The Client with Health Problems of the
16 Integumentary System
The Client with Burns
1. There has been a fi re in an apartment building.
All residents have been evacuated, but many are
burned. Which clients should be transported to a
burn center for treatment? Select all that apply.
■ 1. An 8-year-old with third-degree burns over
10% of his body surface area (BSA).
■ 2. A 20-year-old who inhaled the smoke of the
fi re.
■ 3. A 50-year-old diabetic with fi rst- and seconddegree
burns on his left forearm (about 5% of
his BSA).
■ 4. A 30-year-old with second-degree burns on
the back of his left leg.
■ 5. A 40-year-old with second-degree burns on
his right arm (about 10% of his BSA).
2. The nurse in the immediate care clinic is
assessing an 80-year-old client who lives with his
son’s family and has scald burns on his hands and
both forearms (fi rst- and second-degree burns on
10% of his body surface area). What should the
nurse do fi rst?
■ 1. Clean the wounds with warm water.
■ 2. Apply antibiotic cream.
■ 3. Refer the client to a burn center.
■ 4. Cover the burns with a sterile dressing.
3. During the emergent (resuscitative) phase of
burn injury, which of the following indicates that
the client is requiring additional volume with fluid
resuscitation?
■ 1. Serum creatinine level of 2.5 mg/dL.
■ 2. Little fluctuation in daily weight.
■ 3. Hourly urine output of 60 mL.
■ 4. Serum albumin level of 3.8.
4. A client is admitted to the hospital after
sustaining burns to the chest, abdomen, right arm,
and right leg. The shaded areas in the illustration
indicate the burned areas on the client’s body. Using
the “rule of nines,” the nurse would determine that
about what percentage of the client’s body surface
has been burned?
■ 1. 18%.
■ 2. 27%.
■ 3. 45%.
■ 4. 64%.
5. A priority nursing diagnosis for a client with
burns during the emergent period would be:
■ 1. Excess fluid volume.
■ 2. Imbalanced nutrition: Less than body
requirements.
■ 3. Risk for injury (falling).
■ 4. Risk for infection.
6. Which of the following activities should
the nurse include in the plan of care for a client
with burn injuries to be carried out about one-half
hour before the daily whirlpool bath and dressing
change?
■ 1. Soak the dressing.
■ 2. Remove the dressing.
■ 3. Administer an analgesic.
■ 4. Slit the dressing with blunt scissors.
7. The client with a major burn injury receives
total parenteral nutrition (TPN). The expected outcome
is to:
■ 1. Correct water and electrolyte imbalances.
■ 2. Allow the gastrointestinal tract to rest.
■ 3. Provide supplemental vitamins and minerals.
■ 4. Ensure adequate caloric and protein intake.
8. An advantage of using biologic burn grafts
such as porcine (pigskin) grafts is that they appear
to help:
■ 1. Encourage formation of tough skin.
■ 2. Promote the growth of epithelial tissue.
■ 3. Provide for permanent wound closure.
■ 4. Facilitate development of subcutaneous tissue.
9. Which of the following factors would have
the least influence on the survival and effectiveness
of a burn victim’s porcine grafts?
■ 1. Absence of infection in the wounds.
■ 2. Adequate vascularization in the grafted area.
■ 3. Immobilization of the area being grafted.
■ 4. Use of analgesics as necessary for pain relief.
10. The nurse should plan to begin rehabilitation
efforts for the burn client:
■ 1. Immediately after the burn has occurred.
■ 2. After the client’s circulatory status has been
stabilized.
■ 3. After grafting of the burn wounds has
occurred.
■ 4. After the client’s pain has been eliminated.
11. During the early phase of burn care the nurse
should assess the client for?
■ 1. Hypernatremia.
■ 2. Hyponatremia.
■ 3. Metabolic alkalosis.
■ 4. Hyperkalemia.
12. Which of the following clients with burns
will most likely require an endotracheal or tracheostomy
tube? A client who has:
■ 1. Electrical burns of the hands and arms causing
arrhythmias.
■ 2. Thermal burns to the head, face, and airway
resulting in hypoxia.
■ 3. Chemical burns on the chest and abdomen.
■ 4. Secondhand smoke inhalation.
13. A client is receiving fluid replacement with
Lactated Ringer’s after 40% of his body was burned
10 hours ago. The assessment reveals: temperature
36.2° C; heart rate 122; blood pressure 84/42; CVP
2 mm Hg; and urine output 25 mL for the last 2
hours. The I.V. rate is currently at 375 mL/hour.
Using the SBAR (Situation-Background-Assessment-
Recommendation) technique for communication,
the nurse calls the healthcare provider with the
recommendation for:
■ 1. Furosemide (Lasix).
■ 2. Fresh frozen plasma.
■ 3. I.V. rate increase.
■ 4. Dextrose 5%.
14. After the initial phase of the burn injury, the
client’s plan of care will focus primarily on:
■ 1. Helping the client maintain a positive selfconcept.
■ 2. Promoting hygiene.
■ 3. Preventing infection.
■ 4. Educating the client regarding care of the skin
grafts.
15. The rate at which I.V. fluids are infused is
based on the burn client’s:
■ 1. Lean muscle mass and body surface area
(BSA) burned.
■ 2. Total body weight and BSA burned.
■ 3. Total BSA and BSA burned.
■ 4. Height and weight and BSA burned.
16. The nurse is conducting a focused assess of
the gastrointestinal system of a client with a burn
injury. The nurse should assess the client for:
■ 1. Paralytic ileus.
■ 2. Gastric distention.
■ 3. Hiatal hernia.
■ 4. Curling’s ulcer.
17. In the acute phase of burn injury, which pain
medication would most likely be given to the client
to decrease the perception of the pain?
■ 1. Oral analgesics such as ibuprofen (Motrin) or
acetaminophen (Tylenol).
■ 2. Intravenous opioids.
■ 3. Intramuscular opioids.
■ 4. Oral antianxiety agents such as lorazepam
(Ativan).
18. Using the Parkland Formula, calculate the
hourly rate of fluid replacement with Lactated
Ringer’s solution during the fi rst 8 hours for a client
weighing 75 kg with total body surface area (TBSA)
burn of 40%.
______mL/hour.
The Client with General Problems
of the Integumentary System
19. The nurse is assessing an older adult’s skin.
The assessment will involve inspecting the skin for
color, pigmentation, and vascularity. The critical
component in the nurse’s assessment is noting the:
■ 1. Similarities from one side to the other.
■ 2. Changes from the normal expected fi ndings.
■ 3. Appearance of age-related wrinkles.
■ 4. Skin turgor.
20. Which of the following changes are
associated with normal aging?
■ 1. The outer layer of skin is replaced with new
cells every 3 days.
■ 2. Subcutaneous fat and extracellular water
decrease.
■ 3. The dermis becomes highly vascular and
assists in the regulation of body temperature.
■ 4. Collagen becomes elastic and strong.
21. Which of the following should the nurse
expect to assess as normal skin changes in an
elderly client? Select all that apply.
■ 1. Diminished hair on scalp and pubic areas.
■ 2. Dusky rubor of left lower extremity.
■ 3. Solar lentigo.
■ 4. Wrinkles.
■ 5. Xerosis.
■ 6. Yellow pigmentation.
22. The nurse will anticipate which of the following
problems that can result for the older adult
undergoing abdominal surgery?
■ 1. Increased scarring.
■ 2. Decreased melanin and melanocytes.
■ 3. Decreased healing.
■ 4. Increased immunocompetence.
23. Health maintenance and promotion activities
are especially important for the older adult. Which
of the following activities reflects a health maintenance
activity for an otherwise healthy older adult?
■ 1. Drinks 1,500 mL of fluids per day.
■ 2. Consumes a balanced diet of 1,200 calories
per day.
■ 3. Walks briskly for 10 minutes three times per
week.
■ 4. Sleeps at least 8 hours each night.
24. Which of the following characteristics would
put a client at the greatest risk for impaired wound
healing after abdominal surgery?
■ 1. Age 75 years.
■ 2. Age 30 years, with poorly controlled diabetes.
■ 3. Age 55 years, with myocardial infarction.
■ 4. Age 60 years, with peripheral vascular disease.
25. An 82-year-old female has several ecchymotic
areas on her left arm. The nurse should further
assess the client for:
■ 1. Elder abuse.
■ 2. Self-inflicted injury.
■ 3. Increased capillary fragility and permeability.
■ 4. Increased blood supply to the skin.
26. A 90-year-old male complains of feeling cold
in his room even though the thermostat is set at
75° F (24° C). The client probably feels cold because
older adults have:
■ 1. Increased cellular cohesion.
■ 2. Increased moisture content of the stratum
corneum.
■ 3. Slower cellular renewal time.
■ 4. Decreased ability to thermoregulate.
27. Palpation of the skin provides the nurse useful
information regarding:
■ 1. Bruising of the skin.
■ 2. Color of the skin.
■ 3. Hair distribution.
■ 4. Turgor of the skin.
28. A priority nursing diagnosis for an adult
female who has pruritus and is continuously
scratching the affected areas and demonstrates agitation
and anxiety regarding the itching sensation
would be:
■ 1. Risk for infection related to pruritus.
■ 2. Ineffective health maintenance related to lack
of knowledge of the disease process.
■ 3. Impaired skin integrity related to dehydration
from the treatment medications.
■ 4. Social isolation related to poor self-image.
29. The nurse is applying a hand mitt restraint
for a client with pruritis (see fi gure). The nurse
should fi rst:
■ 1. Verify the physician order to use the restraint.
■ 2. Secure the mitt with ties around the wrist tied
to the bed frame.
■ 3. Place a folded pillow under the wrist.
■ 4. Place the mitt on top of the hand.
30. An older adult client in stage 2 of Parkinson’s
disease is being discharged with cellulitis of the
right lower extremity. Which of the following nursing
diagnoses will guide the discharge teaching?
Select all that apply.
■ 1. Ineffective tissue perfusion related to
decreased cardiac output.
■ 2. Impaired skin integrity related to barrier
changes of the skin.
■ 3. Risk for injury related to environmental hazards.
■ 4. Impaired verbal communication related to
dysarthria.
■ 5. Activity intolerance related to painful lower
extremity.
31. An alert and oriented elderly client is admitted
to the hospital for treatment of cellulitis of the
left shoulder after an arthroscopy. Which fall prevention
strategy is most appropriate for this client?
■ 1. Keep all the lights on in the room at all times.
■ 2. Use a nightlight in the bathroom.
■ 3. Keep all four side rails up at all times.
■ 4. Place the client in a room with a camera
monitor.
32. Prevention of skin breakdown and maintenance
of skin integrity among older clients is important
because they are at greater risk secondary to:
■ 1. Altered balance.
■ 2. Altered protective pressure sensation.
■ 3. Impaired hearing ability.
■ 4. Impaired visual acuity.
The Client with Skin Cancer
38. Which of the following factors places a client
at greatest risk for skin cancer?
■ 1. Fair skin and history of chronic sun
e xposure.
■ 2. Caucasian race and history of hypertension.
■ 3. Dark skin and family history of skin cancer.
■ 4. Dark skin and history of hypertension.
39. A nurse is providing teaching to a client
about skin cancer. Which of the following should
the nurse explain are risk factors for skin cancer?
Select all that apply.
■ 1. Increasing age.
■ 2. Exposure to chemical pollutants.
■ 3. Long-term exposure to the sun.
■ 4. Increased pigmentation.
■ 5. Genetics.
■ 6. Immunosuppression.
40. The nurse is developing a program on skin
cancer prevention for a community group. Which of
the following should be included in the program?
Select all that apply.
■ 1. Purchase sunscreen containing benzophenones
to block UVA and UVB rays.
■ 2. Use sunscreen with a minimum of 15 sun
protection factor (SPF).
■ 3. Obtain genetic screening to identify risk of
melanoma.
■ 4. Apply sunscreen only on sunny days, especially
between 10 AM and 2 PM.
■ 5. Have a pigmented lesion biopsied by shaving
if it looks suspicious.
■ 6. Rub baby oil to lubricate skin before going out
in the sun.
41. A client with malignant melanoma asks the
nurse about the prognosis. The nurse should base a
response that informs the client that the prognosis
depends on:
■ 1. The amount of ulceration of the lesion.
■ 2. The age of the client.
■ 3. The location of the lesion on the body.
■ 4. The thickness of the lesion.
Answers, Rationales, and Test
Taking Strategies
The answers and rationales for each question follow
below, along with keys ( ) to the client need
(CN) and cognitive level (CL) for each question. Use
these keys to further develop your test-taking skills.
For additional information about test-taking skills
and strategies for answering questions, refer to pages
10–21, and pages 25–26 in Part 1 of this book.
The Client with Burns
1. 1, 2, 3. Clients who should be transferred to a
burn center include children under age 10 or adults
over age 50 with second- and third-degree burns
on 10% or greater of their body surface area (BSA),
clients between ages 11 and 49 with second- and
third-degree burns over 20% of their BSA, clients of
any age with third-degree burns on more than 5%
of their BSA, clients with smoke inhalation, and
clients with chronic diseases, such as diabetes and
heart or kidney disease.
CN: Management of care; CL: Analyze
2. 3. The nurse should have the client transported
to a burn center. The client’s age and the
extent of the burns require care by a burn team
and the client meets triage criteria for referral to a
burn center. Because of the age of the client and the
extent of the burns, the nurse should not treat the
burn. Scald burns are not at high risk for infection
and do not need to be cleaned, covered, or treated
with antibiotic cream at this time.
CN: Physiological adaptation;
CL: Synthesize
3. 1. Fluid shifting into the interstitial space
causes intravascular volume depletion and
decreased perfusion to the kidneys. This would
result in an increase in serum creatinine. Urine output
should be frequently monitored and adequately
maintained with intravenous fluid resuscitation that
would be increased when a drop in urine output
occurs. Urine output should be at least 30 mL/hour.
Fluid replacement is based on the Parkland or
Brooke formula and also the client’s response by
monitoring urine output, vital signs, and CVP readings.
Daily weight is important to monitor for fluid
status. Little fluctuation in weight suggests that
there is no fluid retention and the intake is equal to
output. Exudative loss of albumin occurs in burns
causing a decrease in colloid osmotic pressure. The
normal serum albumin is 3.5 to 5 gm/dL.
CN: Physiological adaptation;
4. 3. According to the rule of nines, this client
has sustained burns on about 45% of the body
surface. The right arm is calculated as being 9%, the
right leg is 18%, and the anterior trunk is 18%, for a
total of 45%.
CN: Physiological adaptation; CL: Apply
5. 4. Infection is a priority problem for the
burned victim because of the loss of skin integrity
and alteration in body defenses. Excess fluid or
imbalanced nutrition is not a priority during the
emergent period. A risk for falling is not a priority
for this client because the client would be on bed
rest and most likely in a critical care unit.
CN: Physiological adaptation;
CL: Analyze
6. 3. Removing dressings from severe burns
exposes sensitive nerve endings to the air, which
is painful. The client should be given a prescribed
analgesic about one-half hour before the dressing
change to promote comfort. The other activities are
done as part of the whirlpool and dressing change
process and not one-half hour beforehand.
CN: Reduction of risk potential;
CL: Synthesize
7. 4. Nutritional support with sufficient calories
and protein is extremely important for a client
with severe burns because of the loss of plasma
protein through injured capillaries and an increased
metabolic rate. Gastric dilation and paralytic ileus
commonly occur in clients with severe burns, making
oral fluids and foods contraindicated. Water
and electrolyte imbalances can be corrected by
administration of I.V. fluids with electrolyte additives,
although TPN typically includes all necessary
electrolytes. Resting the gastrointestinal tract may
help prevent paralytic ileus, and TPN provides vita- starting TPN is to provide the protein necessary for
tissue healing.
CN: Pharmacological and parenteral
therapies; CL: Evaluate
8. 2. Biologic dressings such as porcine grafts
serve many purposes for a client with severe burns.
They enhance the growth of epithelial tissues,
minimize the overgrowth of granulation tissue,
prevent loss of water and protein, decrease pain,
increase mobility, and help prevent infection. They
do not encourage growth of tougher skin, provide
for permanent wound closure, or facilitate growth of
subcutaneous tissue.
CN: Physiological adaptation;
CL: Apply
9. 4. Analgesic administration to keep a burn
victim comfortable is important but is unlikely to
influence graft survival and effectiveness. Absence
of infection, adequate vascularization, and immobilization
of the grafted area promote an effective
graft.
CN: Physiological adaptation;
CL: Evaluate
10. 2. Rehabilitation efforts are implemented as
soon as the client’s condition is stabilized. Early
emphasis on rehabilitation is important to decrease
complications and to help ensure that the client will
be able to make the adjustments necessary to return
to an optimal state of health and independence. It
is not possible to completely eliminate the client’s
pain; pain control is a major challenge in burn care.
CN: Basic care and comfort;
CL: Synthesize
11. 4. Immediately after a burn, excessive potassium
from cell destruction is released into the extracellular
fluid. Hyponatremia is a common electrolyte
imbalance in the burn client that occurs within
the fi rst week after being burned. Metabolic acidosis
usually occurs as a result of the loss of sodium
bicarbonate.
CN: Reduction of risk potential;
CL: Analyze
12. 2. Airway management is the priority in
caring for a burn client. Tracheostomy or endotracheal
intubation is anticipated when signifi cant
thermal and smoke inhalation burns occur. Clients
who have experienced burns to the face and neck
usually will be compromised within 1 to 2 hours.
Electrical burns of the hands and arms, even with