NURSING 241 Skin/Burn Critical Thinking Practice Questions

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Skin/Burn Critical Thinking Practice Questions Name______________________ NURSING 241 Skin/Burn Critical Thinking Practice Questions Burns: 1. The client comes into the emergency room in severe pa... in and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? a. Superficial partial thickness. b. Deep partial thickness. c. Full thickness. d. First degree. 2. The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? a. A 22-gauge intravenous line with normal saline infusing. b. Wounds covered with moist sterile dressings. c. No intravenous pain medication. d. Adequate peripheral circulation to both feet ensured. 3. The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? a. Replace fluids and electrolytes. b. Prevent contractures of extremities. c. Monitor urine output hourly. d. Prepare to assist with an escharotomy. 4. The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? a. The client complains of pain when the medication is administered. b. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. c. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. d. The client is able to perform active range-of-motion exercises. 5. The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? a. "The doctor will graft skin from your back to your leg." b. "The skin from a donor will be used to cover your burn." c. "The graft will come from an animal, probably a pig." d. "I think you should ask your doctor about the graft."6. The ICU burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? a. High risk for infection. b. Ineffective coping. c. Impaired physical mobility. d. Knowledge deficit. 7. The nurse writes the nursing diagnosis "impaired skin related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? a. Provide analgesia before pain becomes severe. b. Clean the client's wounds, body, and hair daily. c. Screen visitors for respiratory infections. d. Encourage visitors to bring plants and flowers. 8. Which nursing intervention should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. a. Perform meticulous hand hygiene. b. Use sterile gloves for wound care. c. Wear gown and mask during procedures. d. Change invasive lines once a week. e. Administer antibiotics as prescribed. 9. With deep thickness and partial burns to the chest area. Which one should notify hcp? a. The client is complaining of severe pain. b. The client's pulse oximeter reading is 95%. c. The client has T 100.4˚F, P 100, R 24, and BP 102/60. d. The client's urinary output is 50 mL in two (2) hours. 10. The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? a. Encourage the client's family to bring favorite foods. b. Provide a low-fat, low-cholesterol diet for the client. c. Monitor the client's weight weekly in the same clothes. d. Make a referral to the hospital social worker. 11. The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? a. Apply an ice pack to the right hand. b. Place the hand in cool water. c. Be sure to rupture any blister formation. d. Go immediately to the doctor's office. 12. The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health?a. Encourage the client to stay at home as much as possible. b. Discuss the importance of not relying on the family for needs. c. Tell the client to remember that changes in lifestyle take time. d. Instruct the client to discuss feelings only with the therapist. Pressure Ulcers: 13. The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize? a. Keep the skin moist by leaving the skin damp after the bath. b. Do not rub any lotion into the skin. c. Turn clients who are immobile at least every two (2) hours. d. Only the licensed nursing staff may care for the client's skin. 14. The nurse is caring for a client who has developed stage 4 pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority? a. Impaired cognition. b. Altered nutrition. c. Self-care deficit. d. Altered coping. 15. The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers? a. Constant perineal moisture. b. Ability of the clients to reposition themselves c. Decreased elasticity of the skin. d. Impaired cardiovascular perfusion of the periphery. 16. What is the scientific rationale for placing lift pads under an immobile client? a. The pads will absorb any urinary incontinence and contain stool. b. The pads will prevent the client from being diaphoretic. c. The pads will keep the staff from workplace injuries such as a pulled muscle. d. The pads will help prevent friction shearing when repositioning the client. 17. The paraplegic client is being admitted to a medical unit from home with a stage 4 pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital? a. Complete the Braden Scale. b. Monitor the client on a Glasgow Coma Scale. c. Assess for Babinski's sign. d. Initiate a Brudzinski flow sheet.18. The wound care nurse documented a client's pressure ulcer on admission as 3.3 cm x 4.0 cm stage 2 on the coccyx. Which information would alert the nurse the the client's pressure ulcer is getting worse? a. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch. b. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally. c. The skin covering the coccyx is intact but the client complains of pain in the area. d. The coccyx wound extends to the subcutaneous layer and there is drainage. 19. The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse? a. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance. b. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit. c. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift. d. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing. 20. The nurse is caring for clients on a medical unit. After the shift report, which client should the asses first? a. The 34-year-old client who is quadriplegic and cannot move his arms. b. The elderly client diagnosed with a CVA who is weak on the right side. c. The 78-year-old client with pressure ulcers who has a temperature of 102.3˚F. d. The young adult who is unhappy with the care that was provided last shift. 21. The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions? a. Use a pillow to keep the heels off the bed when supine. b. Order a low air-loss therapy bed immediately. c. Prepare to insert a nasogastric feeding tube. d. Order an occupational therapy consult for strength training. 22. The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is "tired of it all" Which is the nurse's best therapeutic response? a. "These wounds can heal if we get enough protein into you." b. "Are you tired of the treatments and needing to be cared for?" c. "Why would you say that? We are doing our best." d. "Have you made out an advance directive to let the HCP know your wishes?" 23. The nurse writes the problem "impaired skin integrity" for a client with stage 4 pressure ulcers Which intervention should be included in the plan for care? Select all that apply. a. Turn the client every three (3) to four (4) hours. b. Ask the dietitian to consult.c. Have the client sign a consent for pictures of the wounds. d. Obtain an order for a low air-loss bed. e. Elevate the head of the bed at all times. 24. The client diagnosed with stage 4 infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement? a. "This surgery will create a skin flap to cover my wounds." b. "This surgery will get all the old black tissue out of the wound so it can heal." c. “The surgery is important to allow oxygen to get to the tissue for healing to occur." d. "Stool will come out an opening in my abdomen so it won't get in the sore." Skin Cancer: 25. The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching? a. Wear a sunscreen with a protection factor of 10 or less when in the sun. b. Try to stay out of the sun between 0300 and 0500 daily. c. Perform a thorough skin check monthly. d. Remember caps and long sleeves do not help prevent skin cancer. 26. The female client admitted for an unrelated diagnosis asks the nurse to check her back because “it itches all the time in one spot." When the nurse assesses the client's back, the nurse notes an irregular-shaped lesion with some scabbed over areas surrounding the lesion. Which action should the nurse implement first? a. Notify the HCP to check the lesion on rounds. b. Measure the lesion and note the color. c. Apply lotion to the lesion. d. Instruct the client to make sure the HCP checks the lesion. 27. The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first? a. The client scheduled for a skin biopsy who is crying. b. The client who had surgery three (3) hours ago and is sleeping. c. The client who needs to void prior to discharge. d. The client who has received discharge instructions and is ready to go home. 28. Which client is at the greatest risk for the development of skin cancer? a. The African American male who lives in the northeast. b. The elderly Hispanic female who moved from Mexico as a child. c. The client who has a family history of basal cell carcinoma. d. The client with fair complexion who cannot get a tan.29. The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include? a. Teach the client that there is no more risk for cancer. b. Refer the client to a prosthesis specialist for prosthesis. c. Instruct the client how to apply sunscreen to the area. d. Demonstrate care of the surgical site. 30. The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychological problem of "fear." Which nursing interventions should be included in the plan of care? a. Explain to the client that the fears are unfounded. b. Encourage the client to verbalize the feeling of being afraid. c. Have the HCP discuss the client's fear with the client. d. Instruct the client regarding all planned procedures. 31. The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP? a. Stock the rooms with the equipment needed. b. Weigh the clients and position the clients for the examination. c. Discuss problems the client has experienced since the previous visit. d. Take the biopsy specimens to the laboratory. 32. The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma? a. The lesion is asymmetrical and has irregular borders. b. The lesion has a waxy appearance with pearl- like borders. c. The lesion has a thickened and scaly appearance. d. The lesion appeared as a thickened area after an injury. 33. The client has had a squamous cell carcinoma removed from the lip. Which discharge instructions should the nurse provide? a. Notify the HCP if a nonhealing lesion develops around the mouth. b. Squamous cell carcinoma tumors do not metastasize. c. Limit foods to liquid or soft consistency for one (1) month. d. Apply heat to the area for 20 minutes every four (4) hours. 34. Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion? a. The client will express feelings of fear. b. The client will ask questions about the diagnosis.c. The client will state a diminished level of pain. d. The client will demonstrate care of the operative site. 35. The male client diagnosed with acquired immunodeficiency syndrome (AIDS) states that he has developed a purple-brown spot on his calf. Which action should the nurse do first? a. Refer the client to an HCP for a biopsy of the area. b. Assess the lesion for size, color, and symmetry. c. Discuss end-of-life decisions with the client. d. Report the sexually transmitted illness to the health department. 36. The nurse participating in a health fair is discussing malignant melanoma with a group of clients. Which information regarding the use of sunscreen is important to include? a. Sunscreen is only needed during the hottest hours of the day. b. Toddlers should not have sunscreen applied to their skin. c. Sunscreen does not help prevent skin cancer. d. The higher the number of the sunscreen, the more it blocks UV rays. Bacterial Skin Infection: 37. The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to touch, and the client has a temperature of 100.8 degrees Fahrenheit. Which condition would the nurse suspect the client is experiencing? a. Cellulitis. b. Lyme disease. c. Impetigo. d. Deep vein thrombosis. 38. The client comes to the clinic complaining of sudden onset of high fever, chills, and a headache. The nurse assesses a patchy macular rash on the trunk and a circular type of rash that looks like an insect bite. Which question would be most appropriate for the nurse to ask during the interview? a. "Do you own dogs that stay in the yard?" b. "Have you been working in your garden lately?" c. "Have you been deer hunting in the last week?" d. "Do you use sunscreen when you are outside?" 39. The school nurse s discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, "How can I prevent getting impetigo?" Which statement would be the most appropriate response? a. "Wash your hands after using the bathroom." b. "Do not touch any affected areas without gloves." c. "Apply a topical antibiotic to your hands." d. "Keep the child with impetigo isolated in the room."40. The client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse? a. The client has bilaterally weak radial pulses. b. The client is able to move the left fingers. c. The client has a CRT less than 3 seconds. d. The client is unable to remove the wedding ring. 41. The nurse writes the client problem of "acute pain and itching secondary to bacterial skin lesions." Which intervention should be included in the care plan? Select all that apply. a. Keep humidity at less than 20%. b. Maintain a cool environment. c. Use a mild soap for sensitive skin. d. Keep lesions covered at all times. e. Apply skin lotion after bathing. 42. The nurse observes the UAP squeezing the "blackheads" on an elderly client. Which action should the nurse implement first? a. Notify the unit manager of witnessing this activity. b. Instruct the assistant to stop this behavior. c. Demonstrate the correct way to care for the skin. d. Complete an incident report regarding the action. 43. The client is diagnosed with acne vulgaris. Which psychosocial problem is priority? a. Impaired skin integrity. b. Ineffective grieving. c. Body image disturbance. d. Knowledge deficit. 44. Which individual would most likely experience the skin disorder pseudofolliclitis barbae (shaving bumps)? a. A male African American soldier. b. A female Caucasian hairdresser. c. A male Asian food server. d. A female Hispanic schoolteacher. 45. The female client calls the clinic and tells the nurse that she has a really big "boil" in the perineal area that is causing a lot of pain. Which intervention should the nurse implement? a. Schedule an emergency appointment for the client. b. Instruct the client to apply warm, moist compresses to the area. c. Determine if someone can squeeze the boil. d. Explain that this will resolve on its own.46. Which client would most likely be at risk for the development of a carbuncle? a. The young male who is just beginning to shave. b. The female with a fair complexion. c. The male who works out in the gym daily. d. The female diagnosed with diabetes mellitus. 47. The female teacher comes to the school nurse's office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement? a. Instruct the teacher to go to her HCP today. b. Tell the teacher to wash her hands with soap and water. c. Encourage the teacher to rub vitamin E oil on the lesions. d. Explain that the rash will go away in a few days. 48. The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion? a. Instruct the clients to wear dark clothes when hunting. b. Use a sunscreen of at least SPF 30 when outside. c. Avoid dense undergrowth when in a wooded area. d. Do not use any type of insect repellant when deer hunting. Viral Skin Infection: 49. The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client? a. Encourage the client to get the chickenpox immunization. b. Do not engage in oral sex if you have a cold sore on the mouth. c. Wear nonsterile gloves when cleaning the genital area. d. Do not share any type of towel or washcloth with another person. 50. The client is complaining of burning, lancinating, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement? a. Transfer the client to the ED for a cardiac work-up. b. Inform the client that the nurse can't see anything. c. Administer a nonnarcotic analgesic to the client. d. Ask the client if he or she has ever had chickenpox. 51. The client is diagnosed with herpes simplex 2 and prescribed the antiviral medication valacyclovir (Valtrex) Which instructions should the nurse teach? a. This medication will prevent pregnancy and treat the virus. b. This medication must be tapered when discontinuing the medication.c. This medication will suppress symptoms but does not cure the disease. d. This medication may cause the client's urine to turn orange. 52. The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain is at a "5" on a 1- to-10 scale. Which intervention should the nurse implement? a. Turn on soft music and shut the blinds. b. Apply warm, moist heat to the lesions. c. Notify the HCP for more pain medication. d. Encourage the client to ambulate with assistance. 53. The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which intervention should the nurse implement? Select all that apply. a. Place the client in contact isolation. b. Administer a corticosteroid IVP. c. Assess the client's pain on a 1-to-10 scale. d. Request that the client not have any visitors. e. Ensure that only nurses who have had chickenpox care for this client. 54. Which statement by the client diagnosed with chickenpox indicates that the client understands the teaching? a. "I should put rubbing alcohol on the lesions twice a day." b. "I should not scratch myself if at all possible. It might lead to scarring." c. "I can go to work when my lesions have all disappeared." d. "I need to take all my antibiotics no matter how I feel." 55. The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal? a. The client will refrain from scratching the skin. b. The client will maintain intact skin integrity. c. The client will have relief from itching. d. The client will not develop a secondary bacterial infection. 56. The nurse is admitting an 88 year old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the UAP? a. Measure and document the client's skin lesions. b. Apply the antihistamine cream to the lesions. c. Set up the isolation equipment for the client. d. Determine if the client has prepared an advance directive. 57. The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220lbs. and the order reads 10mg per kilogram per day to be administered in equally divided doses every 6 hours. How many milligrams will be administered in one dose? Ans:__250 mg_______________________________________58. The 55 year old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox? a. Deep vein thrombosis. b. Varicella pneumonia. c. Pericarditis. d. Scarring of the skin. 59. The nurse is assessing a young mother who came to the clinic complaining of sores on her skin. Which assessment data would support that the client has chickenpox? a. Crops of lesions that have pus and reddened base. b. Oval scaling lesions that occur on the legs and arms. c. Severe itching of the scalp with tiny eggs visible. d. Ringed red lesions on the face, neck, trunk, and extremities. 60. The long-term care nurse has received the a.m. shift report. Which client should the nurse assess first? a. The client who has not had a bowel movement today. b. The client who needs the indwelling catheter changed. c. The client with periorbital skin lesions. d. The client with a stage I pressure ulcer. Fungal/Parasitic Skin Infection: 61. The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children? a. "I used the comb to remove all the nits." b. "I washed my hair with Kwell shampoo." c. "I removed all the sheets from my bed." d. "I had to fix my daughter's hair with my brush." 62. The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement? a. Instruct the football players to wear tight, snug-fitting jock straps. b. Explain the importance of wearing white socks. c. Teach the football players to not share brushes or combs. d. Discuss the need to dry the groin area thoroughly after bathing.63. The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client's fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data? a. Tinea capitis. b. Herpes simplex 2. c. Scabies. d. Psoriasis. 64. The HCP prescribed Kwell lotion to be applied to the entire body. Which instructions should the nurse teach the client concerning this medication? a. Leave the lotion on for two (2) hours after applying it to the body. b. Make sure that the skin is completely dry before applying the lotion. c. Repeat total body lotion application daily for at least one (1) week. d. Put the lotion in the bathwater and soak for at least 20 minutes. 65. The nurse in the long-term care facility must delegate a nursing task to an UAP. Which nursing task would be most appropriate to delegate? a. Comb the nits out of the client's hair. b. Massage the reddened area on the hip. c. Scrape the burrows to remove the scabies mite. d. Apply antifungal lotion to the groin area. 66. The client has tinea pedis. Which intervention should the nurse teach to the client? a. Soak feet in a vinegar-and-water solution. b. Wear shoes without any type of socks. c. Alternate shoes on a monthly basis. d. Cut toenails straight across. 67. The client with thick, crusty, yellow toenails is diagnosed with tinea unguium (onychomycosis) and asks the clinic nurse what happens if he can’t afford to take the medication the physician prescribed. The nurse's response will be based on which scientific rationale? a. The toes will become gangrenous and may have to be amputated. b. Over-the-counter antifungal creams can be substituted for the oral medication. c. The toenail plate will separate, and the entire toenail may be destroyed. d. Take all the prescribed antibiotics or the infection may return. 68. There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of the parasitic infection? a. Use only hand-washing foam when caring for clients with scabies. b. Wear gloves when providing hands-on care for a client with scabies. c. Wash all linen and clothes in cold water and dry them outside in the sun. d. Instruct clients to use plastic eating utensils for meals.69. The nurse in a dermatology clinic is taking the history of a client. Which questions should the dermatology nurse ask the client? Select all the apply. a. When did you first notice the skin problem? b. What cosmetics or skin products do you use? c. Have you experienced any loss of sensation? d. What is your current and previous occupation? e. Do you experience any itching, burning, or tingling? 70. The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate? a. Gently palpate the affected area using sterile gloves. b. Apply vinegar to the affected area to identify the scabies c. Use a magnifying glass and a penlight to visualize the skin. d. Obtain a Doppler to assess the movement of the mites. 71. The public health nurse is providing a class on skin disorders in the African American community. Which information should the nurse include in the presentation? a. People with dark skin suffer the same skin conditions as people with light skin. b. African American men are more likely to have skin cancer than women. c. Dark-skinned individuals are less likely to form keloids after any type of surgery. d. Buccal mucosa of dark-skinned individuals is usually a bluish-tinged color. 72. Which skin condition would most likely occur in the areas underneath the armpits, and high between the legs? a. Contact dermatitis. b. Herpes zoster. c. Seborrheic dermatitis. d. Scabies. [Show More]

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