Chapter 3 Care of the Patient with an Integumentary Disorder

MULTIPLE CHOICE

1.

What should the nurse do when administering a therapeutic bath to a patient who has severe

pruritus?

1. Use Burow’s solution to help promote healing
2. Rub the skin briskly to decrease pruritus
3. Limit bathing to 3 times a week
4. Ensure that bath area is at least 85 degrees and dehumidified

ANS:
Pruritus is responsible for most of the discomfort. Wet dressings and using Burow’s solution help promote the healing process. A cool environment with increased humidity decreases the pruritus. Give daily baths with an application to cleanse the skin.

DIF: Cognitive Level: Application REF: Page 80 OBJ: 14 TOP: Pruritus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

A frail, older adult home health patient who had chickenpox as a child has been exposed to

varicella (chickenpox) several days ago. What should the nurse do?

1. Assess frequently for herpes zoster
2. Be aware of the patient’s immunity to chickenpox
3. Encourage the patient to have a pneumonia vaccine
4. Arrange for the patient to receive gamma globulin

ANS:
Herpes zoster is caused by the same virus that causes chickenpox (Herpes varicella). The greatest risk occurs to patients who have a lowered resistance to infection, such as those on chemotherapy, aging, or receiving large doses of prednisone, in whom the disease could be fatal because of the patient’s compromised immune system.

DIF: Cognitive Level: Application REF: Page 72 OBJ: 5 TOP: Shingles KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What

should the nurse do when administering this drug?

1. Apply lightly, being careful not to completely cover the lesion
2. After application, wrap in warm wet dressings
3. Use gloves
4. Rub medication into lesions

ANS:
The topical application requires that the nurse uses gloves, completely covers the lesion gently, then leaves it open to the air.

DIF: Cognitive Level: Comprehension REF: Page 70, Table 3-3
OBJ: 5 TOP: Anti-infective
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

2.

3.

4.

A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower

lip and chin. The nurse believes these lesions most likely are:

1. chickenpox.
2. impetigo.
3. shingles.
4. herpes simplex type I.

ANS:
Impetigo is seen at all ages, but is particularly common in children. The crust is honey-colored and easily removed and is associated with pruritus. The disease is highly contagious and spreads by contact.

DIF: Cognitive Level: Comprehension REF: Page 76 OBJ: 6 TOP: Infection KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complains of pain and pruritus. Why would the nurse use a Woods lamp?

1. To dry out the lesions
2. To reduce the pruritus
3. To kill the fungus
4. To cause fluorescence of the infected hairs

ANS:
Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a brilliant blue green.

DIF: Cognitive Level: Knowledge REF: Page 79, Figure 3-7
OBJ: 6 TOP: Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

A patient, age 46, reports to his physician’s office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, “It itches like crazy.” Which type of lesion would the nurse include in her documentation?

a. Macules b. Plaques c. Wheals d. Vesicles

ANS: C
Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border.

DIF: Cognitive Level: Analysis REF: Page 82, Table 3-1
OBJ: 6 TOP: Urticaria KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5.

6.

7. The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?

1. Severity of the symptoms
2. Site of the lesions
3. Symptomatology of the lesions
4. Surface area of the lesions

ANS:
The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present).

DIF: Cognitive Level: Knowledge REF: Page 66 OBJ: 4
TOP: Skin Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

8. What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for her acne?

1. Avoid alcoholic beverages
2. Drink at least 1000 mL of fluid daily
3. Use dependable birth control to avoid pregnancy
4. Avoid exposure to the sun

ANS: C
Accutane has a destructive effect on fetal development. Dependable birth control is important to avoid a pregnancy.

DIF: Cognitive Level: Application REF: Page 70, Table 3-3 OBJ: 6 TOP: Effects of Accutane
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

9. A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?

a. Angioma b. Keloid
c. Melanoma d. Nevus

ANS: B
Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in whites.

DIF: Cognitive Level: Knowledge REF: Page 60, Table 3-1
OBJ: 9 TOP: Keloid KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

10. A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?

1. Within 12 hours after burn trauma
2. 24 to 36 hours after burn trauma
3. 24 to 48 hours after burn trauma
4. 48 to 72 hours after burn trauma