The Client with Health Problems of the16 Integumentary System

The Client with Burns1. There has been a fi re in an apartment building.All residents have been evacuated, but many areburned. Which clients should be transported to aburn center for treatment? Select all that apply.■ 1. An 8-year-old with third-degree burns over10% of his body surface area (BSA).■ 2. A 20-year-old who inhaled the smoke of thefi re.■ 3. A 50-year-old diabetic with fi rst- and seconddegreeburns on his left forearm (about 5% ofhis BSA).■ 4. A 30-year-old with second-degree burns onthe back of his left leg.■ 5. A 40-year-old with second-degree burns onhis right arm (about 10% of his BSA).2. The nurse in the immediate care clinic isassessing an 80-year-old client who lives with hisson’s family and has scald burns on his hands andboth forearms (fi rst- and second-degree burns on10% of his body surface area). What should thenurse 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 ofburn injury, which of the following indicates thatthe client is requiring additional volume with fl uidresuscitation?■ 1. Serum creatinine level of 2.5 mg/dL.■ 2. Little fl uctuation 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 aftersustaining burns to the chest, abdomen, right arm,and right leg. The shaded areas in the illustrationindicate the burned areas on the client’s body. Usingthe “rule of nines,” the nurse would determine thatabout what percentage of the client’s body surfacehas been burned?

■ 1. 18%.

■ 2. 27%.■ 3. 45%.■ 4. 64%.

5. A priority nursing diagnosis for a client withburns during the emergent period would be:■ 1. Excess fl uid volume.■ 2. Imbalanced nutrition: Less than bodyrequirements.■ 3. Risk for injury (falling).■ 4. Risk for infection.

6. Which of the following activities shouldthe nurse include in the plan of care for a clientwith burn injuries to be carried out about one-halfhour before the daily whirlpool bath and dressingchange?■ 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 receivestotal parenteral nutrition (TPN). The expected outcomeis 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 graftssuch 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 havethe least infl uence on the survival and effectivenessof 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 rehabilitationefforts for the burn client:■ 1. Immediately after the burn has occurred.■ 2. After the client’s circulatory status has beenstabilized.■ 3. After grafting of the burn wounds hasoccurred.■ 4. After the client’s pain has been eliminated.11. During the early phase of burn care the nurseshould assess the client for?■ 1. Hypernatremia.■ 2. Hyponatremia.■ 3. Metabolic alkalosis.■ 4. Hyperkalemia.12. Which of the following clients with burnswill most likely require an endotracheal or tracheostomytube? A client who has:■ 1. Electrical burns of the hands and arms causingarrhythmias.■ 2. Thermal burns to the head, face, and airwayresulting in hypoxia.■ 3. Chemical burns on the chest and abdomen.■ 4. Secondhand smoke inhalation.13. A client is receiving fl uid replacement withLactated Ringer’s after 40% of his body was burned10 hours ago. The assessment reveals: temperature36.2° C; heart rate 122; blood pressure 84/42; CVP2 mm Hg; and urine output 25 mL for the last 2hours. 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 therecommendation 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, theclient’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 skingrafts.15. The rate at which I.V. fl uids are infused isbased 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 ofthe gastrointestinal system of a client with a burninjury. 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 painmedication would most likely be given to the clientto decrease the perception of the pain?■ 1. Oral analgesics such as ibuprofen (Motrin) oracetaminophen (Tylenol).■ 2. Intravenous opioids.■ 3. Intramuscular opioids.■ 4. Oral antianxiety agents such as lorazepam(Ativan).18. Using the Parkland Formula, calculate thehourly rate of fl uid replacement with LactatedRinger’s solution during the fi rst 8 hours for a clientweighing 75 kg with total body surface area (TBSA)burn of 40%.___________________________mL/hour.

The Client with General Problemsof the Integumentary System19. The nurse is assessing an older adult’s skin.The assessment will involve inspecting the skin forcolor, pigmentation, and vascularity. The criticalcomponent 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 areassociated with normal aging?■ 1. The outer layer of skin is replaced with newcells every 3 days.■ 2. Subcutaneous fat and extracellular waterdecrease.■ 3. The dermis becomes highly vascular andassists in the regulation of body temperature.■ 4. Collagen becomes elastic and strong.21. Which of the following should the nurseexpect to assess as normal skin changes in anelderly 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 followingproblems that can result for the older adultundergoing abdominal surgery?■ 1. Increased scarring.■ 2. Decreased melanin and melanocytes.■ 3. Decreased healing.■ 4. Increased immunocompetence.23. Health maintenance and promotion activitiesare especially important for the older adult. Whichof the following activities refl ects a health maintenanceactivity for an otherwise healthy older adult?■ 1. Drinks 1,500 mL of fl uids per day.■ 2. Consumes a balanced diet of 1,200 caloriesper day.■ 3. Walks briskly for 10 minutes three times perweek.■ 4. Sleeps at least 8 hours each night.24. Which of the following characteristics wouldput a client at the greatest risk for impaired woundhealing 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 furtherassess the client for:■ 1. Elder abuse.■ 2. Self-infl icted injury.■ 3. Increased capillary fragility and permeability.■ 4. Increased blood supply to the skin.26. A 90-year-old male complains of feeling coldin his room even though the thermostat is set at75° F (24° C). The client probably feels cold becauseolder adults have:■ 1. Increased cellular cohesion.■ 2. Increased moisture content of the stratumcorneum.■ 3. Slower cellular renewal time.■ 4. Decreased ability to thermoregulate.27. Palpation of the skin provides the nurse usefulinformation 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 adultfemale who has pruritus and is continuouslyscratching the affected areas and demonstrates agitationand anxiety regarding the itching sensationwould be:■ 1. Risk for infection related to pruritus.■ 2. Ineffective health maintenance related to lackof knowledge of the disease process.■ 3. Impaired skin integrity related to dehydrationfrom the treatment medications.■ 4. Social isolation related to poor self-image.29. The nurse is applying a hand mitt restraintfor a client with pruritis (see fi gure). The nurseshould fi rst:■ 1. Verify the physician order to use the restraint.■ 2. Secure the mitt with ties around the wrist tiedto 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’sdisease is being discharged with cellulitis of theright lower extremity. Which of the following nursingdiagnoses will guide the discharge teaching?Select all that apply.■ 1. Ineffective tissue perfusion related todecreased cardiac output.■ 2. Impaired skin integrity related to barrierchanges of the skin.■ 3. Risk for injury related to environmental hazards.■ 4. Impaired verbal communication related todysarthria.■ 5. Activity intolerance related to painful lowerextremity.31. An alert and oriented elderly client is admittedto the hospital for treatment of cellulitis of theleft shoulder after an arthroscopy. Which fall preventionstrategy 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 cameramonitor.32. Prevention of skin breakdown and maintenanceof skin integrity among older clients is importantbecause 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 clientat greatest risk for skin cancer?■ 1. Fair skin and history of chronic sune 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 clientabout skin cancer. Which of the following shouldthe 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 skincancer prevention for a community group. Which ofthe following should be included in the program?Select all that apply.■ 1. Purchase sunscreen containing benzophenonesto block UVA and UVB rays.■ 2. Use sunscreen with a minimum of 15 sunprotection factor (SPF).■ 3. Obtain genetic screening to identify risk ofmelanoma.■ 4. Apply sunscreen only on sunny days, especiallybetween 10 AM and 2 PM.■ 5. Have a pigmented lesion biopsied by shavingif it looks suspicious.■ 6. Rub baby oil to lubricate skin before going outin the sun.41. A client with malignant melanoma asks thenurse about the prognosis. The nurse should base aresponse that informs the client that the prognosisdepends 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 TestTaking StrategiesThe answers and rationales for each question follow

below, along with keys ( ) to the client need(CN) and cognitive level (CL) for each question. Usethese keys to further develop your test-taking skills.For additional information about test-taking skillsand strategies for answering questions, refer to pages10–21, and pages 25–26 in Part 1 of this book.The Client with Burns1. 1, 2, 3. Clients who should be transferred to aburn center include children under age 10 or adultsover age 50 with second- and third-degree burnson 10% or greater of their body surface area (BSA),clients between ages 11 and 49 with second- andthird-degree burns over 20% of their BSA, clients ofany age with third-degree burns on more than 5%of their BSA, clients with smoke inhalation, andclients with chronic diseases, such as diabetes andheart or kidney disease.CN: Management of care; CL: Analyze2. 3. The nurse should have the client transportedto a burn center. The client’s age and theextent of the burns require care by a burn teamand the client meets triage criteria for referral to aburn center. Because of the age of the client and theextent of the burns, the nurse should not treat theburn. Scald burns are not at high risk for infectionand do not need to be cleaned, covered, or treatedwith antibiotic cream at this time.CN: Physiological adaptation;CL: Synthesize3. 1. Fluid shifting into the interstitial spacecauses intravascular volume depletion anddecreased perfusion to the kidneys. This wouldresult in an increase in serum creatinine. Urine outputshould be frequently monitored and adequatelymaintained with intravenous fl uid resuscitation thatwould be increased when a drop in urine outputoccurs. Urine output should be at least 30 mL/hour.Fluid replacement is based on the Parkland orBrooke formula and also the client’s response bymonitoring urine output, vital signs, and CVP readings.Daily weight is important to monitor for fl uidstatus. Little fl uctuation in weight suggests thatthere is no fl uid retention and the intake is equal tooutput. Exudative loss of albumin occurs in burnscausing a decrease in colloid osmotic pressure. Thenormal serum albumin is 3.5 to 5 gm/dL.

CN: Physiological adaptation;

4. 3. According to the rule of nines, this clienthas sustained burns on about 45% of the bodysurface. The right arm is calculated as being 9%, theright leg is 18%, and the anterior trunk is 18%, for atotal of 45%.CN: Physiological adaptation; CL: Apply5. 4. Infection is a priority problem for theburned victim because of the loss of skin integrityand alteration in body defenses. Excess fl uid orimbalanced nutrition is not a priority during theemergent period. A risk for falling is not a priorityfor this client because the client would be on bedrest and most likely in a critical care unit.CN: Physiological adaptation;CL: Analyze6. 3. Removing dressings from severe burnsexposes sensitive nerve endings to the air, whichis painful. The client should be given a prescribedanalgesic about one-half hour before the dressingchange to promote comfort. The other activities aredone as part of the whirlpool and dressing changeprocess and not one-half hour beforehand.CN: Reduction of risk potential;CL: Synthesize7. 4. Nutritional support with suffi cient caloriesand protein is extremely important for a clientwith severe burns because of the loss of plasmaprotein through injured capillaries and an increasedmetabolic rate. Gastric dilation and paralytic ileuscommonly occur in clients with severe burns, makingoral fl uids and foods contraindicated. Waterand electrolyte imbalances can be corrected byadministration of I.V. fl uids with electrolyte additives,although TPN typically includes all necessaryelectrolytes. Resting the gastrointestinal tract mayhelp prevent paralytic ileus, and TPN provides vita- starting TPN is to provide the protein necessary fortissue healing.CN: Pharmacological and parenteraltherapies; CL: Evaluate8. 2. Biologic dressings such as porcine graftsserve 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. Theydo not encourage growth of tougher skin, providefor permanent wound closure, or facilitate growth ofsubcutaneous tissue.CN: Physiological adaptation;CL: Apply9. 4. Analgesic administration to keep a burnvictim comfortable is important but is unlikely toinfl uence graft survival and effectiveness. Absenceof infection, adequate vascularization, and immobilizationof the grafted area promote an effectivegraft.CN: Physiological adaptation;CL: Evaluate10. 2. Rehabilitation efforts are implemented assoon as the client’s condition is stabilized. Earlyemphasis on rehabilitation is important to decreasecomplications and to help ensure that the client willbe able to make the adjustments necessary to returnto an optimal state of health and independence. Itis not possible to completely eliminate the client’spain; pain control is a major challenge in burn care.CN: Basic care and comfort;CL: Synthesize11. 4. Immediately after a burn, excessive potassiumfrom cell destruction is released into the extracellularfl uid. Hyponatremia is a common electrolyteimbalance in the burn client that occurs withinthe fi rst week after being burned. Metabolic acidosisusually occurs as a result of the loss of sodiumbicarbonate.CN: Reduction of risk potential;CL: Analyze12. 2. Airway management is the priority incaring for a burn client. Tracheostomy or endotrachealintubation is anticipated when signifi cantthermal and smoke inhalation burns occur. Clientswho have experienced burns to the face and neckusually will be compromised within 1 to 2 hours.Electrical burns of the hands and arms, even withcardiac arrhythmias, or a chemical burn of the chestand abdomen is not likely to result in the need forintubation. Secondhand smoke inhalation doesinfl uence an individual’s respiratory status but does not require intubation unless the individual has anallergic reaction to the smoke.

CN: Physiological adaptation;CL: Analyze13. 3. The decreased urine output, low bloodpressure, low CVP, and high heart rate indicatehypovolemia and the need to increase fl uid volumereplacement. Furosemide is a diuretic that shouldnot be given due to the existing fl uid volume defi cit.Fresh frozen plasma is not indicated. It is given forclients with defi cient clotting factors who are bleeding.Fluid replacement used for burns is LactatedRinger’s solution, Normal Saline, or albumin.CN: Management of care; CL: Synthesize14. 3. The infl ammatory response begins whena burn is sustained. As a result of the burn, theimmune system becomes impaired. There is adecrease in immunoglobulins, changes in whiteblood cells, alterations of lymphocytes, anddecreased levels of interleukin. The human body’sprotective barrier, the skin, has been damaged.As a result, the burn client becomes vulnerable toinfections. Education and interventions to maintaina positive self-concept would be appropriate duringthe rehabilitation phase. Promoting hygiene helpsthe client feel comfortable; however, the primaryfocus is on reducing the risk for infection.CN: Safety and infection control;CL: Synthesize15. 2. During the fi rst 24 hours, fl uid replacementfor an adult burn client is based on total bodyweight and BSA burned. Lean muscle mass considersonly muscle mass; replacement is based on totalbody weight. Total surface area is estimated by takinginto account the individual’s height and weight.Height is not a common variable used in formulasfor fl uid replacement.CN: Physiological adaptation; CL: Apply16. 4. Curling’s ulcer, or gastrointestinal ulceration,occurs in about half of the clients with a burninjury. The incidence of ulceration appears proportionalto the extent of the burns and the ulcerationis believed to be caused by hypersecretion of gastricacid and compromised gastrointestinal perfusion.Paralytic ileus and gastric distention do not resultfrom hypersecretion of gastric acid and stress. Hiatalhernia is not necessarily a potential complication ofa burn injury.

CN: Physiological adaptation;CL: Analyze17. 2. The severe pain experienced by burnclients requires opioid analgesics. In addition,opioids such as morphine sedate and alleviateapprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enoughto effectively manage the intense pain experiencedby the client who is severely burned. Because ofthe altered tissue perfusion from the burn injury,intravenous medications are preferred. Antianxietyagents are not effective against pain.CN: Pharmacological and parenteraltherapies; CL: Synthesize18. 750 mL/hour. Lactated Ringer’s solution4 mL × weight in kg × TBSA; half given over the fi rst8 hours and half given over the next 16 hours.4 mL × 75 kg × 40= 12,000 mL or4 mL 75 kg 40 1 750 mL8 hours 2´ ´´ =hour12,000 mL ×21 = 6,000 mL6,000 mL8 hours= 750 mL/hourCN: Pharmacological and parenteraltherapies; CL: ApplyThe Client with General Problemsof the Integumentary System19. 2. Noting changes from the normal expectedfi ndings is the most important component whenassessing an older client’s integumentary system.Comparing one extremity with the contralateralextremity (i.e., comparing one side with the other)is an important assessment step; however, the mostimportant component is noting changes from anexpected normal baseline. Noting wrinkles relatedto age is not of much consequence unless the clientis admitted for cosmetic surgery to reduce theappearance of age-related wrinkling. Noting skinturgor is an assessment of fl uid status, not an assessmentof the integumentary system.

CN: Health promotion and maintenance;CL: Analyze20. 2. With age, there is a decreased amount ofsubcutaneous fat, muscle laxity, degeneration ofelastic fi bers, and collagen stiffening. The outerlayer of skin is almost completely replaced every 3to 4 weeks. The vascular supply diminishes withage. Collagen thins and diminishes with age.CN: Health promotion and maintenance;CL: Analyze21. 1, 3, 4, 5. Skin changes associated with aginginclude the following: Diminished hair on scalpand pubic areas, solar lentigo (liver spots), wrinkles,and xerosis (dryness). Dusky rubor of the left lower extremity may indicate the individual has a venousstasis problem in the affected extremity and is generallyassociated with “unsuccessful aging.” Yellowpigmentation of the skin that may be associated withliver infl ammation is generally known as jaundice.CN: Health promotion and maintenance;CL: Analyze22. 3. Normal aging consists of decreased proliferativecapacity of the skin. Decreased collagen synthesisslows capillary growth, impairs phagocytosisamong older clients, and results in slow healing.Increased scarring is not a result of age-related skinchanges. Both melanin and melanocytes give colorto the skin and hair but are increased with aging.There is a decrease in the immunocompetence ofthe aging client.CN: Health promotion and maintenance;CL: Analyze23. 1. Drinking at least six 8-oz glasses of fl uidper day helps the client stay well hydrated. Maintainingoptimal fl uid balance is important for allbody systems. Caloric intake varies according toan individual’s size and activity level. An intakeof 1,200 calories/day may be insuffi cient for someolder clients. Walking 10 minutes/day is useful, butan otherwise healthy older client should try to walk20 minutes/day. It is important to get adequate rest;however, the amount of sleep needed varies withthe individual.CN: Health promotion and maintenance;CL: Evaluate24. 2. Poorly controlled diabetes is a serious

risk factor for postoperative wound infection. Otherfactors that delay wound healing include advancedage, nutritional defi ciencies (vitamin C, protein,zinc), inadequate blood supply, use of corticosteroid,infection, mechanical friction on the wound,obesity, anemia, and poor general health.CN: Reduction of risk potential;CL: Analyze25. 3. The aging process involves increased capillaryfragility and permeability. Older clients havea decreased amount of subcutaneous fat. Therefore,there is an increased incidence of bruiselike lesionscaused by collection of extravascular blood in theloosely structured dermis. In addition, older clientsdo not always realize that injury has occurredbecause of a diminished awareness of pain, touch,and peripheral vibration. There are no data to supportelder abuse or self-infl icted bruises. Blood supplyto the skin declines with aging.CN: Health promotion and maintenance;CL: Analyze

26. 4. Older clients have a decreased thermoregulationthat is related to decreased blood supplyand reabsorption of body fat. As a result, olderadults are at risk for hypothermia. Cellular cohesionand moisture content diminish with age and cellularrenewal time is slowed; however, these do not resultin impaired thermoregulation.CN: Health promotion and maintenance;CL: Analyze27. 4. Assessment of the integumentary systemincludes both inspection and palpation. Palpationinvolves assessing temperature, turgor, moisture,and texture. Observing bruises and color and detectinghair distribution are inspection.CN: Health promotion and maintenance;CL: Analyze28. 1. Risk for infection related to pruritus isthe priority nursing diagnosis because it has beendocumented that the client continues to scratch theaffected areas. Satisfactory control of the itchingsensation and discomfort associated with scratchingmay relieve the agitation and anxiety. More informationis required regarding the knowledge levelof the client and her disease process, but learningcannot take place when an individual’s attention is

distracted with pruritus. Impaired skin integrity is apotential problem if the client continues to scratchthe affected areas and destroys the skin, but the riskof infection deserves priority attention because ofthe client’s anxiety. There are no data to support thatthe client has a poor self-image.CN: Reduction of risk potential;CL: Analyze29. 1. Before using any restraints, the nurse mustverify that a physician has written an order for therestraint. The mitt does not need to be secured withties. The client can move the hand as needed. It isnot necessary to place a pillow under the wrist. Thenurse should place the mitt on the palmer surface ofthe hand.CN: Safety and infection control;CL: Synthesize30. 2, 3. Usual aging is associated with dry skin;however, seborrhea (oily skin and dandruff) is oneresult of the biochemical changes associated withParkinson’s disease. The client with Parkinson’sdisease has a higher risk of skin breakdown due tothe moist and oily skin. To maintain skin integrity,a client with Parkinson’s disease needs frequentskin care and aeration of the skin. Gait instabilityin a client with Parkinson’s disease is a result ofmuscle rigidity, change in the center of gravity, andgait shuffl ing. Because of these changes in gait andbalance, the client is at higher risk for injuries in the environment, such as hitting furniture or obstaclesin the client’s path. As a result, the environmentshould be evaluated for potential injury or falls.Tissue perfusion and verbal communication are notproblems typically associated with Parkinson’s disease.The client should not experience activity intolerancefrom the cellulitis or Parkinson’s disease.CN: Pharmacological and parenteraltherapies; CL: Analyze31. 2. Many falls occur when older clientsattempt to get to the bathroom at night. The risk iseven greater in an unfamiliar environment. Use ofa nightlight in the bathroom enables the older adultclient to see the way to the bathroom. Keeping thelights on in the room at all times may contribute tosensory overload and prevent adequate rest. Raisedside rails paradoxically contribute to falls when

the older client tries to climb over them to get tothe bathroom. The upper side rails may be raised,but it is not recommended that all four side rails beelevated. Camera monitoring can be used but doesnothing to prevent a fall.CN: Safety and infection control;CL: Synthesize32. 2. Pressure ulcers usually occur over bonyprominences. An alteration in the protective pressuresensation results from a decline in the numberof Meissner’s and pacinian corpuscles. Older adultsdo have altered balance that may result in falls, butnot skin breakdown. Impaired hearing and vision donot contribute to pressure ulcers.CN: Reduction of risk potential;CL: Analyze

The Client with Skin Cancer38. 1. Caucasians who have fair skin and a highexposure to ultraviolet light are at increased riskfor malignant neoplasms of the skin. The other riskfactors include exposure to tar and arsenicals andfamily history. History of hypertension is a coronaryartery disease risk factor. Clients with dark skinhave increased melanin and are not as prone to skincancer.CN: Health promotion and maintenance;CL: Analyze39. 1, 2, 3, 5, 6. Risk factors associated with skincancer include: Age, exposure to chemical pollutants,exposure to the sun, genetics, and immunosuppression.As individuals age, the risk of developing

skin cancer increases. Long-time exposure to thesun and exposure to chemical pollutants (nitrates,coal, tar, etc.) increases the risk of skin cancer. Individualswho have less skin pigmentation (i.e., fair,blue-eyed people) have a higher risk of skin cancerbecause they tend to incur sunburns rather than tan.Family history plays a role in cancer. Regardless,immunosuppressed individuals are at a higher riskfor the development of any type of cancer, as thebody’s defenses are not functioning properly.CN: Health promotion and maintenance;CL: Apply40. 1, 2. Sunscreen should be applied 20 to30 minutes before going outside, even in cloudy

weather. Sunscreen with a minimum of 15 SPFshould be used. Sunscreen containing benzophenonesblock both UVA and UVB rays. The rays ofthe sun are most dangerous between 10 a.m. and2 p.m. Genetic screening is not indicated, althougha mutated gene has been identifi ed in some familieswith high incidence of melanoma. A prior diagnosisof melanoma and having a fi rst-degree relativediagnosed with melanoma increases a person’s risk.Lesions should not be shave-biopsied; excisionalbiopsy technique is used. Baby oil will increase theadverse effects of sun exposure; sunscreen protectionshould be used.CN: Health promotion and maintenance;CL: Create41. 4. Tumor or lesion thickness is the predictivefactor for survival. Cutaneous melanoma thatis confi ned to the epidermis has a high cure rate.Asymmetry, border, color, and diameter are knownas the “ABCDs” of melanoma. Thus, the amount ofulceration, age, and location are not clearly associatedwith the prognosis.CN: Health promotion and maintenance;