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c.

radiation
50 item Integumentary Exam
d. chemical
50 item Integumentary Exam
5. A nurse assesses the carbon
1. A nurse is caring for a burn client monoxide level of a client following a
who has sustained thoracic burns and burn injury and notes that the level is
smoke inhalation and is risk for 8%. Based on this level, which finding
impaired gas exchange. The nurse would the nurse expect to note during
avoids which action in caring for this the assessment of the client?
client?
a. tachycardia
a. repositioning the client from side to b. tachypnea
side every 2 hours c. coma
b. maintaining the client in a supine d. impaired visual acuity
position with the head of the bed
elevated 6. A nurse assesses the client’s burn
c. suctioning the airway as needed injury and determines that the client
d. providing humidified oxygen as sustained a partial-thickness
prescribed superficial burn. Based on this
determination, which finding did the
nurse note?
2. A client sustains a burn injury to the
entire right arm, entire right leg, and a. a wet, shiny, weeping wound
anterior thorax. According to the rule b. a dry wound surface
of nine’s the nurse determines that c. charring at the wound site
what body percent was injured? d. absence of wound sensation

Answer: 7. A nurse assesses the client’s burn


______________________________________ injury and determines that the client
sustained a partial-thickness deep
3. A nurse assesses a burn injury and burn. Based on this determination,
determines that the client sustained a which finding did the nurse note?
full-thickness fourth-degree burn if
which of the following is noted at the a. a wet, shiny, weeping wound
site of injury? surface
b. a dry wound surface
a. a wet shiny weeping wound surface c. charring at the wound site
b. a dry wound surface d. total absence of wound sensation
c. charring at the wound site
d. blisters 8. On assessment of a child, the nurse
notes the presence of white patches
on the child’s tongue and determines
4. A client is brought to the that they may be indicative of
emergency room following a burn candidiasis (thrush). The nurse
injury. In assessment the nurse notes understands that the white patches of
that the client’s eyebrow and nasal candidiasis (thrush):
hairs are singed. The nurse would
identify this type of burn as: a. adhere to the tongue even when
scraped with tongue blade
a. thermal b. cause the tongue to bleed
b. electrical continuously around the patch
c. produce a red circle in the center of a. client complains of discomfort
the white lesion behind the knee on forced dorsiflexion
d. will occur only in the tongue of the foot
b. a spasm of the facial muscles
elicited by tapping the facial nerve in
9. On assessment, a nurse notes a flat the region of the parotid gland
brown circular nevi on the skin of a c. carpal spasm elicited by
client that measures less than one compressing the upper arm
centimeter. The client asks, “Is this d. the epidermis of the client’s skin
cancer?” The nurse makes which can be rubbed off by slight friction or
response to the client? injury

a. “These are likely to be benign 13. A hospitalized client is diagnosed


moles.” with scabies. Which of the following
b. “These require immediate attention would a nurse expect to note on
because they are probably cancer.” inspection of the client’s skin?
c. “These indicate malignancy.”
d. “These are probably verrucae.” a. the appearance of vesicles or
pustules
10. A nurse is performing a skin b. the presence of white patches
assessment on a client. The nurse scattered about the trunk
understands that moles with c. multiple straight or wavy threadlike
variegated color, irregular borders, lines beneath the skin
and/or an irregular surface should be d. patchy hair loss and round, red
considered: macules with scales

a. suspicious 14. A client is seen in the health care


b. normal clinic and the physician suspects
c. common herpes zoster. The nurse prepares the
d. benign items needed to perform the
diagnostic test to confirm this
11. A client is diagnosed with herpes diagnosis. Which item will the nurse
zoster (shingles). Which obtain?
pharmacological therapy would the
nurse expect to be prescribed to treat a. a biopsy kit
this disorder? b. a wood’s light
c. a culture swab and tube
a. tetracycline hydrochloride d. a patch test kit
(achromycin)
b. erythromycin base (e-mycin) 15. A nurse reviews the health care
c. acyclovir (zovirax) record of a client diagnosed with
d. indomethacin (indocin) herpes zoster. Which finding would the
nurse expect to note as characteristic
12. A nurse reviews the record of a of this disorder?
client diagnosed with pemphigus and
notes that the physician has a. a generalized red body rash that
documented the presence of causes pruritus
Nikolsky’s sign. Based on this b. small blue-white spots with a red
documentation, which of the following base noted on the extremities
would the nurse expect to note? c. a fiery red edematous rash on the
cheeks and neck
d. clustered and grouped skin vesicles assessment of the client?

16. A client returns to the clinic for a a. a deep ulcer that extends into
follow-up treatment following a skin muscle and bone
biopsy of a suspicious lesion b. a deep ulcer that extends into the
performed 1 week ago. The biopsy dermis and the subcutaneous tissue
report indicated that the lesion is a c. an area in which the top layer of
squamous cell carcinoma. The nurse skin is missing
plans care knowing that which of the d. a reddened area that returns to
following describes the characteristic normal skin color after 15 to 20
of this type of a lesion? minutes of pressure relief

a. it is highly metastatic 20. A client is in the health care clinic


b. it does not metastasize for complaints of pruritus. Following
c. it is characterized by local invasion diagnostic studies, it has been
d. it is encapsulated determined that there is not a
pathophysiological process causing
17. A nurse reviews the record of a the pruritus. The nurse prepares
client scheduled for removal of a skin instructions for the client to assist in
lesion. The record indicates that the reducing the problem and tells the
lesion is an irregularly shaped, client to:
pigmented papule with a blue-toned
color. The nurse determines that this a. use a dehumidifier in the home
description of the lesion is b. ensure that the temperature in the
characteristic of: home is high, especially during the
winter months
a. melanoma c. use a cool-mist vaporizer, especially
b. basal cell carcinoma during the winter months
c. squamous cell carcinoma d. avoid use of skin moisturizers
d. actinic keratosis following a bath

18. A nurse is reviewing the nursing 21. A client is seen in the health care
care plan for a client for whom a stage clinic because of complaints of lesions
4 decubiti ulcer has been on the elbows and the knees. The
documented. Which of the following lesions are red raised papules, and
would the nurse expect to note on large plaques covered by silvery
assessment of the client? scales are also noticed on the elbows
and the knees. Psoriasis is diagnosed
a. a reddened area that returns to a and the nurse provides information
normal skin color after 15 to 20 about treatment to the client. The
minutes of pressure relief nurse determines that the client needs
b. intact skin additional information if the client
c. an area in which the top layer of states that which of the following is a
skin is missing component of the treatment plan?
d. a deep ulcer that extends into
muscle and bone. a. tar baths
b. ultraviolet light treatments
19. A nurse notes documentation of a c. topical lubricants
stage 3 pressure ulcer in a client’s d. systemic corticosteroids
record. Which of the following would
the nurse expect to note on 22. A client is seen in the health care
clinic and a biopsy is performed on a b. aspirin with oxycodone (percodan)
skin lesion that the physician suspects via nasogastric tube
malignant melanoma. The nurse c. acetaminophen (tylenol) with
prepares a plan of care for the client codeine sulfate
based on which characteristics of this d. morphine sulfate by the
type of skin cancer? subcutaneous route

a. it is an aggressive cancer that 25. A nurse is assessing the operative


requires aggressive therapy to control site in a client who underwent a
its rapid spread breast reconstruction. The nurse is
b. it is a slow-growing cancer and inspecting the flap and the areola of
seldom metastasizes the nipple and notes that the areola is
c. it can grow so large that an entire a deep red color around the edge. The
area, such as the nose, the lip, or the nurse takes which action first?
ear must be removed and
reconstructed if it occurs on the face a. document the findings
d. it is the most common form of skin b. elevate the breast
cancer c. encourage nipple massage
d. notify the physician

26. A nurse performs a skin


assessment on an assigned client and
notes the presence of lesions that are
red-tan scaly plaques. The nurse
23. A nurse is caring for a client documents this findings as:
brought to the emergency room
following a burn injury that occurred in a. seborrhea
the basement of the home. Which b. xerosis
initial finding would indicate the c. pruritus
presence of inhalation injury? d. actinic keratoses
27. A community health nurse has
a. expectoration of sputum tinged with provided fire safety instructions to a
blood group of individuals who are part of a
b. the presence of singed nasal hair disaster response team. Which
c. absent breath sounds in the lower statement by a group member
lobes bilaterally indicates a need for further
d. tachycardia instructions?

24. A nurse is caring for a client who a. “the victim may be rolled on the
arrives at the emergency room with ground to extinguish the flames”
the emergency medical services team b. “a blanket or another cover can be
following a severe burn injury from an used to smother the flames”
explosion. Once the initial assessment c. “flames should be doused with
has been performed by the physician water”
and life-threatening dysfunctions have d. “keep the victim in standing
been addressed, the nurse reviews the position so flames won’t spread to
physician’s orders anticipating that other parts of the body”
which pain medication will be
prescribed? 28. A community health nurse is
providing a teaching session to
a. intravenous (IV) morphine sulfate firefighters in a small community
regarding care to a victim at the scene the client indicates a need for further
of a burn injury. The community health instructions?
nurse instructs the firefighters that in
the event of a tar burn the immediate a. “I will watch for any drainage from
action would be to: the wound”
b. “I will return tomorrow to have the
a. cool the injury with water sutures removed”
b. remove all clothing immediately c. “I will use antibiotic ointment as
c. remove the tar from the burn injury prescribed”
d. leave any clothing that is saturated d. “I will keep the dressing dry”
with tar in place
33. The nurse preparing to assist the
physician to examine the client’s skin
29. The client who sustained an with a Wood’s light would do which of
inhalation injury arrives in the the following?
emergency department. On
assessment of the client, the nurse a. obtain an informed consent
notes that the client is very confused b. tell the client that the procedure is
and combative. The nurse determines painless
that the client is experiencing: c. shave the skin site
d. prepare a local anesthetic
a. anxiety
b. fear 34. The nurse provides discharge
c. hypoxia instructions to a client following patch
d. pain testing. Which instruction would the
30. The client is diagnosed with stage nurse provide to the client?
1 of Lyme disease. The nurse assesses
the client for the hallmark a. return to the clinic in 2 weeks for
characteristic of this stage. Which the initial reading
assessment finding would the nurse b. reapply the patch if it comes off
expect to note? c. continue all current activities
d. keep the test sites dry
a. dizziness and headaches
b. enlarged and inflamed joints 35. A nurse is preparing a client for
c. arthralgias skin grafting and notes that the
d. skin rash physician has documented that the
31. The emergency department nurse client is scheduled for heterograft. The
is performing an assessment on a nurse understands that the
client who has sustained heterograft used for the burn client is
circumferential burns of both legs. skin from:
Which assessment would be the
priority in caring for this client? a. another species
b. a cadaver
a. assessing peripheral pulses c. the burned client
b. assessing neurological status d. a skin bank
c. assessing urine output
d. assessing blood pressure 36. Following assessment and
diagnostic evaluation, it has been
32. The nurse is reviewing the determined that the client has Stage II
discharge instructions for a client who of Lyme disease. The nurse expects to
had skin biopsy. Which statement by note which assessment finding that is
most indicative of this stage? which of the following to be part of the
treatment plan?
a. erythematous rash
b. cardiac conduction defects a. no treatment unless symptoms
c. arthralgias develop
d. enlargement of joints b. a 3-week course of oral antibiotic
therapy
37. The clinic nurse reads the chart of c. treatment with intravenous
a client that was seen by the penicillin G
physician and notes that the physician d. ultraviolet light therapy
has documented that the client has
Stage III of Lyme disease. Which 40. The client with acquired
clinical manifestation would the nurse immunodeficiency syndrome (AIDS) is
expect to note in the client? suspected of having cutaneous
Kaposi’s sarcoma. The nurse prepares
a. a generalized skin rash the client for which test that will
b. a cardiac dysrhythmia confirm the presence of this type of
c. complaints of joint pain sarcoma?
d. paralysis in the extremity where the
tick bite occurred a. sputum culture
b. liver biopsy
38. A female client arrives at the c. punch biopsy of the lesion
health care clinic and tells the nurse d. white blood cell count
that she was bitten by a tick and
would like to be tested for Lyme 41. The client who is newly admitted
disease. The client tells the nurse that to the hospital for treatment of acute
she removed the tick and flushed it cellulitis of the lower left leg asks the
down the toilet. Which nursing action nurse about the nature of the disorder.
is appropriate? The nurse would respond that cellulitis
is actually:
a. refer the client for a blood test
immediately a. a skin infection into the deep
b. inform the client that the tick is dermis and subcutaneous fat
needed to perform the test b. an acute superficial infection
c. inform the client that she will need c. an inflammation of the epidermis
to return in 6 weeks to be tested d. an epidermal infection caused by
because testing before this time is not Staphylococcus
reliable
d. ask the client about the size and 42. A nurse is preparing a plan of care
color of the tick for a client with a diagnosis of acute
cellulitis of the lower leg. The nurse
anticipates which measure will be
prescribed to treat this condition?
39. The client suspected of having a. warm moist compresses to the
Stage I of Lyme disease is seen in the affected area
health care clinic and is told that the b. cold compresses to the affected
Lyme disease test is positive. The area
client asks the nurse about the c. heat lamp treatments 4 times daily
treatment for the disease. The nurse d. alternating hot to cold compresses
responds to the client, anticipating every 2 hours
client?

43. A clinic nurse provides instructions a. intramuscular


to a client who will be taking b. intravenous
isotretinoin (Accutane) for severe c. oral
cystic acne. Which statement by the d. subcutaneous
client indicates the need for further
instructions?
47. A nurse is performing a skin
a. “I need to return to the clinic for a assessment of a client who is
blood test to check my triglyceride immobile and notes the presence of
level” partial thickness skin loss of the upper
b. “The medication may cause my lips layer of the skin in the sacral area.
to burn” The nurse documents these findings
c. “The medication may cause dryness as a:
and burning in my eyes”
d. “I need to take vitamin A a. stage 1 pressure ulcer
supplements to improve the b. stage 2 pressure ulcer
effectiveness of this treatment” c. stage 3 pressure ulcer
d. stage 4 pressure ulcer
44. A client sustained full-thickness
burns to both hands from scalding 48. A student nurse is instructed by
water. A sheet graft was surgically the registered nurse to monitor a
applied to the wounds. The nurse tells client who has dark skin for cyanosis.
the client that this type of graft is The registered nurse determines that
indicated for which of the following the student needs instructions
primary purposes? regarding physical assessment
techniques for the dark-skinned client
a. better adherence to the wound bed if the student states that the best area
b. better cosmetic result to assess for cyanosis was in the:
c. better donor site availability
d. easier to care for initially a. nail beds
b. lips
45. A client sustained a major burn is c. sclera of the eye
beginning to take an oral diet again. d. tongue
The nurse plans to encourage the
client to eat variety of which of the 49. A client with severe psoriasis has a
following types of foods to best help in nursing diagnosis of Chronic Low Self-
continued wound healing and tissue Esteem. The nurse uses which
repair? therapeutic strategy when working
with this client?
a. high carbohydrate and low protein
b. high fat and low carbohydrate a. listening attentively
c. high protein and high fat b. pretending not to notice affected
d. high protein and high carbohydrate skin areas
c. keeping communications brief
46. A client with a major burn is d. approaching the client in a formal
admitted to the emergency manner
department. The nurse anticipates
that which of the following routes will 50. A nurse caring for a client who
be ordered for analgesics for this sustained a high-voltage electrical
injury analyzes the client’s test
results. Which finding would the nurse
interpret as increasing the client’s risk
of developing acute tubular necrosis?

a. myoglobin in the urine


b. carbonaceous sputum
c. hyperkalemia
d. cloudy cerebrospinal fluid