Module 6 ATI

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? A. "I will be on a special shower table." B. "The water temperature will be very cool to ease my pain." C. "The nurse will use a firm-bristled brush to remove loose skin." D. "The nurse will use scissors to open small blisters."

A. "I will be on a special shower table."

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? A. "May I go with my family to the visitor's lounge." B. "I'll see my friends someday when I feel better." C. "My dad is coming to visit. Can you fix my hair for me?" D. "I told my cousins I'm in protective isolation."

A. "May I go with my family to the visitor's lounge."

A nurse is caring for a client who has deep partial- and full-thickness burns and requires a topical antimicrobial drug. The goal of this medication therapy is to reduce which of the following outcomes? A. bacterial growth B. scarring C. skin graft size D. pain

A. bacterial growth

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? A. immobilize the limb at the level of the heart B. apply a tourniquet to the affected limb C. use a sterile scapula to incise the wound D. apply ice to the skin over the snakebite wound

A. immobilize the limb at the level of the heart

A nurse is assisting with planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface. The client is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A. initiate range-of-motion exercises B. use clean technique to provide wound care C. place the client on a low-protein diet D. maintain the client on bed rest

A. initiate range-of-motion exercises

A nurse in a provider's office is collecting data from a client who has skin lesions. The nurse notes that the lesion are 0.5 cm in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions? A. papules B. macules C. wheals D. vesicles

A. papules

A nurse is reinforcing discharge teaching with a client who is postoperative following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of malignancy of a mole? A. ulceration B. blanching of surrounding skin C. dimpling D. fading of color

A. ulceration

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 of developing malignant melanoma? A. a client who has brown eyes B. a client who has a light complexion C. a client who has black hair D. a client who is 20 years of age

B. a client who has a light complexion

A nurse in a provider's 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? A. zoster vaccine B. acyclovir C. amoxicillin D. infliximab

B. acyclovir

A nurse is reinforcing teaching with a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? A. subcutaneous B. epidermis C. dermis D. stratum corneum

B. epidermis

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? A. hyponatremia B. leukopenia C. hyperchloremia D. elevated BUN

B. 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? A. basal cell carcinomas B. melanomas C. actinic keratoses D. squamous cell carcinomas

B. melanomas

A nurse is caring for a client whose wounds are covered with a heterograft dressing, in response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? A. cadaver skin B. pig skin C. amniotic membranes D. beef collagen

B. pig skin

A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first? A. estimation of burn injury B. respiratory rate C. presence of bowel sounds D. level of pain

B. respiratory rate

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? A. hemoglobin 10 g/dL B. sodium 132 mEq/L C. albumin 3.6 g/dL D. potassium 4.0 mEq/dL

B. sodium 132 mEq/L

A nurse is assisting with the development of a program to educate clients about measures to reduce risk of skin cancer. Which of the following instructions should the nurse include? A. re-apply sunscreen every 4 hours during sun exposure B. wear a sun visor instead of a hat when outside in the sun C. avoid exposure to the midday sun D. use a tanning booth instead of sunbathing outdoors

C. avoid exposure to the midday sun

A nurse in a dermatology clinic is using the ABCDE method while screening several of a client's skin lesions for skin cancer. Which of the following findings should the nurse report to the provider? A. symmetric shape B. border regularity C. color variation within a lesion D. diameter >4 mm

C. color variation within a lesion

A nurse is screening a client for skin cancer. When reinforcing teaching with the client about skin cancer risk, which of the following risk factors should the nurse include? A. cigarette smoking B. low-fiber diet C. excessive exposure to ultraviolet light D. human papillomavirus

C. excessive exposure to ultraviolet light

A nurse is caring for a client who has smoke inhalation and full-thickness burns covering 63% of her body. Which of the following nursing actions is the nurse's priority? A. monitor intake and output B. administer antibiotics C. monitor respiratory status D. encourage fluid and food intake

C. monitor respiratory status

A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A. partial-thickness burn B. stage 3 pressure ulcer C. surgical incision D. dehisced sternal wound

C. surgical incision

A nurse is collecting data from a client who is 3 days postoperative following abdominal surgery. The client's incision is slightly edematous, appears pink with crusting on the edges, and is draining serosanguinous fluid. Which of the following statements describes this incision? A. the incision is showing early signs of infection B. the incision is showing early signs of dehiscence C. the incision is showing signs of healing without complications D. the incision is showing signs of developing a fistula

C. the incision is showing signs of healing without complications

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? A. first-degree frostbite B. second-degree frostbite C. third-degree frostbite D. fourth-degree frostbite

C. third-degree frostbite

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? A. vitamin B1 B. Calcium C. vitamin C D. potassium

C. vitamin C

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? A. "Move between the bed and the wheelchair once every 2 hours." B. "Make sure that your caregiver massages your skin daily." C. "Use a rubber ring when sitting in the wheelchair." D. "Shift your weight in the wheelchair every 15 minutes."

D. "Shift your weight in the wheelchair every 15 minutes."

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 client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? A. Stage IV B. Stage I C. Stage III D. Stage II

D. Stage II

A nurse is caring for a client who has regular occupational exposure to sunlight and presents to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A. a pearly papule that is 0.5 cm wide with raised, indistinct borders on the upper right shoulder B. several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose C. a raised, circumscribed lesion on the face that contains yellow-white purulent material D. an irregularly shaped brown lesion with light blue areas on the neck

D. an irregularly shaped brown lesion with light blue areas on the neck

A community health nurse is reinforcing teaching about melanoma with a group of clients. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? A. solid color B. symmetrical shape C. less than 6 mm in diameter D. irregular border

D. irregular border

A nurse is collecting data from a client who has an arm lesion. Which of the following characteristics is a clinical manifestation of malignant melanoma? A. rough, dry, and scaly B. firm module with crust C. pearly papule with an ulcerated center D. irregularly shaped with blue tones

D. irregularly shaped with blue tones

A nurse is contributing to the plan of care for a client who has been admitted for the treatment of a malignant melanoma of the upper leg without metastasis. The nurse should expect the provider to perform which of the following procedures? A. curettage B. external radiation therapy C. regional chemotherapy D. surgical excision

D. surgical excision

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? A. edema in the affected extremities B. severe pain at the burn sites C. urine output of 30 mL/hr D. temperature of 39.1 (102.4)

D. temperature of 39.1 (102.4)

A nurse is reinforcing discharge teaching about foot care with a client who has diabetes mellitus. Which of the following instructions should the nurse include in the teaching? A. wear nylon socks with shoes every day B. trim toenails by rounding the edges of the nail C. apply lotion between the toes after bathing D. test water temperature with the wrist

D. test water temperature with the wrist