NCLEX: Respiratory, Neuro, GI, Ortho Cardio GI, Endocrine,
Integumentary 1. An adult client was burned as a result of an explosion. The burn
... [Show More] initially
affected the client's entire face (the anterior half of the head) and the upper
half of the anterior torso, and there were circumferential burns to the lower
half of both of the arms. The client's clothes caught on fire, and the client
ran, which caused subsequent burn injuries of the posterior surface of the
head and the upper half of the posterior torso. According to the rule of
nines, what is the extent of this client's burn injury? Fill in the blank.
a. 36%
2. A client returns to the clinic for follow-up treatment after a skin biopsy of a
suspicious lesion that was performed 1 week ago. The biopsy report indicates
that the lesion is a melanoma. The nurse understands that which describes a
characteristic of this type of a lesion?
a. It is highly metastatic.
3. The nurse is reviewing the health care record of a client with a lesion that
has been diagnosed as malignant melanoma. The nurse should expect which
characteristic of this type of lesion to be documented in the client's record?
a. An irregularly shaped lesion
4. The nurse reinforces instructions to a group of clients regarding measures
that will assist with the prevention of skin cancer. Which statement by a
client indicates the need for further teaching?
a. "I need to avoid sun exposure before 10:00 AM and after 4:00 AM."
5. A client arrives at the emergency department and has experienced frostbite
to the right hand. Which should the nurse expect to find when inspecting
the client's hand?
a. A white color of the skin, which is insensitive to touch
6. The evening nurse reviews the nursing documentation in the client's chart
and notes that the day nurse has documented that the client has a stage 2
pressure ulcer in the sacral area. Which should the nurse expect to find when
checking the client's sacral area?
a. Partial-thickness skin loss of the epidermis
7. The nurse inspects the skin of a client who is suspected of having psoriasis.
Which finding should the nurse note if this disorder is present?
a. Silvery-white scaly lesions
8. Which should be the anticipated therapeutic outcome of an escharotomy
procedure performed for a circumferential arm burn?
a. The return of distal pulses
9. The nurse is caring for a client with circumferential burns of both legs.
Which leg position is appropriate for this type of a burn?
a. Elevation above the level of the heart
10. The nurse is assigned to care for a client with herpes zoster. Which
characteristics should the nurse expect to note when checking the lesions
of this infection?
a. Clustered skin vesicles
11. The nurse is caring for a client with a diagnosis of pemphigus vulgaris.
The nurse understands that which is a characteristic of this condition?
a. Blistering skin
12. A client asks the nurse about the causes of acne. The nurse should
respond by making which statement to the client?
a. "The exact cause of acne is not known."
13. The nurse inspects the oral cavity of a client with cancer and notes white
patches on the mucous membranes. The nurse interprets this occurrence as
which?
a. Characteristic of a thrush infection
14. The nurse is caring for a client after an autograft of a burn wound on the
right knee. Which position should the nurse anticipate being prescribed for
the client?
a. Elevating and immobilizing the affected leg
15. The nurse reinforces discharge instructions regarding skin care to a client
after the grafting of burn injuries of the left chest and left arm. Which
statement by the client indicates the need for further teaching?
a. "I should never wear warm clothing over the newly healed skin area."
16. The nurse determines that which individual presenting to the clinic is at the
greatest risk for development of an integumentary disorder?
a. An outdoor construction worker
17. The nurse is reinforcing discharge instructions to a client who had a skin
biopsy. Which statement by the client indicates the need for further
teaching?
a. "I will remove the dressing when I get home and wash the site with tap
water."
18. The nurse prepares to assist a health care provider examine the client's
skin with a Wood's light. Which action should be included in the plan for
this procedure?
a. Darken the room for the examination.
19. The nurse reinforces instructions to a client who has complained of chronic
dry skin and episodes of pruritus. Which client statement indicates the
need for further teaching?
a. "I should use a dehumidifier, especially during the winter months."
20. A client calls the emergency department and tells the nurse that he has been
cleaning a wooded area and that he came into direct 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 makes which statement to the
client?
a. "Take a shower immediately, and lather and rinse several times."
21. A client is being admitted to the hospital for the treatment of acute
cellulitis of the lower left leg. The client asks the nurse to explain what
cellulitis means. Which response should the nurse give to the client's
question?
a. "It is a skin infection that involves the deeper skin layers and
subcutaneous fat."
22. The nurse prepares to care for a client with acute cellulitis of the lower
leg. Which treatment should the nurse anticipate being prescribed for
the client?
a. Warm compresses to the affected area
23. The health care provider suspects a client has herpes zoster. To confirm the
diagnosis of herpes zoster, for which diagnostic test does the nurse gather
equipment?
a. Culture of the lesion
24. A client scheduled for a skin biopsy asks the nurse how painful the
procedure is. The nurse should make which response to the client?
a. "The local anesthetic may cause a burning or stinging sensation."
25. The nurse is checking for the presence of cyanosis in a dark-skinned client.
Which body area should provide the best information?
a. Palms of the hands
26. The nurse reinforces discharge instructions to a client following patch
testing. Which statement by the client indicates the need for further
teaching?
a. "If the patch comes off, I need to reapply it."
27. The nurse prepares to assist in instructing a client about prevention of Lyme
disease. Which should the nurse include in the instructions?
a. It is caused by a tick carried by deer.
28. Following diagnostic evaluation, it has been determined that the client has
Lyme disease, stage 2. The nurse understands that which is most indicative
of this stage?
a. Neurological deficits
29. A client arrives at the health care clinic and tells the nurse that he was just
bitten by a tick and would like to be tested for Lyme disease. Which nursing
action is appropriate?
a. Inform the client that he will need to return in 4 to 6 weeks to
be tested because testing before this time is not reliable.
30. A client with acquired immunodeficiency syndrome (AIDS) is diagnosed
with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse
understands that this has been determined by which?
a. Punch biopsy of the cutaneous lesions
31. Which individual is least likely at risk for the development of Kaposi's
sarcoma?
a. An individual working in an environment in which exposure to
asbestos is possible
32. The nurse reviews a client's chart and notes that the health care provider
has documented a diagnosis of paronychia. Based on this diagnosis,
which should the nurse expect to note during data collection?
a. Red, shiny skin around the nail bed
33. The nurse is assigned to assist in caring for a client with frostbite of the
toes. Which should the nurse anticipate to be prescribed for this condition?
a. Rapid and continual rewarming of the toes in a warm-water bath
until flushing of the skin occurs
34. The nurse is checking her clients for skin breakdown. Which client
should have the lowest priority for concern in the development of skin
breakdown?
a. A client with a lowered mental awareness status
35. A client is undergoing radiation therapy to treat lung cancer. Following the
treatment, the nurse notes that the chest and neck are red, and the client is
complaining of pain at the radiation site. How should the nurse interpret this
data?
a. A superficial injury to tissue from the radiation
36. Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg
wound containing purulent drainage. The nurse is assisting in developing
a plan of care for the client and includes which in the plan?
a. Ensure that the solution is freshly prepared before use.
37. Collagenase (Santyl) is prescribed for a client with a severe burn to the
hand. The nurse provides instructions to the client regarding the use of the
medication. Which statement by the client indicates an accurate
understanding of the use of this medication?
a. "I will apply the ointment once a day and cover it with a sterile
dressing."
38. The nurse inspects a pressure ulcer on a client's sacrum and notes that the
ulcer has partial-thickness skin loss and the formation of a blister. The nurse
should document the ulcer as which category?
a. Stage II
39. A client is receiving topical corticosteroid therapy in the treatment of
psoriasis. The nurse expects the health care provider to prescribe which
measure to maximize the effectiveness of this therapy?
a. Covering the application with a warm, moist dressing and an
occlusive outer wrap
40. Which individuals is least likely at risk for the development of psoriasis?
a. A 32-year-old African American
41. The nurse is assisting in caring for a client with a severe burn who has just
received an autograft to the knee area of the right leg. The nurse plans to
keep the right leg in which position?
a. Elevated and immobilized
42. A client with a burn injury is scheduled for a heterograft. The nurse is
preparing the client for the skin grafting, and the client asks the nurse what
"heterograft" means. Which is the most appropriate response to the
client?
a. "It is skin from another species."
43. The nurse is caring for a client who sustained burns on the entire right leg
and anterior thorax. Using the rule of nines, the extent of the burn injury
would be which percentage?
a. 36% [Show Less]