of the hands and arms causing arrhythmias.
14. Thermal burns to the head, face, and airway resulting in hypoxia.
15. Chemical burns on the chest and abdomen.
16. Secondhand smoke inhalation.

Answer 12

12. 2. Airway management is the priority in caring for a burn client. Tracheostomy or
       endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur.
       Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2
       hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of
       the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation
       does influence an individual’s respiratory status but does not require intubation unless the individualhas an allergic reaction to the smoke.
       CN: Physiological adaptation; CL: Analyze

Question 13

13. A client is receiving fluid replacement with lactated Ringer’s after 40% of the body was
    burned 10 hours ago. The assessment reveals temperature 36.2°C, heart rate 122, blood pressure
    84/42, Central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV
    rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation)
    technique for communication, the nurse calls the health care provider with a recommendation for:
14. Furosemide (Lasix).
15. Fresh frozen plasma.
16. IV rate increase.
17. Dextrose 5%.

Answer 13

13. 3. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate
       hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should
       not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given
       for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is
       lactated Ringer’s solution, normal saline, or albumin.
       CN: Management of care; CL: Synthesize

Question 14

14. After the initial phase of the burn injury, the client’s plan of care will focus primarily on:
15. Helping the client maintain a positive self-concept.
16. Promoting hygiene.
17. Preventing infection.
18. Educating the client regarding care of the skin grafts.

Answer 14

14. 3. The inflammatory response begins when a burn is sustained. As a result of the burn, the
       immune system becomes impaired. There are a decrease in immunoglobulins, changes in white blood
       cells, alterations of lymphocytes, and decreased levels of interleukin. The human body’s protective
       barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections.
       Education and interventions to maintain a positive self-concept would be appropriate during the
       rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus
       is on reducing the risk for infection.
       CN: Safety and infection control; CL: Synthesize

Question 15

15. The rate at which IV fluids are infused is based on the burn client’s:
16. Lean muscle mass and body surface area (BSA) burned.
17. Total body weight and BSA burned.
18. Total BSA and BSA burned.
19. Height and weight and BSA burned.

Answer 15

15. 2. During the first 24 hours, fluid replacement for an adult burn client is based on total body
       weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total
       body weight. Total surface area is estimated by taking into account the individual’s height and weight.
       Height is not a common variable used in formulas for fluid replacement.
       CN: Physiological adaptation; CL: Apply

Question 16

16. The nurse is conducting a focused assessment of the gastrointestinal system of a client with a
    burn injury. The nurse should assess the client for:
17. Paralytic ileus.2. Gastric distention.
18. Hiatal hernia.
19. Curling’s ulcer.

Answer 16

16. 4. Curling’s ulcer, or gastrointestinal ulceration, occurs in about half of the clients with a burn
       injury. The incidence of ulceration appears proportional to the extent of the burns, and the ulceration
       is believed to be caused by hypersecretion of gastric acid and compromised gastrointestinal
       perfusion. Paralytic ileus and gastric distention do not result from hypersecretion of gastric acid and
       stress. Hiatal hernia is not necessarily a potential complication of a burn injury.
       CN: Physiological adaptation; CL: Analyze

Question 17

17. In the acute phase of burn injury, which pain medication would most likely be given to the
    client to decrease the perception of the pain?
18. Oral analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol).
19. Intravenous opioids.
20. Intramuscular opioids.
21. Oral antianxiety agents such as lorazepam (Ativan).

Answer 17

17. 2. The severe pain experienced by burn clients requires opioid analgesics. In addition,
       opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen or
       acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by
       the client who is severely burned. Because of the altered tissue perfusion from the burn injury,
       intravenous medications are preferred. Antianxiety agents are not effective against pain.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 18

Using the Parkland formula, calculate the hourly rate of fluid replacement with lactated Ringer’s
solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn
of 40%.
_______________ mL/hour.

Answer 18

18. 750 mL/hour. Lactated Ringer’s solution 4 mL × weight in kg × TBSA; half given over the
    4 mlx 75 kg x 40 = 12,000 ml
    12,000 x 50% = 6,000 ml
    6,000 ml / 8 hours = 750 ml/hour

first 8 hours and half given over the next 16 hours.
CN: Pharmacological and parenteral therapies; CL: Apply

Question 19

The Client with General Problems of
Integumentary System
the
19. The nurse is assessing an older adult’s skin. The assessment will involve inspecting the skin
for color, pigmentation, and vascularity. The critical component in the nurse’s assessment is noting
the:
1. Similarities from one side to the other.
2. Changes from the normal expected findings.
3. Appearance of age-related wrinkles.
4. Skin turgor.

Answer 19

The Client with General Problems of the Integumentary System
19. 2. Noting changes from the normal expected findings is the most important component when
assessing an older client’s integumentary system. Comparing one extremity with the contralateral
extremity (ie, comparing one side with the other) is an important assessment step; however, the most
important component is noting changes from an expected normal baseline. Noting wrinkles related to
age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the
appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an
assessment of the integumentary system.
CN: Health promotion and maintenance; CL: Analyze

Question 20

20. Which of the following changes are associated with normal aging?
21. The outer layer of skin is replaced with new cells every 3 days.
22. Subcutaneous fat and extracellular water decrease.
23. The dermis becomes highly vascular and assists in the regulation of body temperature.
24. Collagen becomes elastic and strong.

Answer 20

20. 2. With age, there is a decreased amount of subcutaneous fat, muscle laxity, degeneration of
       elastic fibers, and collagen stiffening. The outer layer of skin is almost completely replaced every 3
       to 4 weeks. The vascular supply diminishes with age. Collagen thins and diminishes with age.
       CN: Health promotion and maintenance; CL: Analyze

Question 21

21. Which of the following should the nurse expect to assess as normal skin changes in an elderly
client? Select all that apply.
1. Diminished hair on scalp and pubic areas.
2. Dusky rubor of left lower extremity.
3. Solar lentigo.
4. Wrinkles.
5. Xerosis.
6. Yellow pigmentation.

Answer 21

21. 1, 3, 4, 5. Skin changes associated with aging include the following: diminished hair on scalp
    and pubic areas, solar lentigo (liver spots), wrinkles, and xerosis (dryness). Dusky rubor of the left
    lower extremity may indicate the individual has a venous stasis problem in the affected extremity and
    is generally associated with “unsuccessful aging.” Yellow pigmentation of the skin that may be
    associated with liver inflammation is generally known as jaundice.
    CN: Health promotion and maintenance; CL: Analyze

Question 22

22. The nurse will anticipate which of the following problems that can result for the older adult
undergoing abdominal surgery?
1. Increased scarring.
2. Decreased melanin and melanocytes.
3. Decreased healing.
4. Increased immunocompetence.

Answer 22

22. 3. Normal aging consists of decreased proliferative capacity of the skin. Decreased collagen
       synthesis slows capillary growth, impairs phagocytosis among older clients, and results in slow
       healing. Increased scarring is not a result of age-related skin changes. Both melanin and melanocytes
       give color to the skin and hair but are increased with aging. There is a decrease in the
       immunocompetence of the aging client.
       CN: Health promotion and maintenance; CL: Analyze

Question 23

23. Health maintenance and promotion activities are especially important for the older adult.
    Which of the following activities reflects a health maintenance activity for an otherwise healthy older
    adult?
24. Drinks 1,500 mL of fluids per day.
25. Consumes a balanced diet of 1,200 cal/day.
26. Walks briskly for 10 minutes three times per week.
27. Sleeps at least 8 hours each night.

Answer 23

23. 1. Drinking at least 1,500 mL of fluid per day helps the client stay well hydrated. Maintaining
       optimal fluid balance is important for all body systems. Caloric intake varies according to an
       individual’s size and activity level. An intake of 1,200 cal/day may be insufficient for some older
       clients. Walking 10 minutes per day is useful, but an otherwise healthy older client should try to walk
       20 minutes per day. It is important to get adequate rest; however, the amount of sleep needed varies
       with the individual.
       CN: Health promotion and maintenance; CL: Evaluate

Question 24

24. Which of the following characteristics would put a client at the greatest risk for impaired
    wound healing after abdominal surgery?
25. Age 75 years.
26. Age 30 years, with poorly controlled diabetes.
27. Age 55 years, with myocardial infarction.4. Age 60 years, with peripheral vascular disease.

Answer 24

24. 2. Poorly controlled diabetes is a serious risk factor for postoperative wound infection. Other
       factors that delay wound healing include advanced age, nutritional deficiencies (vitamin C, protein,
       zinc), inadequate blood supply, use of corticosteroid, infection, mechanical friction on the wound,
       obesity, anemia, and poor general health.
       CN: Reduction of risk potential; CL: Analyze

Question 25

25. The client has been diagnosed with herpes zoster (shingles). The nurse should include which
    of the following in a teaching plan? Select all that apply.
26. Instruct the client about taking antiviral agents as prescribed.
27. Demonstrate how to apply wet-to-dry dressings.
28. Explain how to follow proper hand hygiene techniques.
29. Assure the client that the pain from herpes zoster will be gone by 7 days.
30. Tell the client to remain in isolation in a bedroom until the lesions have healed.

Answer 25

25. 1, 2, 3. The nurse should instruct the client and family members about the importance of taking
    antiviral agents as prescribed. The client must be taught how to apply wet dressings or medication to
    the lesions and to follow proper hand hygiene techniques to avoid spreading the virus. The healingtime varies from 7 to 26 days. The most common complication is postherpetic neuralgia, which may
    last longer than 6 months. It is not necessary for the client to remain in isolation.
    CN: Health promotion and maintenance; CL: Create

Question 26

26. Which of the following clients should receive shingles vaccine (Zostavax)? A client who
27. Has never had chickenpox.
28. Is at risk for genital herpes.
29. Is over 60 years of age.
30. Has a compromised immune system.

Answer 26

26. 3. People older than 60 years should receive shingles vaccine to prevent the disease. The
       vaccine is not effective for genital herpes. The vaccine can be given to persons who have or have not
       had chickenpox. The vaccine is not advised for persons with a compromised immune system, for
       example receiving chemotherapy or radiation therapy.
       CN: Health promotion and maintenance; CL: Apply

Question 27

27. An older adult has several ecchymotic areas on the left arm. The nurse should further assess
    the client for:
28. Elder abuse.
29. Self-inflicted injury.
30. Increased capillary fragility and permeability.
31. Increased blood supply to the skin.

Answer 27

27. 3. The aging process involves increased capillary fragility and permeability. Older clients
       have a decreased amount of subcutaneous fat. Therefore, there is an increased incidence of bruise-
       like lesions caused by collection of extravascular blood in the loosely structured dermis. In addition,
       older clients do not always realize that injury has occurred because of a diminished awareness of
       pain, touch, and peripheral vibration. There are no data to support elder abuse or self-inflicted
       bruises. Blood supply to the skin declines with aging.
       CN: Health promotion and maintenance; CL: Analyze

Question 28

28. An older adult reports being cold in the room even though the thermostat is set at 75°F
    (24°C). The client may feel cold because older adults have:
29. Increased cellular cohesion.
30. Increased moisture content of the stratum corneum.
31. Slower cellular renewal time.
32. Decreased ability to thermoregulate.

Answer 28

28. 4. Older clients have a decreased thermoregulation that is related to decreased blood supply
       and reabsorption of body fat. As a result, older adults are at risk for hypothermia. Cellular cohesion
       and moisture content diminish with age and cellular renewal time is slowed; however, these do not
       result in impaired thermoregulation.
       CN: Health promotion and maintenance; CL: Analyze

Question 29

29. The nurse should instruct the client with tinea capitis to do which of the following? Select all
    that apply.
30. Place a dressing saturated with vinegar and water on the area.
31. Apply topical antibacterial ointment to the area.
32. Shampoo hair two or three times with selenium sulfide shampoo.
33. Use antibacterial soap for bathing.
34. Take antifungal medication as prescribed.

Answer 29

29. 3, 5. Tinea capitis is a contagious fungal infection of the hair shaft. The hair should be
    shampooed two or three times with selenium sulfide shampoo. An oral medication will typically be
    prescribed as well, since the shampoo alone will not cure tinea capitis. Using vinegar and water may
    be used to treat tinea pedis. The most common fungal skin infection is tinea (also called ringworm
    because of its characteristic appearance of a ring or rounded tunnel under the skin). Tinea infections
    affect the head, body, groin, feet and nails. Antibacterial ointment and soap are not effective for
    treating fungal infections.
    CN: Physiological adaptation; CL: Create

Question 30

30. Palpation of the skin provides the nurse useful information regarding:
31. Bruising of the skin.
32. Color of the skin.
33. Hair distribution.
34. Turgor of the skin.

Answer 30

30. 4. Assessment of the integumentary system includes both inspection and palpation. Palpation
       involves assessing temperature, turgor, moisture, and texture. Observing bruises and color and
       detecting hair distribution are inspection.
       CN: Health promotion and maintenance; CL: Analyze

Question 31

31. A priority for nursing care for an adult who has pruritus, is continuously scratching the
    affected areas, and demonstrates agitation and anxiety regarding the itching would be:
32. Preventing infection.
33. Instructing the client not to scratch.
34. Increasing fluid intake.4. Avoiding social isolation.

Answer 31

31. 1. The client is at risk for infection because of the pruritus, and the nurse should institute
       measures to help the client control the scratching such as cutting fingernails, using protective gloves
       or mitts, and, if necessary, using antianxiety medications. More information is required regarding the
       knowledge level of the client, but learning cannot take place when an individual’s attention is
       distracted with pruritus. Increasing fluid intake is not a priority at this time. There are no data to
       indicate the client is experiencing social isolation.
       CN: Reduction of risk potential; CL: Synthesize

Question 32

32. The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The nurse
    should first:
33. Verify the physician prescription to use the restraint.
34. Secure the mitt with ties around the wrist tied to the bed frame.
35. Place a folded pillow under the wrist.
36. Place the mitt on top of the hand.

Answer 32

32. 1. Before using any restraints, the nurse must verify that a physician has written a prescriptionfor the restraint. The mitt does not need to be secured with ties. The client can move the hand as
       needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the
       palmar surface of the hand.
       CN: Safety and infection control; CL: Synthesize

Question 33

33. An older adult client in stage 2 of Parkinson’s disease is being discharged with cellulitis of
    the right lower extremity. The nurse should base the discharge plan on which of the following? Select
    all that apply.
34. The client has decreased tissue perfusion.
35. The client is at risk for skin breakdown.
36. The client is at risk for falls or injuries..
37. The client has difficulty communicating.
38. The client has limited activity.

Answer 33

33. 2, 3. Usual aging is associated with dry skin; however, seborrhea (oily skin and dandruff) is
    one result of the biochemical changes associated with Parkinson’s disease. The client with
    Parkinson’s disease has a higher risk of skin breakdown due to the moist and oily skin. To maintain
    skin integrity, a client with Parkinson’s disease needs frequent skin care and aeration of the skin. Gait
    instability in a client with Parkinson’s disease is a result of muscle rigidity, change in the center of
    gravity, and gait shuffling. Because of these changes in gait and balance, the client is at higher risk for
    injuries in the environment, such as hitting furniture or obstacles in the client’s path. As a result, the
    environment should be evaluated for potential injury or falls. Tissue perfusion and verbal
    communication are not problems typically associated with Parkinson’s disease. The client should not
    experience activity intolerance from the cellulitis or Parkinson’s disease.
    CN: Pharmacological and parenteral therapies; CL: Analyze

Question 34

34. An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the
    left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client?
35. Keep all the lights on in the room at all times.
36. Use a nightlight in the bathroom.
37. Keep all four side rails up at all times.
38. Place the client in a room with a camera monitor.

Answer 34

34. 2. Many falls occur when older clients attempt to get to the bathroom at night. The risk is even
       greater in an unfamiliar environment. Use of a nightlight in the bathroom enables the older adult client
       to see the way to the bathroom. Keeping the lights on in the room at all times may contribute to
       sensory overload and prevent adequate rest. Raised side rails paradoxically contribute to falls when
       the older client tries to climb over them to get to the bathroom. The upper side rails may be raised,
       but it is not recommended that all four side rails be elevated. Camera monitoring can be used but does
       nothing to prevent a fall.
       CN: Safety and infection control; CL: Synthesize

Question 35

35. Prevention of skin breakdown and maintenance of skin integrity among older clients is
    important because they are at greater risk secondary to:
36. Altered balance.
37. Altered protective pressure sensation.
38. Impaired hearing ability.
39. Impaired visual acuity.

Answer 35

35. 2. Pressure ulcers usually occur over bony prominences. An alteration in the protective
       pressure sensation results from a decline in the number of Meissner’s and pacinian corpuscles. Older
       adults do have altered balance that may result in falls but not skin breakdown. Impaired hearing and
       vision do not contribute to pressure ulcers.
       CN: Reduction of risk potential; CL: Analyze

Question 36

The Client with a Pressure Ulcer
36. The nurse is assessing a client with dark skin for the presence of a Stage I pressure ulcer. The
nurse should:
1. Use a fluorescent light source to assess the skin.
2. Inspect the skin only when the Braden score is above 12.
3. Look for skin color that is darker than the surrounding tissue.
4. Avoid touching the skin during inspection.

Answer 36

The Client with a Pressure Ulcer
36. 3. When assessing a client with dark skin, the nurse should observe for skin that is darker,
brownish, purplish, or bluish compared to surrounding skin. Fluorescent light casts a blue light,
making skin assessment difficult; natural or halogen light sources help to accurately assess the skin.
Risk assessment using the Braden Scale should be performed on all clients. A Braden score of 12
indicates a high risk for pressure ulcer, and the lower the Braden score, the higher the risk (no risk 19
to 23, at risk 15 to 18, moderate risk 13 to 14, high risk 10 to 12, and very high risk 9 or below). The
nurse should touch the skin to assess consistency and temperature differences.
CN: Physiological adaptation; CL: Analyze

Question 37

37. The nurse is assessing a client who is immobile and notes an area of sacral skin is reddened,
    but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most
    appropriate nursing action at this time is to:
38. Apply a moist to moist dressing, being careful to pack just the wound bed.
39. Consult with a wound-ostomy-continence nurse specialist.
40. Reposition the client off of the reddened skin and reassess in a few hours.
41. Complete and document a Braden skin breakdown risk score for the client.

Answer 37

37. 3. A Stage I ulcer presents as an area of intact, nonblanchable redness, usually over a bony
       prominence, caused by pressure. If a reddened area blanches and refills with fingertip pressure, it
       indicates that there is still some blood flow to the injured area, and the redness may be reversible. It
       may be appropriate to complete and document a Braden score or consult a wound nurse specialist,but it is imperative to reposition the client off the reddened skin area first. Since there is no break in
       the skin, it is not appropriate to apply a moist to moist dressing.
       CN: Basic care and comfort; CL: Synthesize

Question 38

38. The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The
    nurse notes that the client has a 1′′ × 1′′ area on the sacrum in which there is skin breakdown as far as
    the dermis. What should the nurse note on the chart?
39. Stage I pressure ulcer.
40. Stage II pressure ulcer.
41. Stage III pressure ulcer.
42. Stage IV pressure ulcer.

Answer 38

38. 2. Stage I pressure ulcers appear as nonblanching macules that are red in color. Stage II ulcers
       have breakdown of the dermis. Stage III ulcers have full-thickness skin breakdown. In Stage IV
       ulcers, the bone, muscle, and supporting tissue are involved. The nurse should immediately initiate
       plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion.
       CN: Reduction of risk potential; CL: Analyze

Question 39

39. A Stage II pressure ulcer is characterized by:
40. Redness in the involved area.
41. Muscle spasms in the involved area.
42. Pain in the involved area.
43. Tissue necrosis in the involved area.

Answer 39

39. 3. A Stage II skin breakdown involves epidermal sloughing and pain. Redness without
       blanching is noted in Stage I. Stage III involves tissue necrosis with subcutaneous involvement. Stage
       IV involves muscle or bone destruction. Muscle spasm is not a criterion used in the staging process.
       CN: Physiological adaptation; CL: Analyze

Question 40

40. The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home
    bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness
    from friction and shearing force of being in bed. Last month, the client had increased sacral redness
    and the area was classified as a Stage I pressure ulcer. On this visit, the nurse is assessing the sacral
    area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part
    A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure
    ulcer from this visit to the previous visit, the nurse should do which of the following first?
41. Instruct the home health aide to reposition the client every 2 hours while the client is awake.
42. Ask the client’s daughter to purchase a foam mattress.
43. Contact the physician to request a hydrocolloid dressing.
44. Suggest that the client ask a neighbor to purchase antibiotic cream at the drugstore.

Answer 40

40. 3. The pressure ulcer has changed from Stage I to Stage II and requires the use of a protective
       dressing. Repositioning and use of foam mattresses are appropriate interventions for Stage I pressure
       ulcers. There is no indication that the ulcer is infected.
       CN: Reduction of risk potential; CL: Synthesize

Question 41

The Client with Skin Cancer

41. Which of the following factors places a client at greatest risk for skin cancer?
42. Fair skin and history of chronic sun exposure.
43. Caucasian race and history of hypertension.
44. Dark skin and family history of skin cancer.
45. Dark skin and history of hypertension.

Answer 41

The Client with Skin Cancer
41. 1. Caucasians who have fair skin and a high exposure to ultraviolet light are at increased risk
for malignant neoplasms of the skin. The other risk factors include exposure to tar and arsenicals and
family history. History of hypertension is a coronary artery disease risk factor. Clients with dark skin
have increased melanin and are not as prone to skin cancer.
CN: Health promotion and maintenance; CL: Analyze

Question 42

42. A nurse is providing teaching to a client about skin cancer. Which of the following should the
nurse explain are risk factors for skin cancer? Select all that apply.
1. Increasing age.
2. Exposure to chemical pollutants.
3. Long-term exposure to the sun.
4. Increased pigmentation.
5. Genetics.
6. Immunosuppression.

Answer 42

42. 1, 2, 3, 5, 6. Risk factors associated with skin cancer include age, exposure to chemical
    pollutants, exposure to the sun, genetics, and immunosuppression. As individuals age, the risk of
    developing skin cancer increases. Long-time exposure to the sun and exposure to chemical pollutants
    (nitrates, coal, tar, etc.) increases the risk of skin cancer. Individuals who have less skin pigmentation
    (ie, fair, blue-eyed people) have a higher risk of skin cancer because they tend to incur sunburns
    rather than tan. Family history plays a role in cancer. Regardless, immunosuppressed individuals are
    at a higher risk for the development of any type of cancer, as the body’s defenses are not functioning
    properly.
    CN: Health promotion and maintenance; CL: Apply

Question 43

43. The nurse is developing a program about skin cancer prevention for a community group.
    Which of the following should be included in the program? Select all that apply.
44. Purchase sunscreen containing benzophenones to block UVA and UVB rays.
45. Use sunscreen with a minimum of 15 sun protection factor (SPF).
46. Obtain genetic screening to identify risk of melanoma.
47. Apply sunscreen only on sunny days, especially between 10 AM and 2 PM.
48. Have a pigmented lesion biopsied by shaving if it looks suspicious.
49. Rub baby oil to lubricate skin before going out in the sun.

Answer 43

43. 1, 2. Sunscreen should be applied 20 to 30 minutes before going outside, even in cloudy
    weather. Sunscreen with a minimum of 15 SPF should be used. Sunscreen containing benzophenones
    block both UVA and UVB rays. The rays of the sun are most dangerous between 10 AM and 2 PM.
    Genetic screening is not indicated, although a mutated gene has been identified in some families with
    high incidence of melanoma. A prior diagnosis of melanoma and having a first-degree relative
    diagnosed with melanoma increases a person’s risk. Lesions should not be shave biopsied; excisional
    biopsy technique is used. Baby oil will increase the adverse effects of sun exposure; sunscreen
    protection should be used.
    CN: Health promotion and maintenance; CL: Create

Question 44

44. A client with malignant melanoma asks the nurse about the prognosis. The nurse should base
    a response that informs the client that the prognosis depends on:
45. The amount of ulceration of the lesion.
46. The age of the client.
47. The location of the lesion on the body.
48. The thickness of the lesion.

Answer 44

44. 4. Tumor or lesion thickness is the predictive factor for survival. Cutaneous melanoma that is
       confined to the epidermis has a high cure rate. Asymmetry, border, color, and diameter are known as
       the “ABCDs” of melanoma. Thus, the amount of ulceration, age, and location are not clearly
       associated with the prognosis.
       CN: Health promotion and maintenance; CL: Synthesis

Question 45

Managing Care Quality and Safety
45. The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony
prominences of a client on bed rest. The nurse should:
1. Reinforce the UAP’s use of this intervention over the bony prominences.
2. Explain that massage is effective because it improves blood flow to the area.
3. Inform the UAP that massage is even more effective when combined with lotion during the
massage.
4. Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

Answer 45

Managing Care Quality and Safety
45. 4. Massaging areas that are reddened due to pressure is contraindicated because it further
reduces blood flow to the area. The UAP should not massage the bony prominences or use lotion on
the area. Massage does improve circulation and blood flow to muscle areas; however, because the
area is reddened, the client is at risk for further skin breakdown.
CN: Management of care; CL: Synthesize

Question 46

46. The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last
    month five clients were diagnosed with pressure ulcers. The nurse manager should:
47. Use benchmarking procedures to compare the findings with other nursing units in the hospital.
48. Ask the staff education department to conduct an educational session about preventing pressure
    ulcers.
49. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and
    sets improvement outcomes.
50. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to
    the clients with pressure ulcers.

Answer 46

46. 3. The problem of pressure ulcers in hospitalized clients is best addressed by using quality
       improvement techniques to identify the problem, determining strategies for improvement, and setting
       goals for outcomes. Benchmarking for comparison will indicate where this nursing unit compares
       with other units, but does not address the problem for this unit; having clients with pressure ulcers on
       any unit is not acceptable. Educational programs are more effective after there is an understanding of
       the problem. Chart audits and blaming do not solve the problem or address quality improvement
       measures.
       CN: Management of care; CL: Synthesize

Question 47

47. A client has been admitted to the hospital with draining foot lesions. The nurse should do
    which of the following? Select all that apply.
48. Place the client in a room with negative air pressure.
49. Admit the client to a semi-private room.
50. Admit the client to a private room.
51. Post a “contact isolation” sign on the door.
52. Wear a protective gown when in the client’s room.
53. Wear latex-free gloves when providing direct care.

Answer 47

47. 3, 4, 5. Infection control policies must be followed to prevent the spread of infection. Until the
    pathogens are identified, the client must be isolated in a private room. Utilizing contact isolation and
    wearing a protective isolation gown and clean gloves, in addition to following isolation protocol to
    exit the room, may aid in the prevention of spread of infectious agents to others. A draining foot lesion
    does not require a negative air pressure room, which is primarily reserved for preventing spread of
    tuberculosis. Latex-free gloves are not needed unless the client has a latex allergy.
    CN: Safety and infection control; CL: Synthesize

Question 48

48. The nurse is to administer an antibiotic to a client with burns now, but there is no medication
    in the client’s medication box. What should the nurse do first?
49. Inform the unit’s shift coordinator.
50. Contact the client’s physician.
51. Call the pharmacy department.
52. Borrow the medication from another client.

Answer 48

48. 3. By contacting the pharmacy to report the absence of the medication, the pharmacy can bring
       the medication to the client’s medication box. From there on, the pharmacy can make sure the correct
       medications are present. Contacting the shift coordinator or the client’s physician will not correct the
       original cause of the variance. It is never appropriate to “borrow” a medication from another client.
       CN: Management of care; CL: Synthesize

Question 49

49. A client has a wound on the ankle that is not healing. The nurse should assess the client for
    which of the following risk factors for delayed wound healing? Select all that apply.
50. Atrial fibrillation.
51. Advancing age.
52. Type 2 diabetes mellitus.
53. Hypertension.
54. Smoking.

Answer 49

49. 2, 3, 5. Advancing age, type 2 diabetes mellitus, and smoking are risk factors for delayed
    healing. Advanced age slows collagen synthesis by fibroblasts, impairs circulation, and requires a
    longer time for epithelialization of skin. Type 2 diabetes mellitus reduces supply of oxygen and
    nutrients secondary to vascular complications. Nicotine is a potent vasoconstrictor and impedes
    blood flow, which reduces the supply of oxygen and nutrients necessary for healing. Atrial fibrillation
    causes venous stasis in the atria, but does not have an effect on wound healing. Hypertension does not
    have an effect on healing.
    CN: Reduction of risk potential; CL: Analyze

Question 50

50. The nurse is assessing the left lower extremity of a client with type 2 insulin-requiring
    diabetes and cellulitis. The nurse should do which of the following?
51. Instruct the client to elevate the left leg when sitting in the chair.2. Encourage the client to ambulate in the halls on the unit.
52. Massage the left leg with alcohol to stimulate circulation.
53. Cleanse the left lower leg with perfumed liquid soap.

Answer 50

50. 1. The client has cellulitis and should elevate the affected area above heart level. Ambulationstimulates circulation and promotes deposition of pathogens in other areas of the body. Alcohol and
       perfumed soaps are drying to the skin. Massaging lower extremities could dislodge a clot.
       CN: Reduction of risk potential; CL: Synthesize