Medical-Surgical:
A nurse is assisting with the development of an education session about malignant melanoma for a group of clients. The nurse should include that which of the following clients has an increased risk for developing malignant melanoma?
A client who has light complexion
A nurse is collecting data from a client who sustained superficial partial thickness and deep partial thickness burns 72 hrs ago. Which of the following findings should the nurse report to the provider?
A temperature of 39.1 degrees celsius (102.4 F)
A nurse in a providers office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications?
Acyclovir
A nurse is assisting with the care of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?
Sodium 132 mEq/L
A nurse is contributing to the plan of care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should expect the provider to perform which of the following procedures?
Surgical excision
A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention?
Surgical incision
A nurse is observing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following?
Third degree frostbite
A nurse reinforcing discharge teaching with a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of malignancy of a mole?
Ulceration
A nurse is reinforcing teaching with a client who has a large wound healing by secondary intention. The nurse should instruct the client that which of the following nutrients promotes wound healing?
Vitamin C
A nurse is assisting with the admission of a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the clients sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages?
2
A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image?
"May I go to the visitors lounge?"
A nurse is assisting with the development of a program to educate clients about measures to reduce the risk of skin cancer. Which of the following instructions should the nurse include?
Exposure to midday sun
A nurse is reinforcing teaching with a client who has burn injuries to his trunk about what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching?
I will be on a special shower table
A nurse in an urgent care clinic is caring for a client who has a snakebite on her arm. Which of the following actions should the nurse take?
Immobilize the limb at the level of the heart.
A nurse is collecting data from a client who has an arm lesion. Which of the following characteristics is a clinical manifestation of a malignant melanoma?
Irregularly shaped with blue tones
A nurse is caring for a client who has been applying silver sulfadiazine cream to a deep partial thickness arm burn for the past 2 weeks. The nurse should monitor the client for which of the following adverse effects?
Leukopenia
A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses should the nurse make?
Melanomas
A nurse in a providers office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 0.5 cm in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which of the following skin lesions?
Papules
A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the clients questions about the dressing, the nurse explains that it is obtained from which of the following sources?
Pig Skin
A nurse is reinforcing teaching with a client who is wheelchair bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include?
Shift your weight in the wheelchair every 15 minutes