NCLEX practice exam: Integumentary

Which of the following clients are at greatest risk for skin cancer?

Caucasian female with history of lifeguarding for 5 years
African-American male with family history of skin cancer
Hispanic female with a history of hypertension and cherry angiomas
Caucasian male with an occupation of commercial building maintenance

The prognosis of malignant melanoma depends primarily on:

The client’s age
The location of the melanoma
The thickness of the lesion
The ulceration of the lesion

An unlicensed assistive personnel massages the reddened bony prominences on an elderly client. This client is ordered to be on bed rest. The nurse should educate the client and assistive personnel that:

Massage is an approved method of improving circulation over bony prominences
Lotion improves the effectiveness of massage for elderly clients
The plan of care states that massage every 12 hours is indicated for ulcer prevention
Massage decreases blood flow to reddened bony prominences, and is contraindicated

Which of the following clients is at greatest risk for impaired wound healing after abdominal surgery?

Male, age 75 years
Female, age 35, poorly controlled diabetes
Male, age 59, history of myocardial infarction
Female, age 49, history of peripheral vascular disease

While assessing a dark-skinned client’s Stage I pressure ulcer, the nurse should:

Avoid touching the skin during assessment
Use a fluorescent light source
Look for darker skin surrounding the ulcer
Document and report a Braden score greater than 18

An elderly client complains of being cold in spite of a room temperature of 76° F (25°C). The nurse understands that this is:

Abnormal, and may indicate impending sepsis
Normal, due to sensitivity to increased humidity
Normal, due to decreased ability to thermoregulate
Abnormal, due to the ability of the client to ambulate independently

The priority nursing diagnosis for a client with pruritus who constantly scratches affected areas and appears agitated about the itching sensation would be:

Risk for infection related to pruritus
Risk for social isolation related to poor self-image
Impaired skin integrity related to dehydration from treatment medications
Ineffective health maintenance related to lack of knowledge about disease process

A Stage II pressure ulcer is characterized by:

Necrosis
Tissue sloughing and pain
Redness without blanching
Muscle damage

A client arrives at the emergency department with burns on the anterior surfaces of his right leg, right arm, and upper chest. Using the rule of nines, what percentage of this client’s body surface has been burned?

22.5
35
45
60

An elderly client is brought into the urgent care clinic by his son. The client has first- and second-degree scald burns over hands and forearms. What should the nurse do first?

Apply antibiotic cream to burned areas
Wrap the affected areas with dry gauze
Soak the burns in cool water to relieve pain
Refer the client to a burn center