Noninfectious Disorders of Skin: Chapter 43, Care of Patients with Integumentary Disorders and Burns

Question 1 of 9

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Which assessment finding best supports the admitting diagnosis of a stage III pressure ulcer over the presacral region for a frail older adult patient?

• • The patient lives alone on a fixed income without assistance to perform bathing and is not able to cook their own meals.The patient’s economic background is less likely than immobility and incontinence to contribute to the formation of pressure ulcers.
• • The skin is dry with loose skinfolds. The patient has lost 3 pounds over the past year as a result of chronic poor appetite.Dry skin with loose folds would suggest dehydration rather than pressure ulcers.
• • The patient has been diabetic for more than 20 years, follows the American Diabetes Association diet, and takes oral metformin as prescribed.A history of diabetes is less likely than immobility and incontinence to contribute to the formation of pressure ulcers.
• Correct
  • The patient fell 2 weeks ago and has been resting in bed because movement is painful. The patient is having difficulty getting to the bathroom in time.Immobility and lying in bed put increased pressure on bony prominences. Not getting to the bathroom in time leads to incontinence, which affects skin integrity. These findings place this patient at risk for a pressure ulcer.

Question 2 of 9

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The nurse is assessing a patient with suspected skin cancer. The nurse notes a firm, scaly lesion on the patient’s back that has a depressed, ulcerated center. Which kind of skin cancer does the nurse suspect the patient has?

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  • Basal cell carcinomaBasal cell carcinoma often presents with a slowly enlarging, firm, scaly papule that has a crusted or ulcerated center that may be depressed.
• • Squamous cell carcinomaSquamous cell carcinoma presents with variable appearances but often is seen as a well-defined, irregularly shaped nodule or plaque that is elevated.
• • Acral lentiginous melanomaAcral lentiginous melanoma is the rarest type of melanoma and is located on the palms of the hands, soles of the feet, or under fingernails and appears as a dark streak.
• • Superficial spreading melanomaSuperficial spreading melanoma can appear in a variety of colors including white, red, gray, black, or blue and has an irregular surface and notched border.

Question 3 of 9

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Which patient statement indicates an understanding of their diagnosis of squamous cell carcinoma?

• • “There is a high death rate associated with this condition.”Squamous cell carcinoma is treatable if the lesions are removed early in the diagnosis. Malignant melanoma has a high death rate, not squamous cell carcinoma.
• Correct
  • “I need to start treatment right away because it will spread fast.”Squamous cell carcinoma spreads quickly, so it should be treated as quickly as possible.
• • “If the lesions start growing vertically, it means it is getting worse.”Vertical growth of superficial spreading melanoma, not squamous cell carcinoma, indicates a worsening prognosis.
• • “This type of skin cancer was not caused by sun exposure.”Acral lentiginous melanoma is a type of skin cancer that is not caused by sun exposure. Squamous cell carcinoma is caused by sun exposure.

Question 4 of 9

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Which condition increases the risk for developing a pressure ulcer? Select all that apply. One, some, or all responses may be correct.

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  • ObesityObesity is a risk factor for the development of a pressure ulcer due to immobility.
• Correct
  • MalnutritionMalnutrition can increase the risk for the development of pressure ulcers because of the presence of bony prominences.
• • HypothermiaExcessive sweating, not hypothermia, is a risk factor for pressure ulcer development.
• Correct
  • IncontinenceIncontinence is a risk factor for skin breakdown and pressure ulcer development.
• Correct
  • Diabetes mellitusDiabetes mellitus is a risk factor for pressure ulcer development because of impaired wound healing.

Question 5 of 9

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Which nursing intervention is appropriate for the prevention of pressure ulcers?

• • Reposition patient every 6 hours.Patients at risk for skin breakdown should be repositioned every 2 hours to prevent development of pressure ulcers.
• • Massage bony prominences often.Bony prominences should not be massaged as this can accelerate skin breakdown.
• • Keep the patient’s room dry and cool.The patient’s room should be kept warm, with humidity above 40%, to promote wound healing.
• Correct
  • Encourage dietary intake of protein.Dietary protein intake should be encouraged to prevent skin breakdown and improve wound healing.

Question 6 of 9

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The nurse is caring for a patient with a severe burn. Which wound finding would the nurse report to the health care provider as an infection?

• • The wound appears slightly pink.During the granulation stage of repair, the wound should look slightly pink. This is an expected finding.
• Correct
  • There is redness and swelling around the wound.Signs of inflammation, such as redness and swelling of the tissues adjacent to the wound, may indicate cellulitis (acute inflammation of the subcutaneous tissues). Signs of infection should be reported to the health care provider.
• • There is granulation tissue that does not emit exudates.Healthy granulation tissue does not emit exudates. This would be an expected finding, rather than one that indicates infection.
• • The tissue is somewhat shiny.During the granulation stage of repair, the wound should look somewhat shiny. This is an expected finding.

Question 7 of 9

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The nurse is caring for a patient with severe burns on the face and body. Burns on which area of the body should be left undressed?

• • FeetBurn wounds on the feet are cleaned, covered in topical ointment, and dressed.
• • HandsBurns on the hands are typically cleaned with sterile solution and dressed.
• • TorsoWounds on the torso are typically dressed.
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  • EarsBurn wounds on the face and ears are generally left undressed.

Question 8 of 9

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The nurse is assessing a patient with a burn injury. The nurse notes that the skin surface is wet with numerous blisters and does not blanch when pressed. Which type of burn does the nurse document?

• • SuperficialSuperficial burns involve an intact epidermis that blanches with pressure.
• Correct
  • Superficial partial thicknessSuperficial partial-thickness burns are manifested by a wet, weeping surface with blisters that do not blanch with pressure.
• • Full thicknessFull-thickness burns have a dry surface area with thrombosed vessels that are visible.
• • Deep injuryDeep injury burns show charring and involve limited extremity movement.

Question 9 of 9

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The nurse is providing discharge information to a patient. Which statement would the nurse include in the teaching about first aid for minor burns?

• • Pop blisters with a fine needle.Blisters should be left alone and not popped.
• Correct
  • Cover loosely with sterile gauze.Minor burns should be covered with a sterile gauze bandage to prevent infection.
• • Apply ice to the burn immediately.Ice should not be applied to the burn.
• • Run warm water over the burn for 10 minutes.The patient should be instructed to run cool water over the burn for 10 to 15 minutes.