BURNS & PERFUSION Exam 4 Questions and
Verified Answers Detailed Answers Latest A+
An 82-year-old client is being treated in the hospital for a
sacral pressure ulcer. What age-related change is most likely
to affect the client's course of treatment?
A. Increased thickness of the subcutaneous skin layer
B. Increased vascular supply to superficial skin layers
C. Changes in the character and quantity of bacterial skin
flora
D. Increased time required for wound healing
ANS: D
Rationale: Wound healing becomes slower with age, requiring
more time for older adults to recover from surgical and traumatic
wounds. There are no changes in skin flora with increased age.
Vascular supply and skin thickness both decrease with age.
A nurse is reviewing gerontologic considerations relating to
the care of clients with dermatologic problems. What
vulnerability results from the age-related loss of
subcutaneous tissue?
A. Decreased resistance to ultraviolet radiation
B. Increased vulnerability to infection
C. Diminished protection of tissues and organs
D. Increased risk of skin malignancies
ANS: C
Rationale: Loss of the subcutaneous tissue substances of elastin,
collagen, and fat diminishes the protection and cushioning of
underlying tissues and organs, decreases muscle tone, and
results in the loss of the insulating properties of fat. This age-
,related change does not correlate to an increased vulnerability to
sun damage, infection, or cancer.
The nurse is performing an initial assessment of a client who
has a raised, pruritic rash. The client denies taking any
prescription medication and denies any allergies. What
would be an appropriate question to ask this client at this
time?
A. "Is anyone in your family allergic to anything?"
B. "How long have you had this abrasion?"
C. "Do you take any over-the-counter (OTC) drugs or herbal
preparations?"
D. "What do you do for a living?"
ANS: C
Rationale: If suspicious areas are noted, the client is questioned
about nonprescription or herbal preparations that might be in use.
Ascertaining a family history of allergies would not give helpful
information at this time. The client's lesion is not described as an
abrasion. The client's occupation may or may not be relevant; it is
more important to assess for herb or drug reactions.
The nurse is performing a comprehensive assessment of a
client's skin surfaces and intends to assess moisture,
temperature, and texture. The nurse should perform this
component of assessment in what way?
A. By examining the client under a Wood light
B. By inspecting the client's skin in direct sunlight
C. By palpating the client's skin
D. By performing percussion of major skin surfaces
ANS: C
Rationale: Inspection and palpation are techniques commonly
used in examining the skin. A client would only be examined
under a Wood light if there were indications it could be diagnostic.
,The client is examined in a well-lit room, not in direct sunlight.
Percussion is not a technique used in assessing the skin.
A young student is brought to the school nurse after falling
off a swing. The nurse is documenting that the child has
bruising on the lateral aspect of the right arm. What term will
the nurse use to describe bruising on the skin in
documentation?
A. Telangiectasias
B. Ecchymoses
C. Purpura
D. Urticaria
ANS: B
Rationale: Telangiectasias consist of red marks on the skin
caused by stretching of superficial blood vessels. Ecchymoses
are bruises, and purpura consists of pinpoint hemorrhages into
the skin. Urticaria is wheals or hives.
While assessing a dark-skinned client at the clinic, the nurse
notes the presence of patchy, milky-white spots. The nurse
knows that this finding is characteristic of what diagnosis?
A. Cyanosis
B. Addison disease
C. Polycythemia
D. Vitiligo
ANS: D
Rationale: With cyanosis, nail beds are dusky. With polycythemia,
the nurse notes ruddy blue face, oral mucosa, and conjunctiva. A
bronzed appearance, or "external tan," is associated with Addison
disease. Vitiligo is a condition characterized by destruction of the
melanocytes in circumscribed areas of skin and appears in light or
dark skin as patchy, milky-white spots, often symmetric bilaterally.
, A nurse is conducting a health interview and is assessing for
integumentary conditions that are known to have a genetic
component. What assessment question is most appropriate?
A. "Does anyone in your family have eczema or psoriasis?"
B. "Have any of your family members been diagnosed with
malignant melanoma?"
C. "Do you have a family history of vitiligo or port-wine
stains?"
D. "Does any member of your family have a history of keloid
scarring?"
ANS: A
Rationale: Eczema and psoriasis are known to have a genetic
component. This is not true of any of the other listed
integumentary disorders.
A client is brought to the emergency department from the
site of a chemical fire, where the client suffered a burn that
involves the epidermis, dermis, and the muscle and bone of
the right arm. On inspection, the skin appears charred.
Based on these assessment findings, what is the depth of
the burn on the client's arm?
A. Superficial partial thickness
B. Deep partial thickness
C. Full partial thickness
D. Full thickness
ANS: D
Rationale: A full-thickness burn involves total destruction of the
epidermis and dermis and, in some
cases, underlying tissue as well. Wound color ranges widely from
white to red, brown, or black. The
burned area is painless because the nerve fibers are destroyed.
The wound can appear leathery; hair follicles and sweat glands
Verified Answers Detailed Answers Latest A+
An 82-year-old client is being treated in the hospital for a
sacral pressure ulcer. What age-related change is most likely
to affect the client's course of treatment?
A. Increased thickness of the subcutaneous skin layer
B. Increased vascular supply to superficial skin layers
C. Changes in the character and quantity of bacterial skin
flora
D. Increased time required for wound healing
ANS: D
Rationale: Wound healing becomes slower with age, requiring
more time for older adults to recover from surgical and traumatic
wounds. There are no changes in skin flora with increased age.
Vascular supply and skin thickness both decrease with age.
A nurse is reviewing gerontologic considerations relating to
the care of clients with dermatologic problems. What
vulnerability results from the age-related loss of
subcutaneous tissue?
A. Decreased resistance to ultraviolet radiation
B. Increased vulnerability to infection
C. Diminished protection of tissues and organs
D. Increased risk of skin malignancies
ANS: C
Rationale: Loss of the subcutaneous tissue substances of elastin,
collagen, and fat diminishes the protection and cushioning of
underlying tissues and organs, decreases muscle tone, and
results in the loss of the insulating properties of fat. This age-
,related change does not correlate to an increased vulnerability to
sun damage, infection, or cancer.
The nurse is performing an initial assessment of a client who
has a raised, pruritic rash. The client denies taking any
prescription medication and denies any allergies. What
would be an appropriate question to ask this client at this
time?
A. "Is anyone in your family allergic to anything?"
B. "How long have you had this abrasion?"
C. "Do you take any over-the-counter (OTC) drugs or herbal
preparations?"
D. "What do you do for a living?"
ANS: C
Rationale: If suspicious areas are noted, the client is questioned
about nonprescription or herbal preparations that might be in use.
Ascertaining a family history of allergies would not give helpful
information at this time. The client's lesion is not described as an
abrasion. The client's occupation may or may not be relevant; it is
more important to assess for herb or drug reactions.
The nurse is performing a comprehensive assessment of a
client's skin surfaces and intends to assess moisture,
temperature, and texture. The nurse should perform this
component of assessment in what way?
A. By examining the client under a Wood light
B. By inspecting the client's skin in direct sunlight
C. By palpating the client's skin
D. By performing percussion of major skin surfaces
ANS: C
Rationale: Inspection and palpation are techniques commonly
used in examining the skin. A client would only be examined
under a Wood light if there were indications it could be diagnostic.
,The client is examined in a well-lit room, not in direct sunlight.
Percussion is not a technique used in assessing the skin.
A young student is brought to the school nurse after falling
off a swing. The nurse is documenting that the child has
bruising on the lateral aspect of the right arm. What term will
the nurse use to describe bruising on the skin in
documentation?
A. Telangiectasias
B. Ecchymoses
C. Purpura
D. Urticaria
ANS: B
Rationale: Telangiectasias consist of red marks on the skin
caused by stretching of superficial blood vessels. Ecchymoses
are bruises, and purpura consists of pinpoint hemorrhages into
the skin. Urticaria is wheals or hives.
While assessing a dark-skinned client at the clinic, the nurse
notes the presence of patchy, milky-white spots. The nurse
knows that this finding is characteristic of what diagnosis?
A. Cyanosis
B. Addison disease
C. Polycythemia
D. Vitiligo
ANS: D
Rationale: With cyanosis, nail beds are dusky. With polycythemia,
the nurse notes ruddy blue face, oral mucosa, and conjunctiva. A
bronzed appearance, or "external tan," is associated with Addison
disease. Vitiligo is a condition characterized by destruction of the
melanocytes in circumscribed areas of skin and appears in light or
dark skin as patchy, milky-white spots, often symmetric bilaterally.
, A nurse is conducting a health interview and is assessing for
integumentary conditions that are known to have a genetic
component. What assessment question is most appropriate?
A. "Does anyone in your family have eczema or psoriasis?"
B. "Have any of your family members been diagnosed with
malignant melanoma?"
C. "Do you have a family history of vitiligo or port-wine
stains?"
D. "Does any member of your family have a history of keloid
scarring?"
ANS: A
Rationale: Eczema and psoriasis are known to have a genetic
component. This is not true of any of the other listed
integumentary disorders.
A client is brought to the emergency department from the
site of a chemical fire, where the client suffered a burn that
involves the epidermis, dermis, and the muscle and bone of
the right arm. On inspection, the skin appears charred.
Based on these assessment findings, what is the depth of
the burn on the client's arm?
A. Superficial partial thickness
B. Deep partial thickness
C. Full partial thickness
D. Full thickness
ANS: D
Rationale: A full-thickness burn involves total destruction of the
epidermis and dermis and, in some
cases, underlying tissue as well. Wound color ranges widely from
white to red, brown, or black. The
burned area is painless because the nerve fibers are destroyed.
The wound can appear leathery; hair follicles and sweat glands
