Saunders Medsurg Skin Integumentary Revised 20 August 2019Saunders Medsurg Skin Integumentary
1. A client calls the emergency department and tells the
... [Show More] nurse that he came directly into 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 should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rinsing several times."
4. "It is not necessary to do anything if you cannot see anything on your skin."
Answer:
3. "Take a shower immediately, lathering and rinsing several times."
Rationale:
When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible
film on the human skin. The client should be instructed to cleanse the area by showering immediately
and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap
will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if
dermatitis develops. The client does not need to be seen in the emergency department at this time.
2. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg.
During the admission assessment, the nurse expects to note which finding?
1. An inflammation of the epidermis only
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. An epidermal and lymphatic infection caused by Staphylococcus
Answer:
2. A skin infection of the dermis and underlying hypodermis
Rationale:
Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema
without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous,
edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading
inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the
epidermis.
3. The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical
treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations
of psoriasis? Select all that apply.
1. Presence of striae
2. Palpable radial pulses
3. Absence of any ecchymosis on the extremities
4. Thinner and decrease in number of reddish papules
5. Scarce amount of silvery-white scaly patches on the arms
Answers:
4. Thinner and decrease in number of reddish papules
5. Scarce amount of silvery-white scaly patches on the arms
Rationale:
Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A
decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch
marks), palpable pulses, or lack of ecchymosis is not related to psoriasis.
4. The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster
(shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse
determines that this definitive diagnosis was made by which diagnostic test?
1. Positive patch test
2. Positive culture results
3. Abnormal biopsy results
4. Wood's light examination indicative of infection
Answer:
2. Positive culture results
Rationale:
With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral
culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation
of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the
administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would
provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under
ultraviolet light to identify superficial infections of the skin.
5. 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 characteristics? Select all that apply.
1. Lesion is painful to touch.
2. Lesion is highly metastatic.
3. Lesion is a nevus that has changes in color.
4. Skin under the lesion is reddened and warm to touch. [Show Less]