Medical-Surgical: Dermatological

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 a light complexion

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 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?

Avoid exposure to the midday sun

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 The nurse should anticipate a client who is in the resuscitation phase of a burn injury to have a low sodium level because sodium is trapped in the interstitial space.

The nurse is contributing to the plan of care for a patient 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 The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting.

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 With primary intention, a clean wound is closed mechanically, leaving well approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention

A nurse is collecting data from a client who sustained superficial partial thickness and deep partial thickness burns 72 hours ago. Which of the following findings should the nurse report to the provider?

Temperature of 39.1 C or 102.4 F And elevated temperature is an indication of infection in the nurse should report this binding to the provider. Sepsis is a critical finding following a major burn injury. Initially Byrneland are relatively pathogen free. On approximately the third day following the injury, early colonization of the wound surface by Graham negative organisms changes to predominantly gram-positive opportunistic organisms.

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 When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood filled in the skin does not blanch.

A nurse is reinforcing discharge teaching with a client who is postoperative following a surgical excision of basal cell carcinoma. Which of the following findings should the nurse include as an indication of malignancy of a mole?

Ulceration Ulceration, bleeding, or exudation are indications of a moles potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow up evaluations and the proper techniques for self examination of the skin every month.

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 reinforcing teaching with a client who has burn injuries to his trunk about what to expect from the prescribed Hydro therapy. Which of the following statements by the client indicates an understanding of the teaching?

I will be on a special shower table Hydrotherapy is a special shower table that facilitates examination and debridement of the wound. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature and there is lower risk of wound infection.

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?

II With a stage II pressure ulcer, there is partial thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Adema persists, and the ulcer can become infected. The client might report pain in there might be a small amount of drainage.

A nurse in an urgent care clinic is caring for a client who has a snake bite on her arm. Which of the following actions should the nurse take?

Immobilize the limb at the level of the heart The emergency management of a client who has a snakebite focuses on limiting the spread of venom any constructive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized 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 Malignant melanoma's are irregularly shaped and can be blue, red, or white in tone. They often occur on the clients upper back and lower legs.

A nurse is caring for a client who has been applying silver sulfadiazine Cream to a deep partial thickness arm burn for the past two weeks. The nurse should monitor the client for which of the following adverse effects?

Leukopenia Transient leukopenia is an adverse effect of silver sulfadiazine; therefore, the nurse should monitor the client for an allergic reaction causing a decrease in the clients wbc count.

A nurse is caring for an adolescent client who has burn rooms 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 with my family to the visitors lounge?

A nurse is caring for a client who has a lesion on the back of his right hand. The client asked the nurse which type of skin cancer is the most serious. Which of the following responses should the nurse make?

Melanomas Melanomas are malignant neoplasm's with atypical melanocytes in both the epidermis, dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastasis in the bone, liver, lungs, spleen, and the CNS, and lymph nodes.

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 Heterografts are obtained from an animal, usually a pig. Homographs are obtained from cadaver 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