Nclex Review Integumentary

Front 1

Normal skin changes with aging include:

Back 1

hyperpigmented areas such as
seborrheic and keratoses

Front 2

Psoriasis is:

Back 2

a chronic disorder that affects the skin and the joints causing red scaly patches to appear on the skin. The patches are areas of inflammation and excessive skin production

Front 3

Psoriasis is exacerbated by:

Back 3

stress

Front 4

Tx for Psoriasis:

Back 4

ultraviolet light therapy is used up to 15 minutes per tx. with only the areas being treated exposed

Front 5

Wounds:

Back 5

draining wounds may need a wound vac

may be seen by the nurse epidemiologist to help providers of care control infections

wound infections may be tx with topical antibiotics

Front 6

Superficial burn:

Back 6

painful
no edema
redness
blanches with pressure.

Front 7

Superficial partial thickness:

Back 7

painful
red
blistered

Front 8

Partial thickness

Back 8

entire epidermis and part of dermis affected.
painful
mottled
red
weeping
edematous

Significant in children if > 25% of BSA

Front 9

Full thickness

Back 9

involves epidermis, dermis and sub-q tissue and beyond

Dry
discolored
no pain

significant in children if > 10%

Front 10

Any burn above the waist :

Back 10

be aware of respiratory involvement.

Front 11

IV FLUID calculations:

Back 11

Parkland (Baxter) formula is used:

weight X 4 mL/kg X % body burned

Front 12

IV administration:

Back 12

One half of ttl amount of fluid (LR) should be administered in first 8 hours.

Calculated from time of burn

Front 13

IV amounts:

Back 13

not uncommon to give over 1000 mls per hour during various phases of burns

Front 14

IV monitoring:

Back 14

monitor carefully for possible fluid overload

Do not give free water to burn victims.

All input of fluids must be strictly managed

Front 15

rules of nine:

Back 15

head 9% 4 1/2 front 4 1/2 back

torso: 18% front 18% back

arms: 9% each 4/12 front 4/12 back

legs 18% each 9% front 9 % back

perineum: 1%

Front 16

Central lines:

Back 16

used in larger burns in order to deliver 10,000 kcals per day of nutrients

Front 17

Monitor:

Back 17

I & O
electrolytes
daily weights
IV fluid replacements

Front 18

The first 48 hours after a severe burn the potassium will be:

Back 18

K+ will be high due to large amounts of it being released from damaged cells and into the extracellular fluids

Front 19

The second 48 hours after a severe burn the potassium will be:

Back 19

Low. this is due to hyper-hydration with IV fluids

Front 20

Due to sodium being lost in the edematous tissue, the pt. Na+ will be:

Back 20

Low

Front 21

In burns above the chest always be aware of:

Back 21

possible airway control needed. Often intubation is necessary to establish and maintain a patent airway before swelling sets in

Front 22

Burn patients may require a NG tube and can be at risk for an:

Back 22

ileus

Front 23

H2 Blockers are given in order to ward off:

Back 23

stress ulcers that often occur due to vasoconstriction of the blood vessels that supply the GI mucosa

Front 24

Diet must include high levels of:

Back 24

Protein

Front 25

Burn dressings: initially:

Back 25

covering is something clean such as a sheet in order to keep moisuture in and prevent further infection or contamination

Front 26

ROM is started:

Back 26

as soon as possible.

this is to prevent contractures of skin and joints and muscles

Front 27

Topicals such as :

Back 27

Mefenide (Sulfamylon) may be used twice a day.


do not use Silver Nitrate as it may precipitate electrolyte imbalances

Front 28

Pain medications should be administered:

Back 28

prior to application of topical medications.

Front 29

Preferred pain medication and route for burn victims:

Back 29

Morphine via IV

Front 30

Heterograft and allograft are:

Back 30

temporary grafts.
may be pig skin
used to relieve pain and promote rapid epitheliazation

Front 31

Homograft

Back 31

skin graft from another person

homo sapien

Front 32

Autograft

Back 32

skin from the client

own skin

Front 33

Electric injury entrance wound:

Back 33

appears as a burn

Front 34

Electrical injury exit wound:

Back 34

in an area close to ground dependent on the position of the client when injury occurred

Front 35

Stage I pressure sore:

Back 35

skin is intact but reddened skin

Front 36

Stage II pressure sore:

Back 36

partial loss of the dermis. It is superficial and presents as an abrasion, blister or shallow crater

Front 37

Stage III pressure sore:

Back 37

full thickness loss of skin and sinus tracts may be present

Front 38

Stage IV pressure sore:

Back 38

full thickness loss with extension destruction, tissue necrosis, damage to muscle, bone or supporting structures

Front 39

Deep tissue injuries:

Back 39

cannot be staged

Front 40

Slough is:

Back 40

yellow material in a wound

Front 41

Eschar is:

Back 41

black tissue which can be seen on pressure sores and burn injuries

Front 42

Nevi

Back 42

can be removed with laser

solution to cleanse: 1/2 hydrogen peroxide

Front 43

Laser treatment :

Back 43

minimal discomfort

avoid sunlight for at least 3 months after tx

redness and swelling is expected after the procedure

Front 44

Basal cell cancer:

Back 44

pearly with center crater and rolled waxy boarder.

MOST COMMON

Front 45

Squamous cell:

Back 45

firm, nodular lesion that is topped with a trust and has an area of ulceration.

REMEMBER; Squamous squirms in and metastasizes

Front 46

Melanoma:

Back 46

red, white or blue toned lesion

Metastasis to the brain, lung bone, liver and skin

Spreads via lymph system and blood vessels

Front 47

Actinic Keratosis:

Back 47

premalignant and presents as a yellow or brown scale.