Integumentary

Parents are concerned because their child was exposed to varicella in day care. Which statement by the nurse would be most accurate? "The treatment of choice is aspirin." "A child is no longer contagious once the rash has crusted over." "Varicella has an incubation period of 5 to 10 days." "The rash is nonvesicular."

"A child is no longer contagious once the rash has crusted over."

A client understands what resources are available to help him perform wound care at home when he states the following: "I'll call the social worker if I run out of supplies." "I'll schedule an appointment with my physician to have my dressing changed." "Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need." "I'm so relieved that I have a home health care nurse to take care of my wound for me."

"Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need."

A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client? "Wash the area with soap and water daily." "Apply lubricating lotion to the graft site." "Message the area three times a day." "Cover the area when in direct sunlight."

"Cover the area when in direct sunlight."

The nurse is caring for an older adult client who is unable to reposition in bed independently. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? Post a schedule for repositioning the client at the bedside. Slide the client, rather than lifting, when turning. Massage moisturizing lotion into hips and coccyx twice daily. Turn and reposition the client once every 8 hours.

Post a schedule for repositioning the client at the bedside.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? Scale Ulcer Crust Scar

Scale

Which statement would the nurse include when reinforcing education for a parent about salmon patches (stork bites)? "They're treatable with laser pulse surgery in late adolescence and adulthood." "They're benign and usually fade in adult life." "They're usually associated with syndromes of the neonate." "They can cause mild hypertrophy of the muscle associated with the lesion."

"They're benign and usually fade in adult life."

A client admitted with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take? Obtain oxygen saturation using pulse oximetry. Obtain the client's blood pressure. Allow client uninterrupted rest time. Administer 4 mg lorazepam.

Obtain oxygen saturation using pulse oximetry.

When assessing a client with partial thickness burns over 60% of the body, which finding should the nurse report immediately? Urine output of 70 ml within the first hour Hoarseness of the voice Moderate to severe pain Reports of intense thirst

Hoarseness of the voice

The nurse is caring for a 4-year-old with a full-thickness burn. Before sending the child to hydrotherapy for a scheduled wound debridement, which nursing action is a priority? Provide high-protein drinks. Administer a fluid bolus of 500 mL. Initiate antibiotics as prescribed. Implement pain control measures.

Implement pain control measures.

The nurse is caring for a child in the burn unit who sustained partial thickness burns to the lower extremities. What does the nurse determine the nutritional needs of this child will be? Caloric needs can be lowered by controlling environmental temperature. The hypermetabolic state after a burn injury can lead to poor healing if not corrected. Maintaining a hypermetabolic rate will lower the child's risk of infection. A child needs 100 cal/kg during hospitalization.

The hypermetabolic state after a burn injury can lead to poor healing if not corrected.

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 1 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? Pustules Vesicles Bullae Cysts

Vesicles

A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client? Charge nurse Wound care nurse Physician Risk management

Wound care nurse

A nurse is assisting with the development of a plan of care for a client diagnosed with ringworm. Which medication should the nurse anticipate discussing with this client? corticosteroid cream no medication treatment is required. antibiotic antifungal

antifungal

The nurse completes a wet-to-dry dressing change on a client's lower extremity wound. When should the nurse document the dressing change? the next time they access the client's record to update vital signs immediately prior to the next dressing change as soon as they finish performing the dressing change just before the end of the shift, prior to giving a report

as soon as they finish performing the dressing change

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy? client with a compromised skin graft client with chronic obstructive pulmonary disease client with Legionella-related pneumonia client with an open fracture of the femur

client with a compromised skin graft

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? strict enteric respiratory contact

contact

The nurse is gathering data from a child suspected of being a victim of abuse. What observation by the nurse would lead to this suspicion? contusions at the same stages of healing multiple contusions of the shins large contusion and hematoma of the forehead contusions of the back and buttocks

contusions of the back and buttocks

The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis? tonsillar exudate vesicular lesions dry, cracked lips, strawberry tongue Koplik spots

dry, cracked lips, strawberry tongue

A child fell at camp and sustained a bruise to the thigh. Which description would accurately describe the bruise after 1 week? greenish yellow resolved reddish blue dark blue to bluish brown

greenish yellow

A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize? whole-grain products legumes and cheese fruits and vegetables lean meats and low-fat milk

lean meats and low-fat milk

The nurse is gathering data from a child that has a rash on the face, trunk, and extremities, but not on the palms of the hand. Which disorder should the nurse suspect this child may have? measles syphilis coxsackievirus Rocky Mountain spotted fever

measles

The nurse is admitting a client who states, "I was bit by a brown recluse spider." Which observations made by the nurse would indicate the client's report is accurate? line of papules and vesicles that appear 1 to 3 days after exposure bull's-eye rash herald patch of oval lesions painful rash around a necrotic lesion

painful rash around a necrotic lesion

The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the: other nursing staff members. risk manager. physician. case manager.

risk manager.

A nurse is reinforcing education for a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates that education has been effective? "I'll eat plenty of fruits and vegetables." "I'll limit my intake of protein." "My foot will continue to feel cold until my blood flow gets better." "I'll make sure that the bandage is wrapped tightly."

"I'll eat plenty of fruits and vegetables."

The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is most important for the nurse to tell the client? Avoid thermal burns. Avoid immunosuppression. Avoid exposure to sun. Avoid exposure to radiation.

Avoid exposure to sun

A college student living in the dormitory comes to the school health clinic stating, "I think I have ringworm on the bottom of my foot." What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply. Change socks at least once a day. Wear shoes that prevent air from circulating around the feet. Do not cut toenails short. Be sure to wear shower shoes when using a public shower. Keep skin clean and dry.

Be sure to wear shower shoes when using a public shower. Change socks at least once a day. Keep skin clean and dry.

The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? Explain to the client what is happening and provide support. Ask the client to drink as much fluid as possible. Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. Push the protruding organs back into the abdominal cavity.

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

The licensed practical nurse is collecting a wound culture from a client's gaping surgical incision. Which would the nurse consider to ensure proper culture collection? Gently roll a sterile swab from the center of the wound outward to collect drainage. Thoroughly irrigate the wound with normal saline before collecting the culture. Use one sterile swab to collect drainage from several possible infected sites along the incision. Use a sterile swab to wipe the crusty area around the outside of the wound.

Gently roll a sterile swab from the center of the wound outward to collect drainage.

The nurse observes several areas of ecchymosis on a client's arms and is informed by the client that she is being abused by her partner. What's the most appropriate nursing intervention? Immediately inform the health care provider about the physical violence. Tell the client that the health care provider will be contacted to obtain referrals for personal counseling. Tell the client that the local police will need to be called. Make sure the client has a safe place to go if needed.

Make sure the client has a safe place to go if needed.

The nurse is performing diabetic education with an older adult client and notes a 1-cm (0.4 inches) black raised lesion with a crusty appearance on the client's cheek. The client says it has been present for several months, has gotten larger, and never fully heals but is not painful. Which response is the nurse's priority? Recommend the client speak to a health care provider about getting a biopsy of the lesion as soon as possible. Teach the client how to clean the lesion due to the increased risk for infection in clients with diabetes. Ask what remedies the client has used on the lesion such as over-the-counter topical antibiotics or steroids. Ask the client about recent exposure to allergens or irritants that may have contributed to the lesion forming.

Recommend the client speak to a health care provider about getting a biopsy of the lesion as soon as possible.

The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce? Take the drug with or without meals. Take the drug on an empty stomach with small amounts of water. Take the drug with milk and milk products. Take the drug 1 hour before or 2 hours after meals with large amounts of water.

Take the drug 1 hour before or 2 hours after meals with large amounts of water.

After sustaining a stroke, a client is transferred to the rehabilitation unit. A medical-surgical nurse reviews the client's residual neurological deficits with a rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown? Urinary incontinence and right-sided hemiparesis Right-sided visual deficit and dysarthria Constipation and lower extremity weakness Dysarthria and left-sided visual deficit

Urinary incontinence and right-sided hemiparesis

A child is brought to the health care provider's office for multiple scratches and bites from a kitten and is being evaluated for cat-scratch disease. While collecting data, which symptom would the nurse expect to find with cat-scratch disease? abdominal pain fever adenitis pruritus

adenitis

The nurse is gathering data from several children in the clinic with reports of diarrhea. Which child would be at greatest risk for giardiasis? child that attends group day care child that rides a school bus child that attended a sporting event at a large arena child that plays on a playground close to home

child that attends group day care

A family that recently went camping brings their child to the clinic with a report of a rash after a tick bite. Which finding should the nurse expect to see in a child with Lyme disease? erythematous rash surrounding a necrotic lesion onset of a diffuse rash over the entire body 2 months after exposure a linear rash of papules and vesicles that occurs 1 to 3 days after exposure bright rash with red outer border circling the bite site

bright rash with red outer border circling the bite site

A nurse is caring for a client who was admitted to the burn unit after suffering burns from a house fire. During the acute phase of a burn, the nurse should collect data on which topic? tobacco use lifestyle circulatory status alcohol use

circulatory status

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should: wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious. remove any observable mites. apply a topical corticosteroid to the lesions. place the client on enteric precautions.

wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.