Integumentary Disorders NCLEX Questions
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Question 1 of 5.
The nurse is explaining facelift (rhytidectomy) surgery to the client and describing the site where the incision is most commonly made. Place an X on the site where the incision most commonly used for rhytidectomy is made.
A. An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face.
Explanation: An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face. Incisions in the forehead and periorbital area are for blepharoplasty and browlift. Head and neck reconstruction utilizes the chin site.
Question 2 of 5.
The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?
A. Superficial partial thickness.
B. Deep partial thickness.
C. Full thickness.
D. First degree.
Explanation: Blistered, mottled red skin with edema indicates deep partial-thickness burns, affecting the dermis with severe pain. Superficial partial thickness has no blisters, full thickness is painless and leathery, and first degree is superficial with erythema.
Question 3 of 5.
The nurse writes the nursing diagnosis 'impaired skin integrity related to open burn wounds.' Which intervention would be appropriate for this nursing diagnosis?
A. Provide analgesia before pain becomes severe.
B. Clean the client's wounds, body, and hair daily.
C. Screen visitors for respiratory infections.
D. Encourage visitors to bring plants and flowers.
Explanation: Daily wound cleaning prevents infection and promotes healing, addressing impaired skin integrity. Analgesia addresses pain, visitor screening is for infection control, and plants increase infection risk.
Question 4 of 5.
The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?
A. Keep the skin moist by leaving the skin damp after the bath.
B. Do not rub any lotion into the skin.
C. Turn clients who are immobile at least every two (2) hours.
D. Only the licensed nursing staff may care for the client's skin.
Explanation: Turning every 2 hours prevents pressure ulcers by relieving pressure. Damp skin risks breakdown, lotion is beneficial, and UAPs can assist with skin care.
Question 5 of 5.
The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
A. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance.
B. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit.
C. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift.
D. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing.
Explanation: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
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