The Client with Health Problems of the Integumentary System 685

Answers, Rationales, and Test 4. 3. According to the rule of nines, this cli-
ent has sustained burns on about 45% of the body
Taking Strategies surface. The right arm is calculated as being 9%, the
right leg is 18%, and the anterior trunk is 18%, for a
The answers and rationales for each question follow total of 45%.
below, along with keys ( ) to the client need CN: Physiological adaptation; CL: Apply
(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 trans-
ported 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 out-
put 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 read-
ings. 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;
CL: Analyze
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 calo-
ries 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, mak-
ing oral fluids and foods contraindicated. Water
and electrolyte imbalances can be corrected by
administration of I.V. fluids with electrolyte addi-
tives, although TPN typically includes all necessary
electrolytes. Resting the gastrointestinal tract may
help prevent paralytic ileus, and TPN provides vita-

Billings_Part 2_Chap 3_Test 16.indd 685 8/7/2010 10:29:12 AM

 686 The Nursing Care of Adults with Medical and Surgical Health Problems
mins and minerals; however, the primary reason for
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 immo-
bilization 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 potas-
sium from cell destruction is released into the extra-
cellular fluid. Hyponatremia is a common electro-
lyte imbalance in the burn client that occurs within
the first 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 endotra-
cheal intubation is anticipated when significant
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
cardiac arrhythmias, or a chemical burn of the chest
and abdomen is not likely to result in the need for
intubation. Secondhand smoke inhalation does
influence an individual’s respiratory status but does
Billings_Part 2_Chap 3_Test 16.indd 686
not require intubation unless the individual has an
allergic reaction to the smoke.
CN: Physiological adaptation;
CL: Analyze
13. 3. The decreased urine output, low blood
pressure, low CVP, and high heart rate indicate
hypovolemia and the need to increase fluid volume
replacement. Furosemide is a diuretic that should
not be given due to the existing fluid volume deficit.
Fresh frozen plasma is not indicated. It is given for
clients with deficient clotting factors who are bleed-
ing. Fluid replacement used for burns is Lactated
Ringer’s solution, Normal Saline, or albumin.
CN: Management of care; CL: Synthesize
14. 3. The inflammatory response begins when
a burn is sustained. As a result of the burn, the
immune system becomes impaired. There is a
decrease in immunoglobulins, changes in white
blood cells, alterations of lymphocytes, and
decreased levels of interleukin. The human body’s
protective barrier, the skin, has been damaged.
As a result, the burn client becomes vulnerable to
infections. Education and interventions to maintain
a positive self-concept would be appropriate during
the rehabilitation phase. Promoting hygiene helps
the client feel comfortable; however, the primary
focus is on reducing the risk for infection.
CN: Safety and infection control;
CL: Synthesize
15. 2. During the first 24 hours, fluid replace-
ment for an adult burn client is based on total body
weight and BSA burned. Lean muscle mass consid-
ers only muscle mass; replacement is based on total
body weight. Total surface area is estimated by tak-
ing into account the individual’s height and weight.
Height is not a common variable used in formulas
for fluid replacement.
CN: Physiological adaptation; CL: Apply
16. 4. Curling’s ulcer, or gastrointestinal ulcer-
ation, occurs in about half of the clients with a burn
injury. The incidence of ulceration appears propor-
tional to the extent of the burns and the ulceration
is believed to be caused by hypersecretion of gastric
acid and compromised gastrointestinal perfusion.
Paralytic ileus and gastric distention do not result
from hypersecretion of gastric acid and stress. Hiatal
hernia is not necessarily a potential complication of
a burn injury.
CN: Physiological adaptation;
CL: Analyze
17. 2. The severe pain experienced by burn
clients requires opioid analgesics. In addition,
opioids such as morphine sedate and alleviate
apprehension. Oral analgesics such as ibuprofen
8/7/2010 10:29:13 AM
 The Client with Health Problems of the Integumentary System
or acetaminophen are unlikely to be strong enough
to effectively manage the intense pain experienced
by the client who is severely burned. Because of
the altered tissue perfusion from the burn injury,
intravenous medications are preferred. Antianxiety
agents are not effective against pain.
CN: Pharmacological and parenteral
therapies; CL: Synthesize
18. 750 mL/hour. Lactated Ringer’s solution
4 mL × weight in kg × TBSA; half given over the first
8 hours and half given over the next 16 hours.
4 mL × 75 kg × 40= 12,000 mL or
4 mL ´ 75 kg ´ 40 1 750 mL
´ =
8 hours 2 hour
12,000 mL × 1 = 6,000 mL
2 CN: Health promotion and maintenance;
6,000 mL
= 750 mL/hour
8 hours
CN: Pharmacological and parenteral
therapies; CL: Apply
The Client with General Problems
of the Integumentary System
19. 2. Noting changes from the normal expected
findings is the most important component when
assessing an older client’s integumentary system.
Comparing one extremity with the contralateral
extremity (i.e., comparing one side with the other)
is an important assessment step; however, the most
important component is noting changes from an
expected normal baseline. Noting wrinkles related
to age is not of much consequence unless the cli-
ent is admitted for cosmetic surgery to reduce the
appearance of age-related wrinkling. Noting skin
turgor is an assessment of fluid status, not an assess-
ment of the integumentary system.
CN: Health promotion and maintenance;
CL: Analyze
20. 2. With age, there is a decreased amount of
subcutaneous fat, muscle laxity, degeneration of
elastic fibers, and collagen stiffening. The outer
layer of skin is almost completely replaced every 3
to 4 weeks. The vascular supply diminishes with
age. Collagen thins and diminishes with age.
CN: Health promotion and maintenance;
CL: Analyze
21. 1, 3, 4, 5. Skin changes associated with aging
include the following: Diminished hair on scalp
and pubic areas, solar lentigo (liver spots), wrinkles,
and xerosis (dryness). Dusky rubor of the left lower
Billings_Part 2_Chap 3_Test 16.indd 687
687
extremity may indicate the individual has a venous
stasis problem in the affected extremity and is gen-
erally associated with “unsuccessful aging.” Yellow
pigmentation of the skin that may be associated with
liver inflammation is generally known as jaundice.
CN: Health promotion and maintenance;
CL: Analyze
22. 3. Normal aging consists of decreased prolif-
erative capacity of the skin. Decreased collagen syn-
thesis slows capillary growth, impairs phagocytosis
among older clients, and results in slow healing.
Increased scarring is not a result of age-related skin
changes. Both melanin and melanocytes give color
to the skin and hair but are increased with aging.
There is a decrease in the immunocompetence of
the aging client.
CL: Analyze
23. 1. Drinking at least six 8-oz glasses of fluid
per day helps the client stay well hydrated. Main-
taining optimal fluid balance is important for all
body systems. Caloric intake varies according to
an individual’s size and activity level. An intake
of 1,200 calories/day may be insufficient for some
older clients. Walking 10 minutes/day is useful, but
an otherwise healthy older client should try to walk
20 minutes/day. It is important to get adequate rest;
however, the amount of sleep needed varies with
the individual.
CN: Health promotion and maintenance;
CL: Evaluate
24. 2. Poorly controlled diabetes is a serious
risk factor for postoperative wound infection. Other
factors that delay wound healing include advanced
age, nutritional deficiencies (vitamin C, protein,
zinc), inadequate blood supply, use of corticoster-
oid, infection, mechanical friction on the wound,
obesity, anemia, and poor general health.
CN: Reduction of risk potential;
CL: Analyze
25. 3. The aging process involves increased cap-
illary fragility and permeability. Older clients have
a decreased amount of subcutaneous fat. Therefore,
there is an increased incidence of bruiselike lesions
caused by collection of extravascular blood in the
loosely structured dermis. In addition, older cli-
ents do not always realize that injury has occurred
because of a diminished awareness of pain, touch,
and peripheral vibration. There are no data to sup-
port elder abuse or self-inflicted bruises. Blood sup-
ply to the skin declines with aging.
CN: Health promotion and maintenance;
CL: Analyze
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 688 The Nursing Care of Adults with Medical and Surgical Health Problems
26. 4. Older clients have a decreased thermo-
regulation that is related to decreased blood sup-
ply and reabsorption of body fat. As a result, older
adults are at risk for hypothermia. Cellular cohesion
and moisture content diminish with age and cellular
renewal time is slowed; however, these do not result
in impaired thermoregulation.
CN: Health promotion and maintenance;
CL: Analyze
27. 4. Assessment of the integumentary system
includes both inspection and palpation. Palpation
involves assessing temperature, turgor, moisture,
and texture. Observing bruises and color and detect-
ing hair distribution are inspection.
CN: Health promotion and maintenance;
CL: Analyze
28. 1. Risk for infection related to pruritus is
the priority nursing diagnosis because it has been
documented that the client continues to scratch the
affected areas. Satisfactory control of the itching
sensation and discomfort associated with scratching
may relieve the agitation and anxiety. More infor-
mation is required regarding the knowledge level
of the client and her disease process, but learning
cannot take place when an individual’s attention is
distracted with pruritus. Impaired skin integrity is a
potential problem if the client continues to scratch
the affected areas and destroys the skin, but the risk
of infection deserves priority attention because of
the client’s anxiety. There are no data to support that
the client has a poor self-image.
CN: Reduction of risk potential;
CL: Analyze
29. 1. Before using any restraints, the nurse must
verify that a physician has written an order for the
restraint. The mitt does not need to be secured with
ties. The client can move the hand as needed. It is
not necessary to place a pillow under the wrist. The
nurse should place the mitt on the palmer surface of
the hand.
CN: Safety and infection control;
CL: Synthesize
30. 2, 3. Usual aging is associated with dry skin;
however, seborrhea (oily skin and dandruff) is one
result of the biochemical changes associated with
Parkinson’s disease. The client with Parkinson’s
disease has a higher risk of skin breakdown due to
the moist and oily skin. To maintain skin integrity,
a client with Parkinson’s disease needs frequent
skin care and aeration of the skin. Gait instability
in a client with Parkinson’s disease is a result of
muscle rigidity, change in the center of gravity, and
gait shuffling. Because of these changes in gait and
balance, the client is at higher risk for injuries in the
Billings_Part 2_Chap 3_Test 16.indd 688
environment, such as hitting furniture or obstacles
in the client’s path. As a result, the environment
should be evaluated for potential injury or falls.
Tissue perfusion and verbal communication are not
problems typically associated with Parkinson’s dis-
ease. The client should not experience activity intol-
erance from the cellulitis or Parkinson’s disease.
CN: Pharmacological and parenteral
therapies; CL: Analyze
31. 2. Many falls occur when older clients
attempt to get to the bathroom at night. The risk is
even greater in an unfamiliar environment. Use of
a nightlight in the bathroom enables the older adult
client to see the way to the bathroom. Keeping the
lights on in the room at all times may contribute to
sensory overload and prevent adequate rest. Raised
side rails paradoxically contribute to falls when
the older client tries to climb over them to get to
the bathroom. The upper side rails may be raised,
but it is not recommended that all four side rails be
elevated. Camera monitoring can be used but does
nothing to prevent a fall.
CN: Safety and infection control;
CL: Synthesize
32. 2. Pressure ulcers usually occur over bony
prominences. An alteration in the protective pres-
sure sensation results from a decline in the number
of Meissner’s and pacinian corpuscles. Older adults
do have altered balance that may result in falls, but
not skin breakdown. Impaired hearing and vision do
not contribute to pressure ulcers.
CN: Reduction of risk potential;
CL: Analyze
The Client with a Pressure Ulcer
33. 3. When assessing a client with dark skin, the
nurse should observe for skin that is darker, brown-
ish, purplish, or bluish compared to surrounding
skin. Fluorescent light casts a blue light making skin
assessment difficult; natural or halogen light sources
help to accurately assess the skin. Risk assessment
using the Braden Scale should be performed on all
clients. A Braden score of 12 indicates a high risk
for pressure ulcer and the lower the Braden score,
the higher the risk (no risk 19–23, at risk 15–18,
moderate risk 13–14, high risk 10–12, and very high
risk 9 or below). The nurse should touch the skin to
assess consistency and temperature differences.
CN: Physiological adaptation;
CL: Analyze
34. 2. Stage I pressure ulcers appear as non-
blanching macules that are red in color. Stage II
ulcers have breakdown of the dermis. Stage III
8/7/2010 10:29:15 AM
 The Client with Health Problems of the Integumentary System
ulcers have full-thickness skin breakdown. In stage
IV ulcers, the bone, muscle, and supporting tissue
are involved. The nurse should immediately initiate
plans to relieve the pressure, ensure good nutrition,
and protect the area from abrasion.
CN: Reduction of risk potential;
CL: Analyze
35. 3. A stage II skin breakdown involves epider-
mal sloughing and pain. Redness without blanching
is noted in stage I. Stage III involves tissue necrosis
with subcutaneous involvement. Stage IV involves
muscle or bone destruction. Muscle spasms are not
a criterion used in the staging process.
CN: Physiological adaptation;
CL: Analyze
36. 3, 4, 5. The client has a Stage II pressure
ulcer. The nurse should take measures to relieve
the pressure, treat the local infection, and protect
the wound. The nurse should keep the ulcer cov-
ered with a protective dressing.. The client should
turn every 2 hours and use an alternating-pressure
mattress to relieve pressure on the buttocks. The
head of the bed should be elevated no more than
30 degrees. All wounds have bacteria and obtaining
frequent cultures (unless ordered otherwise) are not
necessary.
CN: Safety and infection control;
CL: Synthesize
37. 3. The pressure ulcer has changed from Stage
I to Stage II and requires the use of a protective
dressing. Repositioning and use of foam mattresses
are appropriate interventions for Stage I pressure
ulcers. There is no indication that the ulcer is
infected.
CN: Reduction of risk potential;
CL: Synthesize
The Client with Skin Cancer
38. 1. Caucasians who have fair skin and a high
exposure to ultraviolet light are at increased risk
for malignant neoplasms of the skin. The other risk
factors include exposure to tar and arsenicals and
family history. History of hypertension is a coronary
artery disease risk factor. Clients with dark skin
have increased melanin and are not as prone to skin
cancer.
CN: Health promotion and maintenance;
CL: Analyze
39. 1, 2, 3, 5, 6. Risk factors associated with skin
cancer include: Age, exposure to chemical pollut-
ants, exposure to the sun, genetics, and immunosup-
pression. As individuals age, the risk of developing
Billings_Part 2_Chap 3_Test 16.indd 689
689
skin cancer increases. Long-time exposure to the
sun and exposure to chemical pollutants (nitrates,
coal, tar, etc.) increases the risk of skin cancer. Indi-
viduals who have less skin pigmentation (i.e., fair,
blue-eyed people) have a higher risk of skin cancer
because they tend to incur sunburns rather than tan.
Family history plays a role in cancer. Regardless,
immunosuppressed individuals are at a higher risk
for the development of any type of cancer, as the
body’s defenses are not functioning properly.
CN: Health promotion and maintenance;
CL: Apply
40. 1, 2. Sunscreen should be applied 20 to
30 minutes before going outside, even in cloudy
weather. Sunscreen with a minimum of 15 SPF
should be used. Sunscreen containing benzophe-
nones block both UVA and UVB rays. The rays of
the sun are most dangerous between 10 a.m. and
2 p.m. Genetic screening is not indicated, although
a mutated gene has been identified in some families
with high incidence of melanoma. A prior diagno-
sis of melanoma and having a first-degree relative
diagnosed with melanoma increases a person’s risk.
Lesions should not be shave-biopsied; excisional
biopsy technique is used. Baby oil will increase the
adverse effects of sun exposure; sunscreen protec-
tion should be used.
CN: Health promotion and maintenance;
CL: Create
41. 4. Tumor or lesion thickness is the predic-
tive factor for survival. Cutaneous melanoma that
is confined to the epidermis has a high cure rate.
Asymmetry, border, color, and diameter are known
as the “ABCDs” of melanoma. Thus, the amount of
ulceration, age, and location are not clearly associ-
ated with the prognosis.
CN: Health promotion and maintenance;
CL: Synthesis
Managing Care Quality and Safety
42. 4. Massaging areas that are reddened due
to pressure is contraindicated because it further
reduces blood flow to the area. The UAP should not
massage the bony prominences or use lotion on the
area. Massage does improve circulation and blood
flow to muscle areas; however, because the area is
reddened, the client is at risk for further skin break-
down.
CN: Management of care; CL: Synthesize
43. 3. The problem of pressure ulcers in hospi-
talized clients is best addressed by using quality
improvement techniques to identify the problem,
determining strategies for improvement, and setting
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 690 The Nursing Care of Adults with Medical and Surgical Health Problems
goals for outcomes. Benchmarking for comparison
will indicate where this nursing unit compares with
other units, but does not address the problem for
this unit; having clients with pressure ulcers on any
unit is not acceptable. Educational programs are
more effective after there is an understanding of the
problem. Chart audits and blaming do not solve the
problem or address quality improvement measures.
CN: Management of care; CL: Synthesize
44. 3, 4, 5. Infection control policies must be fol-
lowed to prevent the spread of infection. Until the
pathogens are identified, the client must be isolated
in a private room. Utilizing contact isolation, wear-
ing a protective isolation gown and clean gloves, in
addition to following isolation protocol to exit the
room, may aid in the prevention of spread of infec-
tious agents to others. A draining foot lesion does
Billings_Part 2_Chap 3_Test 16.indd 690
not require a negative air pressure room, which is
primarily reserved for preventing spread of tuber-
culosis. Latex free gloves are not needed unless the
client has a latex allergy.
CN: Safety and infection control;
CL: Synthesize
45. 3. By contacting the pharmacy to report the
absence of the medication, the pharmacy can bring
the medication to the client’s medication box. From
there on, the pharmacy can make sure the correct
medications are present. Contacting the shift coor-
dinator or the client’s physician will not correct the
original cause of the variance. It is never appropriate
to “borrow” a medication from another client.
CN: Management of care; CL: Synthesize
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