Burns, Skin, & Immune Exam 3 75 Questions with 100% Correct Answers. 2022/2023. Rated A

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Burns, Skin, & Immune Exam 3 75 Questions with 100% Correct Answers 1. The clinic nurse assesses the skin of a client with a diagnosis of psoriasis. The nurse understands that which characteristic ... is associated with this skin disorder? 1. Oily skin 2. Clear, thin nail beds 3. Red-purplish scaly lesions 4. Silvery-white scaly patches - 4. Silvery-white scaly patches Rationale: Psoriatic patches are covered with silvery white scales. Affected areas include the scalp, elbows, knees, shins, sacral area, and trunk. Thickening, pitting, and discoloration of the nails occur. Pruritus may occur. IGGY page 498-499 2. 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 characteristic? 1. Metastasis is rare. 2. It is encapsulated. 3. It is highly metastatic. 4. It is characterized by local invasion. - 3. It is highly metastatic. Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. IGGY page 502 3. When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding? 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border - 1. An irregularly shaped lesion Rationale: A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. 4. 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 site3. Decreasing edema formation 4. Formation of granulation tissue - 1. 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. 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 5. A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? 1. Transfusing 1 unit of packed red blood cells 2. Administering a diuretic to increase urine output 3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4. Changing the IV lactated Ringer's solution to one that contains dextrose in water - 3. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. IGGY page 526 & 257 5. 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 - 4. 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% are expected during the first 24 hours after injury, with return to normal by 36 hoursafter injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts. IGGY page 524 6. The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Avoid sun exposure in the late afternoon and early evening hours. 5. Examine your body monthly for any lesions that may be suspicious. - 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 5. Examine your body monthly for any lesions that may be suspicious. Rationale: The client should be instructed to avoid sun exposure between the hours of 10 am and 4 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or any precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced IGGY Page 503 7. Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. The nurse should take which most appropriate action? 1. Discontinue the medication. 2. Notify the health care provider. 3. Inform the client that this is expected 4. Apply a thinner film than prescribed to the burn site. - 3. Inform the client that this is expected Rationale: Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning and that this is a normal reaction. Kee Hayes page 757 8. A burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? 1. Hyperventilation 2. Local rash at the burn site3. Elevated blood pressure 4. Local pain at the burn site - 1. Hyperventilation Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 2 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury. Kee Hayes page 756 757 9. Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication will permanently stain my skin." 4. "The medication should be applied directly to the wound." - 3. "The medication will permanently stain my skin." Rationale: Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not stain the skin. An adult client trapped in a burning house has suffered burns to the back of the head, upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what does the nurse determine the extent of the burn injury to be? Fill in the blank. - 22.5% Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5% IGGY page 523 A client is diagnosed with a full-thickness burn. The nurse understands that which structural areas of the skin are involved? 1. Epidermis only 2. Epidermis and deeper dermis 3. Epidermis and upper layer of dermis 4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat - 4. Epidermis, entire dermis, and epithelial portion of subcutaneous fat Rationale: A full-thickness burn involves the epidermis, entire dermis, and epithelial portion of subcutaneous fat layer. Option 1 describes a superficial burn. Option 2 describes a deep partial-thickness burn. Option 3 describes a partial-thickness burn.IGGY Page 513 Blood work has been drawn on a client who has been taking cyclosporine (Sandimmune) following allogenic liver transplantation. The nurse should check the results of which test to determine the presence of an adverse effect related to this medication? 1. Hematocrit level 2. Cholesterol level 3. Hemoglobin level 4. Blood urea nitrogen (BUN) level - 4. Blood urea nitrogen (BUN) level Rationale: Nephrotoxicity is one of the most common adverse effects of cyclosporine. Nephrotoxicity is evaluated by monitoring the BUN and creatinine levels. A client with a burn injury is applying mafenide (Sulfamylon) to the wound. The client calls the health care provider's office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action? 1. Discontinue the medication. 2. Continue with the treatment, as this is expected. 3. Apply a thinner film than prescribed to the burn site. 4. Come to the office to see the health care provider (HCP) immediately. - 2. Continue with the treatment, as this is expected. Rationale: Mafenide is used to treat partial- and full-thickness burns. It is bacteriostatic for both gram-negative and -positive organisms present in avascular tissues. The client should be warned that the medication will cause local discomfort and burning. The nurse does not instruct a client to alter a medication prescription IGGY page 534 A client with psoriasis is being treated with calcipotriene (Dovonex) cream. Administration of high doses of this medication can cause which adverse effect? 1. Alopecia 2. Hyperkalemia 3. Hypercalcemia 4. Thinning of the skin - 3. Hypercalcemia Rationale: Calcipotriene (Dovonex), an analogue of vitamin D3, is indicated for mild to moderate psoriasis. Responses are equal to those achieved with medium-potency topical glucocorticoids. The most common adverse effect is local irritation. Unlike glucocorticoids, calcipotriene does not cause thinning of the skin. At high doses, calcipotriene has caused hypercalcemia. Alopecia and hyperkalemia is not associated with this medication Kee Hayes page 751A nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? 1. Sclera 2. Oral mucosa 3. Soles of the foot 4. Palms of the hand - 2. Oral mucosa IGGY page 863 The nurse asks the student nurse, "What does it mean that an antibiotic is classified as a bactericidal agent?" Which response by the nursing student indicates an understanding of a bactericidal agent? 1. Has low efficacy 2. Has a very low potency 3. Kills the infectious agent 4. Slows the growth of the infectious agent - 3. Kills the infectious agent IGGY page 445 446 A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the last 3 days. Which laboratory abnormality indicates that the client is experiencing an adverse effect of this medication? 1. Serum sodium of 120 mEq/L 2. Serum potassium of 3.0 mEq/L 3. White blood cells of 3000 cells/mm3 4. pH 7.30, Pco2 of 35 mm Hg, HCO3- of 19 mEq/L - 3. White blood cells of 3000 cells/mm3 Rationale: Transient leukopenia typically occurs after 2 to 3 days of treatment. Knowing this and knowing normal white blood cell values will direct you to option 3. IGGY page 534 A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 1. 1200 mL of 5% dextrose in water solution 2. 2400 mL of 0.45% normal saline solution 3. 4800 mL of 0.9% normal saline solution 4. 9600 mL of lactated Ringer's solution - 4. 9600 mL of lactated Ringer's solution Rationale: The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL. IGGY page 526 Which individual is least likely to be at risk for development of psoriasis? 1. A 32-year-old African American 2. A woman experiencing menopause 3. A client with a family history of the disorder4. An individual who has experienced a significant amount of emotional distress - 1. A 32-year-old African American Rationale: Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. Various forms exist, with psoriasis vulgaris being the most common type. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a cause. The disorder also may be exacerbated by the use of certain medications. Psoriasis occurs equally among women and men, although the incidence is lower in darker-skinned races and ethnic groups. IGGY page 498 499 Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instructions? 1. "Treatments are limited to two or three times a week." 2. "The UV light treatments are given on consecutive days." 3. "Eye goggles need to be worn to prevent exposure to UV light." 4. "Just the area requiring treatment should be exposed to the UV light." - 2. "The UV light treatments are given on consecutive days." Rationale: UV light treatments are limited to two or three times a week and are not given on consecutive days. Safety precautions are required during UV light therapy. It is best to expose only those areas requiring treatment to the UV light. Protective wraparound goggles prevent exposure of the eyes to UV light. The face should be shielded with a loosely applied pillow case if it is unaffected. Direct contact with the light bulbs of the treatment unit should be avoided to prevent burning of the skin. IGGY page 500 The nurse is reviewing discharge instructions for a client who had a skin biopsy. Which statement by the client indicate a need for further instruction? 1. "I will use the antibiotic ointment as prescribed." 2. "I will return in 7 days to have the sutures removed." 3. "I will remove the dressing as soon as I get home and wash it with tap water." 4. "I will call the health care provider (HCP) if I see any drainage from the wound." - 3. "I will remove the dressing as soon as I get home and wash it with tap water." Rationale: After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After the dressing is removed, the site is cleaned once daily with tap water or saline to remove any dry blood or crusts. The HCP may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures usually are removed 7 to 10 days after biopsy. IGGY page 468A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is. Which statement is the appropriate response by the nurse? 1. "There is no pain associated with this procedure." 2. "The local anesthetic may cause a burning or stinging sensation." 3. "A preoperative medication will be given so you will be sleeping and will not feel any pain." 4. "There is some pain, but the health care provider will prescribe an opioid analgesic after the procedure." - 2. "The local anesthetic may cause a burning or stinging sensation." IGGY page 468 The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet light (UVL) therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? 1. "Each treatment will last at least 30 minutes." 2. "Your entire body will be exposed to the light treatment." 3. "You will need to wear cotton clothes during the treatment." 4. "You will need to wear dark eye goggles during the treatment." - 4. "You will need to wear dark eye goggles during the treatment." Rationale: Safety precautions are required during UVL therapy. Protective dark eye goggles are required to prevent exposure of the eyes to the UVL; it may be necessary to wear the goggles for the remainder of the day following treatment. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Most UVL therapies require the client to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UVL. Direct contact with the light bulbs used for the treatment should be avoided to prevent burning of the skin. IGGY page 500 A complete blood cell count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE? 1. Decreased platelets only 2. Increased red blood cell count 3. Increased white blood cell count 4. Decreased number of all cell types - 4. Decreased number of all cell types Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease in the number of all cell types. This finding is most likely caused by a direct attack of all blood cells or bone marrow by immune complexes. IGGY page 345 An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? 1. Determines the presence of antigens2. Identifies which additional tests need to be performed 3. Confirms the diagnosis of a connective tissue disorder 4. Confirms the presence of inflammation or infection in the body - 4. Confirms the presence of inflammation or infection in the body Rationale: The ESR can confirm the presence of inflammation or infection in the body. It is particularly useful for the management of connective tissue disease because the rate measured directly correlates with the degree of inflammation and later with the severity of the disease. IGGY page 336 The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued." - 1. "I should take hot baths because they are relaxing." Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness. IGGY page 345 A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? 1. Maintain bed rest as much as possible. 2. Administer corticosteroids as prescribed for inflammation. 3. Advise the client to remain supine for 1 to 2 hours after meals. 4. Keep the room temperature warm during the day and cool at night - 2. Administer corticosteroids as prescribed for inflammation. Rationale: Scleroderma is a chronic connective tissue disease similar to systemic lupus erythematosus. Corticosteroids may be prescribed to treat inflammation. Topical agents may provide some relief from joint pain. Activity is encouraged as tolerated and the room temperature needs to be constant. Clients need to sit up for 1 to 2 hours after meals if esophageal involvement is present. IGGY page 347 348 The nurse in the ambulatory care unit is providing h [Show More]

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