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Saunders Medsurg Skin Integumentary Exam: Questions & Answers, Exams of Nursing

Touro CollegeNursing

A collection of actual exam questions related to the skin and integumentary system, covering topics such as poison ivy, cellulitis, psoriasis, herpes zoster, melanoma, frostbite, pressure ulcers, and burn injuries. Each question includes a detailed answer and rationale, offering valuable insights into the concepts and clinical applications of skin and integumentary care. This resource can be beneficial for students preparing for exams in medical-surgical nursing.

Typology: Exams

2024/2025

Available from 01/16/2025

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2024 SAUNDERS MEDSURG SKIN INTEGUMENTARY
EXAM
ACTUAL EXAM QUESTIONS WITH 100% CORRECT AND
DETAILED ANSWERS WITH RATIONALES /ALREADY
PASSED
1. A client calls the emergency department and tells the nurse that he came directly into contact
with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the
nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rinsing several times."
4. "It is not necessary to do anything if you cannot see anything on your skin."
Answer:
3. "Take a shower immediately, lathering and rinsing several times."
Rationale:
When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible
film on the human skin. The client should be instructed to cleanse the area by showering immediately
and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap
will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if
dermatitis develops. The client does not need to be seen in the emergency department at this time.
2. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg.
During the admission assessment, the nurse expects to note which finding?
1. An inflammation of the epidermis only
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. An epidermal and lymphatic infection caused by Staphylococcus
Answer:
2. A skin infection of the dermis and underlying hypodermis
Rationale:
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. The infection is not superficial and extends deeper than the
epidermis.
KEY:
All un-highlighted questions are required for Medsurg 1
Red Text = Should Understand
Green Text = Absolutely Should Know
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Download Saunders Medsurg Skin Integumentary Exam: Questions & Answers and more Exams Nursing in PDF only on Docsity!

2024 SAUNDERS MEDSURG SKIN INTEGUMENTARY

EXAM

ACTUAL EXAM QUESTIONS WITH 100% CORRECT AND

DETAILED ANSWERS WITH RATIONALES /ALREADY

PASSED

  1. A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?
    1. "Come to the emergency department."
    2. "Apply calamine lotion immediately to the exposed skin areas."
    3. "Take a shower immediately, lathering and rinsing several times."
    4. "It is not necessary to do anything if you cannot see anything on your skin." **Answer:
  2. "Take a shower immediately, lathering and rinsing several times." Rationale** : When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.
  3. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?
    1. An inflammation of the epidermis only
    2. A skin infection of the dermis and underlying hypodermis
    3. An acute superficial infection of the dermis and lymphatics
    4. An epidermal and lymphatic infection caused by Staphylococcus **Answer:
  4. A skin infection of the dermis and underlying hypodermis Rationale** : 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. The infection is not superficial and extends deeper than the epidermis.

KEY:

All un-highlighted questions are required for Medsurg 1

Red Text = Should Understand

Green Text = Absolutely Should Know

3. The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. 1. Presence of striae 2. Palpable radial pulses 3. Absence of any ecchymosis on the extremities 4. Thinner and decrease in number of reddish papules 5. Scarce amount of silvery-white scaly patches on the arms **Answers:

  1. Thinner and decrease in number of reddish papules
  2. Scarce amount of silvery-white scaly patches on the arms Rationale:** Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.
  3. The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?
    1. Positive patch test
    2. Positive culture results
    3. Abnormal biopsy results
    4. Wood's light examination indicative of infection **Answer:
  4. Positive culture results Rationale** : With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.
  5. 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 characteristics? Select all that apply.
    1. Lesion is painful to touch.
    2. Lesion is highly metastatic.
    3. Lesion is a nevus that has changes in color.
    4. Skin under the lesion is reddened and warm to touch.

intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

  1. An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?
    1. 18%
    2. 24%
    3. 36%
    4. 48% **Answer:
  2. 36% Rationale** : According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.
  3. 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?
    1. Return of distal pulses
    2. Brisk bleeding from the site
    3. Decreasing edema formation
    4. Formation of granulation tissue **Answer:
  4. Return of distal pulses Rationale** : Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. 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.
  1. 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?
    1. Decreased heart rate
    2. Increased urinary output
    3. Increased blood pressure
    4. Elevated hematocrit levels **Answer:
  2. Elevated hematocrit levels Rationale** : 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. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.
  3. 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?
    1. Vital signs
    2. Urine output
    3. Mental status
    4. Peripheral pulses **Answer:
  4. Urine output Rationale** : 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, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.
  5. The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?
    1. Out-of-bed activities
    2. Bathroom privileges
    3. Immobilization of the affected leg

Scabies can be identified by the multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.

  1. The nurse is concerned about potential skin integrity problems for an unconscious client. Which interventions would be most appropriate to include in the plan of care for this client? Select all that apply.
    1. Reposition every 2 hours.
    2. Use a bed cradle as indicated.
    3. Apply protective pads to heels and elbows.
    4. Add a small amount of alcohol to the daily bath water.
    5. Provide perineal care every 8 hours and after incontinence. **Answers:
  2. Reposition every 2 hours.
  3. Use a bed cradle as indicated.
  4. Apply protective pads to heels and elbows.
  5. Provide perineal care every 8 hours and after incontinence. Rationale:** Unconscious clients are completely immobile, having lost the protective reflexes to shift body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours. Use of a bed cradle can protect the client's toes from breakdown due to weight from linens. Protective pads can be applied to the heels and elbows to reduce friction and shear. Appropriate perineal care is essential to keep waste products from excoriating the skin. The nurse can reduce skin dryness and irritation by adding a superfatty solution (such as baby oil or castile soap) to the daily bath water. Drying agents such as alcohol are avoided because dry skin can crack and break down.
  6. The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the health care provider's prescriptions and should plan to question which prescription?
    1. Gastric lavage
    2. Intravenous (IV) fluid therapy
    3. Nothing by mouth (NPO) status
    4. Preparation for laboratory studies **Answer:
  7. Gastric lavage Rationale** :

The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve.

  1. The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder?
    1. An athlete
    2. An adolescent
    3. An older client
    4. A client who tans in an indoor tanning bed **Answer:
  2. A client who tans in an indoor tanning bed Rationale** : Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme conditions can damage the skin, posing the highest risk for skin disorders. An athlete would be at low risk of developing an integumentary problem. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. An older client may be at a higher risk than a younger person.
  3. The nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The nurse should make which response to the client?
    1. "The procedure is painless."
    2. "A preoperative medication will put you to sleep."
    3. "An analgesic will be prescribed after the procedure."
    4. "The local anesthetic may cause a stinging sensation." **Answer:
  4. "The local anesthetic may cause a stinging sensation." Rationale** : A skin biopsy is not painless. The most common source of pain during a skin biopsy is the initial local anesthetic, which can produce a burning or stinging sensation. A preoperative medication that puts the client to sleep is not a component of this procedure. Analgesics may be prescribed after the procedure, but this option does not address the issue related to the amount or type of pain associated with the procedure itself.
  5. The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction?
    1. "I will keep the dressing dry."
    2. "I will watch for any drainage from the wound."

One bath or one shower per day for 15 to 20 minutes with warm water and a mild soap should be followed immediately by the application of an emollient to prevent evaporation of water from the hydrated epidermis. The client should avoid using a dehumidifier because this will further dry room air. The client should be instructed to avoid applying rubbing alcohol, astringents, or other drying agents to the skin. A bath using a dilute alcohol solution will cause further drying of the skin.

  1. The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease?
    1. It is caused by a tick bite.
    2. It can be contagious by skin contact with an infected person.
    3. It can be caused by the inhalation of spores from bird droppings.
    4. It is caused by contamination from cat feces or the consumption of rare or raw meat. **Answer:
  2. It is caused by a tick bite. Rationale** : Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from 1 person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused from the inhalation of cysts from contaminated cat feces or the consumption of rare or raw meat.
  3. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis?
    1. "It is an acute superficial infection."
    2. "It is an inflammation of the epidermis."
    3. "Staphylococcus is the cause of this epidermal infection."
    4. "This skin infection involves the deep dermis and subcutaneous fat." **Answer:
  4. "This skin infection involves the deep dermis and subcutaneous fat." Rationale** : Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red erythema without sharp borders and spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Options 1, 2, and 3 are incorrect descriptions.
  5. The nurse expects to note which prescription for a client with a skin infection that extends into the dermis?
    1. Applying warm compresses to the affected area
    2. Placing iced compresses to the affected area every 4 hours
    3. Alternating the application of hot and iced compresses every 2 hours
  1. Placing antibiotic ointment on the affected site followed by continuous heat lamp application **Answer:
  2. Applying warm compresses to the affected area Rationale** : Warm compresses may be prescribed to decrease the discomfort, erythema, and edema associated with a skin infection that is characteristic of cellulitis. The nurse should also provide supportive care as prescribed to manage associated symptoms such as fever or chills. After tissue and blood are obtained for culture, antibiotics are initiated. Heat lamps can cause more disruption to already inflamed tissue. Iced compresses are not prescribed because they can damage tissue.
  3. The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin?
  4. Clustered skin vesicles
  5. A generalized body rash
  6. Small blue-white spots with a red base
  7. A fiery-red edematous rash on the cheeks **Answer:
  8. Clustered skin vesicles Rationale** : The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Options 2, 3, and 4 are incorrect descriptions.
  9. The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse should instruct the client to take which measure?
  10. Avoid the use of sunscreen on the skin for at least 2 years.
  11. Apply an emollient lotion to the skin to enhance softening.
  12. Scrub the skin vigorously with soap and water to remove the dead skin.
  13. Soak the skin for 1 hour 6 times daily to assist in removing any dry scales. **Answer:
  14. Apply an emollient lotion to the skin to enhance softening. Rationale** : The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days; however, soaking for 1 hour 6 times daily is excessive and could lead to skin breakdown. The skin should not be scrubbed vigorously because this action also could lead to skin breakdown. The skin should be patted dry, and a lubricating lotion should be applied. The client should avoid overexposing the skin to the sunlight.
  1. A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type?
    1. Superficial
    2. Full-thickness
    3. Deep partial-thickness
    4. Partial-thickness superficial **Answer:
  2. Full-thickness Rationale** : Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.
  3. A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate?
    1. Allow the client to have full liquids.
    2. Give the client small glasses of clear liquids.
    3. Order the client a full meal tray with extra liquids.
    4. Keep the client on NPO (nothing by mouth) status. **Answer:
  4. Keep the client on NPO (nothing by mouth) status. Rationale** : The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst.
  5. A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound?
    1. Dry sterile dressing
    2. Wet to dry dressing
    3. Gelfoam sponge dressing
    4. Semipermeable film dressing **Answer:
  6. Semipermeable film dressing**

Rationale : Semipermeable film dressings are used on superficial wounds, on ulcers, and occasionally on some deep, draining, or necrotic ulcers. These dressings have the advantage of staying in place for several days, allowing tissues to heal underneath. Dry sterile dressings would stick to the wound and are inappropriate. Wet to dry dressings are unnecessary because the tissue does not need debridement. Gelfoam sponge dressings are a type of enzyme dressing used in the treatment of necrotic tissue.

  1. A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment?
    1. Gastric pH of 3
    2. Absence of abdominal discomfort
    3. GI drainage that is guaiac negative
    4. Presence of hypoactive bowel sounds **Answer:
  2. Gastric pH of 3 Rationale** : The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor–blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake.
  3. The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client?
    1. Pillow
    2. Foam pad
    3. Folded blankets
    4. Plastic-lined absorbent pad **Answer:
  4. Foam pad Rationale** : The client who cannot shift weight unassisted should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for this purpose are those that have a tendency to equalize the client's weight on the pad. These include foam, water, gel, and alternating air products. A pillow provides cushion but does not distribute weight equally. A plastic-lined pad and folded blankets provide no pressure relief.
  5. A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse should tell the client to take which measure?

Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial- thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold.

  1. The nurse provides home care instructions to a client diagnosed with impetigo. Which statement by the client indicates the need for further instruction?
    1. "I need to continue with the antibiotics as prescribed."
    2. "I need to wash my hands thoroughly and frequently throughout the day."
    3. "I should wash my dishes separately from those of other household members."
    4. "It is not necessary to separate my linens and towels from those of other household members." **Answer:
  2. "It is not necessary to separate my linens and towels from those of other household members."** Rationale: The client needs to separate his or her linens and towels from those of other household members. Thorough hand washing, separating linens and towels, and separate washing of the client's dishes are required because the infection is contagious so long as skin lesions are present. Antibiotics are administered and should be continued as prescribed.
  3. The nurse has been working with the client diagnosed with candidiasis (thrush). What should the nurse assess for in this client?
    1. The presence of blisters
    2. The presence of white patches
    3. The presence of purple patches
    4. The presence of numerous small, red, pinpoint lesions **Answer:
  4. The presence of white patches Rationale** : Assessment of the client with candidiasis (thrush) will reveal white patches on the tongue, palate, and buccal mucosa. The lesions adhere firmly to the tissues and are difficult to remove. The lesions often are referred to as "milk curds" because of their appearance. Clients often describe the lesions as dry and hot. Options 1, 3, and 4 are not characteristics of thrush.
  5. The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction?
    1. "I should use tepid water for bathing."
    2. "I need to keep my skin lubricated and cool."
    3. "After bathing, I should pat my skin dry rather than rubbing it."
  1. "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry." **Answer:
  2. "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry." Rationale:** The client should be instructed that a lubricant is applied immediately after the bath, while the skin is still damp, to help increase hydration of the stratum corneum. Options 1, 2, and 3 are appropriate home care measures to control the symptoms associated with pruritus.
  3. The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply.
  4. Red, raised papules
  5. Large plaques covered by silvery scales
  6. Tiny red vesicles that weep serous material
  7. Erythema noted mostly under the breast area
  8. Pink to dark red, patchy eruptions on the skin **Answers:
  9. Red, raised papules
  10. Large plaques covered by silvery scales Rationale:** Psoriasis lesions appear as red, raised papules that may coalesce into large plaques covered by silvery scales. Eczema can manifest as tiny red vesicles that weep serous or purulent material. Erythema noted mostly under the breast area is characteristic of seborrheic dermatitis. Pink to dark red, patchy eruptions on the skin may be indicative of exfoliative dermatitis.
  11. The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase?
  12. The entire period of time during which rehabilitation occurs
  13. The period from the time the client is stable to the time when all burns are covered with skin
  14. The period from the time the burn was incurred to the time when the client is admitted to the hospital
  15. The period from the time the burn was incurred to the time when the client is considered physiologically stable **Answer:
  16. The period from the time the burn was incurred to the time when the client is considered physiologically stable Rationale** :
  1. "You will need to see the health care provider because this may indicate a complication of the procedure." **Answer:
  2. "In many cases the nose and upper lip are numb for up to 6 months." Rationale:** The nurse should instruct the client that after this procedure ecchymosis will last approximately 2 weeks, and the nose and upper lip may be numb for approximately 6 months. Options 1, 3, and 4 are inappropriate and inaccurate nursing responses.
  3. A client is admitted to the hospital with a partial-thickness skin loss and blister on the sacrum. The nurse should develop a plan of care for which stage of pressure ulcer? Refer to Figure. View Figure
  4. Stage I ulcer
  5. Stage II ulcer
  6. Stage III ulcer
  7. Stage IV ulcer **Answer:
  8. Stage II ulcer**

Rationale : A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage I ulcer is characterized by a reddened area and intact skin. Stage III ulcers are full-thickness lesions of the skin. Stage IV ulcers also are full-thickness lesions, with exposed muscle, bone, or supportive tissue.

  1. A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What should the nurse include in client teaching to maximize the effects of the treatment?
    1. Rub the application into the skin.
    2. Place the area under a heat lamp for 20 minutes.
    3. Apply a dry sterile dressing over the affected area.
    4. Cover the application with a warm, moist dressing and an occlusive outer wrap. **Answer:
  2. Cover the application with a warm, moist dressing and an occlusive outer wrap.**