VN 36 Test 4 S.G Integumentary system

Question 1

1. Types of drainage (PP slide 27)

Answer 1

 Serous: clear, watery plasma
 Purulent: Thick, yellow, green, Tan, or brown
 Serosanguineous: Pale, pink, watery: mixture of clear & red fluid
 Sanguineous: bright red (active bleeding)

Question 2

2. Best prevention of pressure ulcers (PP slide 16 & slide 17)

Answer 2

 Priority is prevention, identify those at greatest risk! (Use Braden scale to identify or predict who is at sore risk)

People at risk:
 Reduced mobility
 Sensory impairment
 Neuropathy
 Acute illness
 Level of consciousness
 Malnutrition & dehydration

Question 3

Stages of ulcers (PP slide 16 & 17)

Answer 3

Stage 1: skin hasn’t broken, pain, itching, non-blanchable (still intact)
Stage 2: partial thickness skin, can look like abrasion or blister
Stage 3: full thickness skin loss, necrosis of subcutaneous layer. Can extend to fascia but won’t go through it. Deep crater w/or w/out tunneling
Stage 4: Full tissue thickness necrosis : Muscle, bone, or tendons are visible. Deep pockets of infection & tunneling.
Unstageable: stage can’t be determined due to Escher or slough covering the visibility of the wound.

Question 4

3. Impetigo manifestations (PP slide 9)

Answer 4

 Lesions begin as macules & develop into pustules
 Pustules ruptures- form honey (colored exudate)
 Usually affects face, hands, arms & legs
 Highly contagious (direct or indirect contact)
 Low grade fever (leukocytosis)

Question 5

4. Eczema client education & nursing interventions (PP slide 15)

Answer 5

 Pharm management: corticosteroids, coal tar preparations
 Reduce exposure to allergen
 Hydration of skin (cool wet compresses)
 Lotions: Eucerin, Lubriderm- 3-4x/day

Question 6

5. z-track instruction (pg.398)

Answer 6

 Obtain & attach a needle that is at least 1 1/2inch – 2inches long onto syringe
 Draw up an additional 0.2mL of air in the syringe
 Using the side of your hand, pull the tissue laterally about 1 inch (2.5cm) until it is taut
 Swab the site with alcohol & insert @ 90-degree angle while continuing to hold the tissue laterally
 Aspirate for blood return
 After instilling medication wait 10 seconds w/the needle in place & the skin still held taut
 Withdraw the needle & immediately release taut skin
 Apply direct pressure to the injection site w/guaze square (DON’T rub site!)

Question 7

6. Wood’ light nursing actions (PP slide 11)

Answer 7

 Needs to be in a darkened room
 Keep area clean & dry

Question 8

7. Cushing manifestations (pp slide 5, flash card 105)

Answer 8

 Rosy cheeks
 Striae
 Hirsutism (look for increase or decrease of hair)
 Moon face
 “Buffalo hump” of the neck
 HTN
 Increased blood sugar
 Weight gain
 Hypernatremia, hypokalemia

Question 9

8. Warts manifestations (PP slide 21)

Answer 9

 Benign, viral warty skin lesion
 Common locations: Hands, arms & fingers-on extremities do not hurt
 Transmitted skin to skin
 Educate client about changes in warts

Question 10

Wart treatment (PP slide 21)

Answer 10

 Cauterization
 Solid carbon dioxide
 Liquid nitrogen
 Salicylic acid

Question 11

9. Skin cancer incidence and risks (PP slide 22)

Answer 11

 Exposure to UV
 Low skin melanin
 Higher altitude
 Prolonged outdoor exposure

Question 12

10. Acne client education/ Nursing interventions (PP slide 10)

Answer 12

 Keep skin & hair clean
 Water-based make up w/gentle washing
 Avoid sun exposure

Question 13

11. Psoriasis client education and medical management (PP slide 14)

Answer 13

 Topical steroids
 Tar preparations
 Salicylic acid
 Ultraviolet light
 Lifelong care is usually needed

Question 14

12. Skin cancer manifestations (PP slide 23)

Answer 14

Basal Cell carcinoma:
 Small translucent, pearly appearance, might crust over
 Most common on face & upper trunk

Squamous cell carcinoma:
 Firm, nodular lesion
 Ulceration & indurated margins
 Sun-exposed areas: sites of chronic irritation

Question 15

13. Dehiscence nursing actions (PP slide 27)

Answer 15

 Partial or total separation of wound layers
 Place client in supine position & cover w/sterile dressing
 Good hand washing to prevent infection

Question 16

14. Herpes zoster nursing actions (PP slide 8)

Answer 16

 Analgesics, steroids, Kenalog lotion, corticosteroids, acyclovir (Zovirax)
 Ativan &n Atarax (decrease anxiety)
 Narcotics for pain

Question 17

Herpes zoster client education (PP slide 8)

Answer 17

 Avoid persons who have not had chicken pox
 Cool compresses on areas
 Can still shed virus even without active lesions (wear condoms)

Question 18

15. Scabies client education/Nursing management (PP slide 12)

Answer 18

 Pharmacological
 Treat all family members
 Wash linens & clothing in hot water using mild detergent
 Cool baths & temperature for comfort
 Avoid scratching

Question 19

16. Wound healing client education & management (pp slide 26)

Answer 19

 Prevent & manage infection
 Clean the wound
 Remove nonviable tissue
 Manage exudate
 Maintain the wound in a moist environment
 Protect the wound
 Nutrition & supplement considerations (vitamin A & C)

Question 20

17. Nevi-moles manifestations NTK (PP slide 21)

Answer 20

 Congenital skin blemish
 Usually benign, but may become malignant
 Assess for any change in color, size or texture
Asses for bleeding or pruritus

Question 21

18. Eviscerations (PP slide 27)

Answer 21

 Total separation of wound the visceral organ protrudes through the wound opening
 Place sterile towels soaked in normal saline invasion, surgery!

Question 22

Addison’s Disease manifestations

Answer 22

-Hyperpigmentation of the skin
-weight loss
-anorexia
-n/v, diarrhea
-hypotension
-hypovolemia
-fatigue
-depression
-confused
-Hyponatremia, hypernkalemia