The Client with Health Problems of the
16 Integumentary System
The Client with Burns
1. There has been a fi re in an apartment building.
All residents have been evacuated, but many are
burned. Which clients should be transported to a
burn center for treatment? Select all that apply.
■ 1. An 8-year-old with third-degree burns over
10% of his body surface area (BSA).
■ 2. A 20-year-old who inhaled the smoke of the
fi re.
■ 3. A 50-year-old diabetic with fi rst- and seconddegree
burns on his left forearm (about 5% of
his BSA).
■ 4. A 30-year-old with second-degree burns on
the back of his left leg.
■ 5. A 40-year-old with second-degree burns on
his right arm (about 10% of his BSA).
2. The nurse in the immediate care clinic is
assessing an 80-year-old client who lives with his
son’s family and has scald burns on his hands and
both forearms (fi rst- and second-degree burns on
10% of his body surface area). What should the
nurse do fi rst?
■ 1. Clean the wounds with warm water.
■ 2. Apply antibiotic cream.
■ 3. Refer the client to a burn center.
■ 4. Cover the burns with a sterile dressing.
3. During the emergent (resuscitative) phase of
burn injury, which of the following indicates that
the client is requiring additional volume with fl uid
resuscitation?
■ 1. Serum creatinine level of 2.5 mg/dL.
■ 2. Little fl uctuation in daily weight.
■ 3. Hourly urine output of 60 mL.
■ 4. Serum albumin level of 3.8.
4. A client is admitted to the hospital after
sustaining burns to the chest, abdomen, right arm,
and right leg. The shaded areas in the illustration
indicate the burned areas on the client’s body. Using
the “rule of nines,” the nurse would determine that
about what percentage of the client’s body surface
has been burned?
■ 1. 18%.
■ 2. 27%.
■ 3. 45%.
■ 4. 64%.
5. A priority nursing diagnosis for a client with
burns during the emergent period would be:
■ 1. Excess fl uid volume.
■ 2. Imbalanced nutrition: Less than body
requirements.
■ 3. Risk for injury (falling).
■ 4. Risk for infection.
6. Which of the following activities should
the nurse include in the plan of care for a client
with burn injuries to be carried out about one-half
hour before the daily whirlpool bath and dressing
change?
■ 1. Soak the dressing.
■ 2. Remove the dressing.
■ 3. Administer an analgesic.
■ 4. Slit the dressing with blunt scissors.
7. The client with a major burn injury receives
total parenteral nutrition (TPN). The expected outcome
is to:
■ 1. Correct water and electrolyte imbalances.
■ 2. Allow the gastrointestinal tract to rest.
■ 3. Provide supplemental vitamins and minerals.
■ 4. Ensure adequate caloric and protein intake.
8. An advantage of using biologic burn grafts
such as porcine (pigskin) grafts is that they appear
to help:
■ 1. Encourage formation of tough skin.
■ 2. Promote the growth of epithelial tissue.
■ 3. Provide for permanent wound closure.
■ 4. Facilitate development of subcutaneous tissue.
9. Which of the following factors would have
the least infl uence on the survival and effectiveness
of a burn victim’s porcine grafts?
■ 1. Absence of infection in the wounds.
■ 2. Adequate vascularization in the grafted area.
■ 3. Immobilization of the area being grafted.
■ 4. Use of analgesics as necessary for pain relief.
10. The nurse should plan to begin rehabilitation
efforts for the burn client:
■ 1. Immediately after the burn has occurred.
■ 2. After the client’s circulatory status has been
stabilized.
■ 3. After grafting of the burn wounds has
occurred.
■ 4. After the client’s pain has been eliminated.
11. During the early phase of burn care the nurse
should assess the client for?
■ 1. Hypernatremia.
■ 2. Hyponatremia.
■ 3. Metabolic alkalosis.
■ 4. Hyperkalemia.
12. Which of the following clients with burns
will most likely require an endotracheal or tracheostomy
tube? A client who has:
■ 1. Electrical burns of the hands and arms causing
arrhythmias.
■ 2. Thermal burns to the head, face, and airway
resulting in hypoxia.
■ 3. Chemical burns on the chest and abdomen.
■ 4. Secondhand smoke inhalation.
13. A client is receiving fl uid replacement with
Lactated Ringer’s after 40% of his body was burned
10 hours ago. The assessment reveals: temperature
36.2° C; heart rate 122; blood pressure 84/42; CVP
2 mm Hg; and urine output 25 mL for the last 2
hours. The I.V. rate is currently at 375 mL/hour.
Using the SBAR (Situation-Background-AssessmentRecommendation) technique for communication,
the nurse calls the healthcare provider with the
recommendation for:
■ 1. Furosemide (Lasix).
■ 2. Fresh frozen plasma.
■ 3. I.V. rate increase.
■ 4. Dextrose 5%.
14. After the initial phase of the burn injury, the
client’s plan of care will focus primarily on:
■ 1. Helping the client maintain a positive selfconcept.
■ 2. Promoting hygiene.
■ 3. Preventing infection.
■ 4. Educating the client regarding care of the skin
grafts.
15. The rate at which I.V. fl uids are infused is
based on the burn client’s:
■ 1. Lean muscle mass and body surface area
(BSA) burned.
■ 2. Total body weight and BSA burned.
■ 3. Total BSA and BSA burned.
■ 4. Height and weight and BSA burned.
16. The nurse is conducting a focused assess of
the gastrointestinal system of a client with a burn
injury. The nurse should assess the client for:
■ 1. Paralytic ileus.
■ 2. Gastric distention.
■ 3. Hiatal hernia.
■ 4. Curling’s ulcer.
17. In the acute phase of burn injury, which pain
medication would most likely be given to the client
to decrease the perception of the pain?
■ 1. Oral analgesics such as ibuprofen (Motrin) or
acetaminophen (Tylenol).
■ 2. Intravenous opioids.
■ 3. Intramuscular opioids.
■ 4. Oral antianxiety agents such as lorazepam
(Ativan).
18. Using the Parkland Formula, calculate the
hourly rate of fl uid replacement with Lactated
Ringer’s solution during the fi rst 8 hours for a client
weighing 75 kg with total body surface area (TBSA)
burn of 40%.
___________________________mL/hour.
The Client with General Problems
of the Integumentary System
19. The nurse is assessing an older adult’s skin.
The assessment will involve inspecting the skin for
color, pigmentation, and vascularity. The critical
component in the nurse’s assessment is noting the:
■ 1. Similarities from one side to the other.
■ 2. Changes from the normal expected fi ndings.
■ 3. Appearance of age-related wrinkles.
■ 4. Skin turgor.
20. Which of the following changes are
associated with normal aging?
■ 1. The outer layer of skin is replaced with new
cells every 3 days.
■ 2. Subcutaneous fat and extracellular water
decrease.
■ 3. The dermis becomes highly vascular and
assists in the regulation of body temperature.
■ 4. Collagen becomes elastic and strong.
21. Which of the following should the nurse
expect to assess as normal skin changes in an
elderly client? Select all that apply.
■ 1. Diminished hair on scalp and pubic areas.
■ 2. Dusky rubor of left lower extremity.
■ 3. Solar lentigo.
■ 4. Wrinkles.
■ 5. Xerosis.
■ 6. Yellow pigmentation.
22. The nurse will anticipate which of the following
problems that can result for the older adult
undergoing abdominal surgery?
■ 1. Increased scarring.
■ 2. Decreased melanin and melanocytes.
■ 3. Decreased healing.
■ 4. Increased immunocompetence.
23. Health maintenance and promotion activities
are especially important for the older adult. Which
of the following activities refl ects a health maintenance
activity for an otherwise healthy older adult?
■ 1. Drinks 1,500 mL of fl uids per day.
■ 2. Consumes a balanced diet of 1,200 calories
per day.
■ 3. Walks briskly for 10 minutes three times per
week.
■ 4. Sleeps at least 8 hours each night.
24. Which of the following characteristics would
put a client at the greatest risk for impaired wound
healing after abdominal surgery?
■ 1. Age 75 years.
■ 2. Age 30 years, with poorly controlled diabetes.
■ 3. Age 55 years, with myocardial infarction.
■ 4. Age 60 years, with peripheral vascular disease.
25. An 82-year-old female has several ecchymotic
areas on her left arm. The nurse should further
assess the client for:
■ 1. Elder abuse.
■ 2. Self-infl icted injury.
■ 3. Increased capillary fragility and permeability.
■ 4. Increased blood supply to the skin.
26. A 90-year-old male complains of feeling cold
in his room even though the thermostat is set at
75° F (24° C). The client probably feels cold because
older adults have:
■ 1. Increased cellular cohesion.
■ 2. Increased moisture content of the stratum
corneum.
■ 3. Slower cellular renewal time.
■ 4. Decreased ability to thermoregulate.
27. Palpation of the skin provides the nurse useful
information regarding:
■ 1. Bruising of the skin.
■ 2. Color of the skin.
■ 3. Hair distribution.
■ 4. Turgor of the skin.
28. A priority nursing diagnosis for an adult
female who has pruritus and is continuously
scratching the affected areas and demonstrates agitation
and anxiety regarding the itching sensation
would be:
■ 1. Risk for infection related to pruritus.
■ 2. Ineffective health maintenance related to lack
of knowledge of the disease process.
■ 3. Impaired skin integrity related to dehydration
from the treatment medications.
■ 4. Social isolation related to poor self-image.
29. The nurse is applying a hand mitt restraint
for a client with pruritis (see fi gure). The nurse
should fi rst:
■ 1. Verify the physician order to use the restraint.
■ 2. Secure the mitt with ties around the wrist tied
to the bed frame.
■ 3. Place a folded pillow under the wrist.
■ 4. Place the mitt on top of the hand.
30. An older adult client in stage 2 of Parkinson’s
disease is being discharged with cellulitis of the
right lower extremity. Which of the following nursing
diagnoses will guide the discharge teaching?
Select all that apply.
■ 1. Ineffective tissue perfusion related to
decreased cardiac output.
■ 2. Impaired skin integrity related to barrier
changes of the skin.
■ 3. Risk for injury related to environmental hazards.
■ 4. Impaired verbal communication related to
dysarthria.
■ 5. Activity intolerance related to painful lower
extremity.
31. An alert and oriented elderly client is admitted
to the hospital for treatment of cellulitis of the
left shoulder after an arthroscopy. Which fall prevention
strategy is most appropriate for this client?
■ 1. Keep all the lights on in the room at all times.
■ 2. Use a nightlight in the bathroom.
■ 3. Keep all four side rails up at all times.
■ 4. Place the client in a room with a camera
monitor.
32. Prevention of skin breakdown and maintenance
of skin integrity among older clients is important
because they are at greater risk secondary to:
■ 1. Altered balance.
■ 2. Altered protective pressure sensation.
■ 3. Impaired hearing ability.
■ 4. Impaired visual acuity.
The Client with Skin Cancer
38. Which of the following factors places a client
at greatest risk for skin cancer?
■ 1. Fair skin and history of chronic sun
e xposure.
■ 2. Caucasian race and history of hypertension.
■ 3. Dark skin and family history of skin cancer.
■ 4. Dark skin and history of hypertension.
39. A nurse is providing teaching to a client
about skin cancer. Which of the following should
the nurse explain are risk factors for skin cancer?
Select all that apply.
■ 1. Increasing age.
■ 2. Exposure to chemical pollutants.
■ 3. Long-term exposure to the sun.
■ 4. Increased pigmentation.
■ 5. Genetics.
■ 6. Immunosuppression.
40. The nurse is developing a program on skin
cancer prevention for a community group. Which of
the following should be included in the program?
Select all that apply.
■ 1. Purchase sunscreen containing benzophenones
to block UVA and UVB rays.
■ 2. Use sunscreen with a minimum of 15 sun
protection factor (SPF).
■ 3. Obtain genetic screening to identify risk of
melanoma.
■ 4. Apply sunscreen only on sunny days, especially
between 10 AM and 2 PM.
■ 5. Have a pigmented lesion biopsied by shaving
if it looks suspicious.
■ 6. Rub baby oil to lubricate skin before going out
in the sun.
41. A client with malignant melanoma asks the
nurse about the prognosis. The nurse should base a
response that informs the client that the prognosis
depends on:
■ 1. The amount of ulceration of the lesion.
■ 2. The age of the client.
■ 3. The location of the lesion on the body.
■ 4. The thickness of the lesion.
Answers, Rationales, and Test
Taking Strategies
The answers and rationales for each question follow
below, along with keys ( ) to the client need
(CN) and cognitive level (CL) for each question. Use
these keys to further develop your test-taking skills.
For additional information about test-taking skills
and strategies for answering questions, refer to pages
10–21, and pages 25–26 in Part 1 of this book.
The Client with Burns
1. 1, 2, 3. Clients who should be transferred to a
burn center include children under age 10 or adults
over age 50 with second- and third-degree burns
on 10% or greater of their body surface area (BSA),
clients between ages 11 and 49 with second- and
third-degree burns over 20% of their BSA, clients of
any age with third-degree burns on more than 5%
of their BSA, clients with smoke inhalation, and
clients with chronic diseases, such as diabetes and
heart or kidney disease.
CN: Management of care; CL: Analyze
2. 3. The nurse should have the client transported
to a burn center. The client’s age and the
extent of the burns require care by a burn team
and the client meets triage criteria for referral to a
burn center. Because of the age of the client and the
extent of the burns, the nurse should not treat the
burn. Scald burns are not at high risk for infection
and do not need to be cleaned, covered, or treated
with antibiotic cream at this time.
CN: Physiological adaptation;
CL: Synthesize
3. 1. Fluid shifting into the interstitial space
causes intravascular volume depletion and
decreased perfusion to the kidneys. This would
result in an increase in serum creatinine. Urine output
should be frequently monitored and adequately
maintained with intravenous fl uid resuscitation that
would be increased when a drop in urine output
occurs. Urine output should be at least 30 mL/hour.
Fluid replacement is based on the Parkland or
Brooke formula and also the client’s response by
monitoring urine output, vital signs, and CVP readings.
Daily weight is important to monitor for fl uid
status. Little fl uctuation in weight suggests that
there is no fl uid retention and the intake is equal to
output. Exudative loss of albumin occurs in burns
causing a decrease in colloid osmotic pressure. The
normal serum albumin is 3.5 to 5 gm/dL.
CN: Physiological adaptation;
4. 3. According to the rule of nines, this client
has sustained burns on about 45% of the body
surface. The right arm is calculated as being 9%, the
right leg is 18%, and the anterior trunk is 18%, for a
total of 45%.
CN: Physiological adaptation; CL: Apply
5. 4. Infection is a priority problem for the
burned victim because of the loss of skin integrity
and alteration in body defenses. Excess fl uid or
imbalanced nutrition is not a priority during the
emergent period. A risk for falling is not a priority
for this client because the client would be on bed
rest and most likely in a critical care unit.
CN: Physiological adaptation;
CL: Analyze
6. 3. Removing dressings from severe burns
exposes sensitive nerve endings to the air, which
is painful. The client should be given a prescribed
analgesic about one-half hour before the dressing
change to promote comfort. The other activities are
done as part of the whirlpool and dressing change
process and not one-half hour beforehand.
CN: Reduction of risk potential;
CL: Synthesize
7. 4. Nutritional support with suffi cient calories
and protein is extremely important for a client
with severe burns because of the loss of plasma
protein through injured capillaries and an increased
metabolic rate. Gastric dilation and paralytic ileus
commonly occur in clients with severe burns, making
oral fl uids and foods contraindicated. Water
and electrolyte imbalances can be corrected by
administration of I.V. fl uids with electrolyte additives,
although TPN typically includes all necessary
electrolytes. Resting the gastrointestinal tract may
help prevent paralytic ileus, and TPN provides vita- starting TPN is to provide the protein
necessary for
tissue healing.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
8. 2. Biologic dressings such as porcine grafts
serve many purposes for a client with severe burns.
They enhance the growth of epithelial tissues,
minimize the overgrowth of granulation tissue,
prevent loss of water and protein, decrease pain,
increase mobility, and help prevent infection. They
do not encourage growth of tougher skin, provide
for permanent wound closure, or facilitate growth of
subcutaneous tissue.
CN: Physiological adaptation;
CL: Apply
9. 4. Analgesic administration to keep a burn
victim comfortable is important but is unlikely to
infl uence graft survival and effectiveness. Absence
of infection, adequate vascularization, and immobilization
of the grafted area promote an effective
graft.
CN: Physiological adaptation;
CL: Evaluate
10. 2. Rehabilitation efforts are implemented as
soon as the client’s condition is stabilized. Early
emphasis on rehabilitation is important to decrease
complications and to help ensure that the client will
be able to make the adjustments necessary to return
to an optimal state of health and independence. It
is not possible to completely eliminate the client’s
pain; pain control is a major challenge in burn care.
CN: Basic care and comfort;
CL: Synthesize
11. 4. Immediately after a burn, excessive potassium
from cell destruction is released into the extracellular
fl uid. Hyponatremia is a common electrolyte
imbalance in the burn client that occurs within
the fi rst week after being burned. Metabolic acidosis
usually occurs as a result of the loss of sodium
bicarbonate.
CN: Reduction of risk potential;
CL: Analyze
12. 2. Airway management is the priority in
caring for a burn client. Tracheostomy or endotracheal
intubation is anticipated when signifi cant
thermal and smoke inhalation burns occur. Clients
who have experienced burns to the face and neck
usually will be compromised within 1 to 2 hours.
Electrical burns of the hands and arms, even with
cardiac arrhythmias, or a chemical burn of the chest
and abdomen is not likely to result in the need for
intubation. Secondhand smoke inhalation does
infl uence an individual’s respiratory status but does not require intubation unless the
individual has an
allergic reaction to the smoke.
CN: Physiological adaptation;
CL: Analyze
13. 3. The decreased urine output, low blood
pressure, low CVP, and high heart rate indicate
hypovolemia and the need to increase fl uid volume
replacement. Furosemide is a diuretic that should
not be given due to the existing fl uid volume defi cit.
Fresh frozen plasma is not indicated. It is given for
clients with defi cient clotting factors who are bleeding.
Fluid replacement used for burns is Lactated
Ringer’s solution, Normal Saline, or albumin.
CN: Management of care; CL: Synthesize
14. 3. The infl ammatory response begins when
a burn is sustained. As a result of the burn, the
immune system becomes impaired. There is a
decrease in immunoglobulins, changes in white
blood cells, alterations of lymphocytes, and
decreased levels of interleukin. The human body’s
protective barrier, the skin, has been damaged.
As a result, the burn client becomes vulnerable to
infections. Education and interventions to maintain
a positive self-concept would be appropriate during
the rehabilitation phase. Promoting hygiene helps
the client feel comfortable; however, the primary
focus is on reducing the risk for infection.
CN: Safety and infection control;
CL: Synthesize
15. 2. During the fi rst 24 hours, fl uid replacement
for an adult burn client is based on total body
weight and BSA burned. Lean muscle mass considers
only muscle mass; replacement is based on total
body weight. Total surface area is estimated by taking
into account the individual’s height and weight.
Height is not a common variable used in formulas
for fl uid replacement.
CN: Physiological adaptation; CL: Apply
16. 4. Curling’s ulcer, or gastrointestinal ulceration,
occurs in about half of the clients with a burn
injury. The incidence of ulceration appears proportional
to the extent of the burns and the ulceration
is believed to be caused by hypersecretion of gastric
acid and compromised gastrointestinal perfusion.
Paralytic ileus and gastric distention do not result
from hypersecretion of gastric acid and stress. Hiatal
hernia is not necessarily a potential complication of
a burn injury.
CN: Physiological adaptation;
CL: Analyze
17. 2. The severe pain experienced by burn
clients requires opioid analgesics. In addition,
opioids such as morphine sedate and alleviate
apprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be
strong enough
to effectively manage the intense pain experienced
by the client who is severely burned. Because of
the altered tissue perfusion from the burn injury,
intravenous medications are preferred. Antianxiety
agents are not effective against pain.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
18. 750 mL/hour. Lactated Ringer’s solution
4 mL × weight in kg × TBSA; half given over the fi rst
8 hours and half given over the next 16 hours.
4 mL × 75 kg × 40= 12,000 mL or
4 mL 75 kg 40 1 750 mL
8 hours 2
´´
´=
hour
12,000 mL ×
2
1 = 6,000 mL
6,000 mL
8 hours
= 750 mL/hour
CN: Pharmacological and parenteral
therapies; CL: Apply
The Client with General Problems
of the Integumentary System
19. 2. Noting changes from the normal expected
fi ndings is the most important component when
assessing an older client’s integumentary system.
Comparing one extremity with the contralateral
extremity (i.e., comparing one side with the other)
is an important assessment step; however, the most
important component is noting changes from an
expected normal baseline. Noting wrinkles related
to age is not of much consequence unless the client
is admitted for cosmetic surgery to reduce the
appearance of age-related wrinkling. Noting skin
turgor is an assessment of fl uid status, not an assessment
of the integumentary system.
CN: Health promotion and maintenance;
CL: Analyze
20. 2. With age, there is a decreased amount of
subcutaneous fat, muscle laxity, degeneration of
elastic fi bers, and collagen stiffening. The outer
layer of skin is almost completely replaced every 3
to 4 weeks. The vascular supply diminishes with
age. Collagen thins and diminishes with age.
CN: Health promotion and maintenance;
CL: Analyze
21. 1, 3, 4, 5. Skin changes associated with aging
include the following: Diminished hair on scalp
and pubic areas, solar lentigo (liver spots), wrinkles,
and xerosis (dryness). Dusky rubor of the left lower extremity may indicate the individual
has a venous
stasis problem in the affected extremity and is generally
associated with “unsuccessful aging.” Yellow
pigmentation of the skin that may be associated with
liver infl ammation is generally known as jaundice.
CN: Health promotion and maintenance;
CL: Analyze
22. 3. Normal aging consists of decreased proliferative
capacity of the skin. Decreased collagen synthesis
slows capillary growth, impairs phagocytosis
among older clients, and results in slow healing.
Increased scarring is not a result of age-related skin
changes. Both melanin and melanocytes give color
to the skin and hair but are increased with aging.
There is a decrease in the immunocompetence of
the aging client.
CN: Health promotion and maintenance;
CL: Analyze
23. 1. Drinking at least six 8-oz glasses of fl uid
per day helps the client stay well hydrated. Maintaining
optimal fl uid balance is important for all
body systems. Caloric intake varies according to
an individual’s size and activity level. An intake
of 1,200 calories/day may be insuffi cient for some
older clients. Walking 10 minutes/day is useful, but
an otherwise healthy older client should try to walk
20 minutes/day. It is important to get adequate rest;
however, the amount of sleep needed varies with
the individual.
CN: Health promotion and maintenance;
CL: Evaluate
24. 2. Poorly controlled diabetes is a serious
risk factor for postoperative wound infection. Other
factors that delay wound healing include advanced
age, nutritional defi ciencies (vitamin C, protein,
zinc), inadequate blood supply, use of corticosteroid,
infection, mechanical friction on the wound,
obesity, anemia, and poor general health.
CN: Reduction of risk potential;
CL: Analyze
25. 3. The aging process involves increased capillary
fragility and permeability. Older clients have
a decreased amount of subcutaneous fat. Therefore,
there is an increased incidence of bruiselike lesions
caused by collection of extravascular blood in the
loosely structured dermis. In addition, older clients
do not always realize that injury has occurred
because of a diminished awareness of pain, touch,
and peripheral vibration. There are no data to support
elder abuse or self-infl icted bruises. Blood supply
to the skin declines with aging.
CN: Health promotion and maintenance;
CL: Analyze
26. 4. Older clients have a decreased thermoregulation
that is related to decreased blood supply
and reabsorption of body fat. As a result, older
adults are at risk for hypothermia. Cellular cohesion
and moisture content diminish with age and cellular
renewal time is slowed; however, these do not result
in impaired thermoregulation.
CN: Health promotion and maintenance;
CL: Analyze
27. 4. Assessment of the integumentary system
includes both inspection and palpation. Palpation
involves assessing temperature, turgor, moisture,
and texture. Observing bruises and color and detecting
hair distribution are inspection.
CN: Health promotion and maintenance;
CL: Analyze
28. 1. Risk for infection related to pruritus is
the priority nursing diagnosis because it has been
documented that the client continues to scratch the
affected areas. Satisfactory control of the itching
sensation and discomfort associated with scratching
may relieve the agitation and anxiety. More information
is required regarding the knowledge level
of the client and her disease process, but learning
cannot take place when an individual’s attention is
distracted with pruritus. Impaired skin integrity is a
potential problem if the client continues to scratch
the affected areas and destroys the skin, but the risk
of infection deserves priority attention because of
the client’s anxiety. There are no data to support that
the client has a poor self-image.
CN: Reduction of risk potential;
CL: Analyze
29. 1. Before using any restraints, the nurse must
verify that a physician has written an order for the
restraint. The mitt does not need to be secured with
ties. The client can move the hand as needed. It is
not necessary to place a pillow under the wrist. The
nurse should place the mitt on the palmer surface of
the hand.
CN: Safety and infection control;
CL: Synthesize
30. 2, 3. Usual aging is associated with dry skin;
however, seborrhea (oily skin and dandruff) is one
result of the biochemical changes associated with
Parkinson’s disease. The client with Parkinson’s
disease has a higher risk of skin breakdown due to
the moist and oily skin. To maintain skin integrity,
a client with Parkinson’s disease needs frequent
skin care and aeration of the skin. Gait instability
in a client with Parkinson’s disease is a result of
muscle rigidity, change in the center of gravity, and
gait shuffl ing. Because of these changes in gait and
balance, the client is at higher risk for injuries in the environment, such as hitting
furniture or obstacles
in the client’s path. As a result, the environment
should be evaluated for potential injury or falls.
Tissue perfusion and verbal communication are not
problems typically associated with Parkinson’s disease.
The client should not experience activity intolerance
from the cellulitis or Parkinson’s disease.
CN: Pharmacological and parenteral
therapies; CL: Analyze
31. 2. Many falls occur when older clients
attempt to get to the bathroom at night. The risk is
even greater in an unfamiliar environment. Use of
a nightlight in the bathroom enables the older adult
client to see the way to the bathroom. Keeping the
lights on in the room at all times may contribute to
sensory overload and prevent adequate rest. Raised
side rails paradoxically contribute to falls when
the older client tries to climb over them to get to
the bathroom. The upper side rails may be raised,
but it is not recommended that all four side rails be
elevated. Camera monitoring can be used but does
nothing to prevent a fall.
CN: Safety and infection control;
CL: Synthesize
32. 2. Pressure ulcers usually occur over bony
prominences. An alteration in the protective pressure
sensation results from a decline in the number
of Meissner’s and pacinian corpuscles. Older adults
do have altered balance that may result in falls, but
not skin breakdown. Impaired hearing and vision do
not contribute to pressure ulcers.
CN: Reduction of risk potential;
CL: Analyze
The Client with Skin Cancer
38. 1. Caucasians who have fair skin and a high
exposure to ultraviolet light are at increased risk
for malignant neoplasms of the skin. The other risk
factors include exposure to tar and arsenicals and
family history. History of hypertension is a coronary
artery disease risk factor. Clients with dark skin
have increased melanin and are not as prone to skin
cancer.
CN: Health promotion and maintenance;
CL: Analyze
39. 1, 2, 3, 5, 6. Risk factors associated with skin
cancer include: Age, exposure to chemical pollutants,
exposure to the sun, genetics, and immunosuppression.
As individuals age, the risk of developing
skin cancer increases. Long-time exposure to the
sun and exposure to chemical pollutants (nitrates,
coal, tar, etc.) increases the risk of skin cancer. Individuals
who have less skin pigmentation (i.e., fair,
blue-eyed people) have a higher risk of skin cancer
because they tend to incur sunburns rather than tan.
Family history plays a role in cancer. Regardless,
immunosuppressed individuals are at a higher risk
for the development of any type of cancer, as the
body’s defenses are not functioning properly.
CN: Health promotion and maintenance;
CL: Apply
40. 1, 2. Sunscreen should be applied 20 to
30 minutes before going outside, even in cloudy
weather. Sunscreen with a minimum of 15 SPF
should be used. Sunscreen containing benzophenones
block both UVA and UVB rays. The rays of
the sun are most dangerous between 10 a.m. and
2 p.m. Genetic screening is not indicated, although
a mutated gene has been identifi ed in some families
with high incidence of melanoma. A prior diagnosis
of melanoma and having a fi rst-degree relative
diagnosed with melanoma increases a person’s risk.
Lesions should not be shave-biopsied; excisional
biopsy technique is used. Baby oil will increase the
adverse effects of sun exposure; sunscreen protection
should be used.
CN: Health promotion and maintenance;
CL: Create
41. 4. Tumor or lesion thickness is the predictive
factor for survival. Cutaneous melanoma that
is confi ned to the epidermis has a high cure rate.
Asymmetry, border, color, and diameter are known
as the “ABCDs” of melanoma. Thus, the amount of
ulceration, age, and location are not clearly associated
with the prognosis.
CN: Health promotion and maintenance;