Saunders Comprehensive 9

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. Does the nurse understand that which characteristics describe this type of lesion? Select all that apply. 1. Metastasis is rare. 2. It is encapsulated. 3. It is highly metastatic. 4. It is characterized by local invasion. 5. Lesion is a nevus that has changed in color. 3, 5 Rationale: Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis.

1周前对可疑病变进行皮肤活检后，客户返回诊所接受后续治疗。活检报告表明病变是黑色素瘤。护士是否理解哪些特征描述了这种类型的病变？选择所有符合条件的。 1.转移很少见。 2.它被封装。 3.它具有高度转移性。 4.它的特点​​是局部入侵。 5.病变是颜色改变的痣。 3 5 原理：黑色素瘤是色素性恶性病变，起源于表皮产生黑色素的细胞。病变是颜色改变的痣。这种皮肤癌具有高度转移性，一个人的生存取决于早期诊断和治疗。基底细胞癌出现在表皮的基底细胞层。早期恶性基底细胞病变通常不被注意到，尽管转移很少见，但潜在的组织破坏可能会发展到包括重要结构。鳞状细胞癌是表皮的恶性肿瘤。它们的特征在于局部浸润和转移的可能性。

2. Adapalene: Similar to tretinoin and sensitizes the skin to UV light; adverse effects include burning and itching after application, redness, dryness, and scaling of the skin. Initially may worsen acne; benefits seen in 8 to 12 weeks. 3. Tazarotene a) Is a derivative of vitamin A (vitamin A supplements should be discontinued during therapy) b) In addition to acne, it is used to treat wrinkles and psoriasis. c) Can cause itching, burning, and dry skin and sensitizes the skin to UV light. 4. Azelaic acid can cause burning, itching, stinging, and redness of the skin; it can also cause hypopigmentation of the skin in clients with a dark complexion. D) Oral antibiotics 1. Includes doxycycline, minocycline, tetracycline, and erythromycin. 2. Improvement develops slowly with the use of oral antibiotics and may take 3 to 6 months for some improvement to be noted; following control of symptoms, the client is usually switched to a topical antibiotic.

2. Adapalene：类似于维甲酸，可使皮肤对紫外线敏感。不良影响包括涂抹后灼痛和瘙痒，发红，干燥和皮肤鳞屑。最初可能会使粉刺恶化；在8到12周内看到的好处。 3.他扎罗汀 a）是维生素A的衍生物（治疗期间应停用维生素A补充剂） b）除粉刺外，它还可用于治疗皱纹和牛皮癣。 c）可能引起皮肤瘙痒，灼热和干燥，并使皮肤对紫外线敏感。 4.壬二酸会引起灼痛，瘙痒， 刺痛和发红；它还会导致肤色较深的客户皮肤色素沉着不足。 D）口服抗生素 1.包括强力霉素，米诺环素，四环素和红霉素。 2.口服抗生素的改善缓慢，可能需要3到6个月的时间才能观察到改善。在症状得到控制后，服务对象通常会改用局部抗生素。

2. Interventions a) Monitor for tracheal or laryngeal edema and administer respiratory treatments as prescribed. b) Monitor the pulse oximetry and prepare for arterial blood gas and carboxyhemoglobin levels if inhalation injury is suspected. c) Elevate the head of the bed to 30 degrees or more for burns of the face and head. d) Monitor for fluid overload and pulmonary edema. e) Initiate electrocardiographic monitoring. f) Monitor the temperature and check for infection. g) Initiate protective isolation techniques; maintain strict handwashing; use sterile sheets and linens when caring for the client; and use gloves, cap, masks, shoe covers, scrub clothes, and plastic aprons. h) Clip body hair around wound margins. i) Monitor daily weights, expecting a weight gain of 15 lbs to 20 lbs during the first 72 hours. j) Monitor gastric output and pH levels and for gastric discomfort and bleeding, indicating a stress ulcer. k) Administer antacids, H - 2 receptor antagonists, and antiulcer medications such as prescribed to prevent a stress ulcer. l) Auscultate the bowel sounds for ileus and monitor for abdominal distention and gastrointestinal dysfunction. m) Monitor stools for occult blood. n) Obtain a urine specimen for myoglobin and hemoglobin levels.

2.干预 a）监测气管或喉头水肿，并按规定进行呼吸治疗。 b）监测脉搏血氧饱和度，如果怀疑有吸入性损伤，则准备动脉血气和羧基血红蛋白水平。 c）将床头抬高至30度或更高，以烧伤面部和头部。 d）监测体液超负荷和肺水肿。 e）启动心电图监测。 f）监测温度并检查是否感染。 g）启动保护隔离技术；保持严格的洗手；照顾客户时使用无菌的床单和床单；并使用手套，帽子，口罩，鞋套，磨砂衣服和塑料围裙。 h）将体毛剪在伤口边缘周围。 i）监控每日体重，预计在前72个小时内体重增加15磅到20磅。 j）监测胃排泄物和pH值以及胃部不适和出血，表明有应激性溃疡。 k）服用抗酸药，H-2受体拮抗剂和抗溃疡药，如预防应激性溃疡的处方药。 l）听诊肠梗阻并监测腹胀和胃肠道功能障碍。 m）监测大便中潜血。 n）获得尿液样本中的肌红蛋白和血红蛋白水平。

3. Deep partial-thickness burn: a) Extends deeper into the skin dermis b) Blister formation usually does not occur because the dead tissue layer is thick and sticks to the underlying viable dermis. c) Wound surface is red and dry with white areas in deeper parts. d) May or may not blanch, and edema is moderate. e) Can convert to a full-thickness burn when tissue damage increases with infection, hypoxia, or ischemia. f) Generally heals in 3 to 6 weeks, but scar formation results and skin grafting may be necessary. 4. Full-thickness burn: a) Involves injury and destruction of the epidermis and the dermis; the wound will not heal by reepithelialization and grafting may be required. b) Appears as a dry, hard, leathery eschar (burn crust or dead tissue must slough off or be removed from the wound before healing can occur). c) Appears waxy white, deep red, yellow, brown, or black. d) Injured surface appears dry. e) Edema is present under the eschar. f) Sensation is reduced or absent because of nerve ending destruction. g) Healing may take weeks to months and depends on establishing an adequate blood supply. h) Scarring and wound contractures are likely to develop. 5. Deep full-thickness burn: a) Injury extends beyond the skin into underlying fascia and tissues, and muscle, bone, and tendons are damaged. b) Injured area appears black and the sensation is completely absent. c) Eschar is hard and inelastic. d) Healing takes months and grafts are required.

3.局部烧伤较深： a）深入皮肤真皮 b）通常不会发生水疱，因为死组织层很厚并粘在下面的活真皮上。 c）伤口表面为红色且干燥，在较深的部分带有白色区域。 d）可能会发烫或可能不会发烫，并且水肿是中度的。 e）当组织损伤随感染，缺氧或局部缺血而增加时，可转变为全层烧伤。 f）通常会在3到6周内，愈，但可能需要形成疤痕和植皮。 4.全层烧伤： a）涉及表皮和真皮的损伤和破坏；伤口将无法通过再上皮愈合，可能需要移植。 b）表现为干燥，坚硬，皮革状的焦char（灼伤的硬皮或死组织必须脱落或从伤口上清除，然后才能愈合）。 c）呈现蜡状白色，深红色，黄色，棕色或黑色。 d）受伤的表面显得干燥。 e）焦char下存在水肿。 f）由于神经末梢的破坏，感觉减少或消失。 g）may愈可能需要数周至数月，并取决于建立足够的血液供应。 h）可能会形成疤痕和伤口挛缩。 5.深层全烧伤： a）伤害超出了皮肤范围，延伸至下面的筋膜和组织，并且肌肉，骨骼和肌腱受到了损害。 b）受伤的部位显示为黑色，并且完全没有感觉。 c）焦char坚硬而无弹性。 d）愈合需要几个月的时间，并且需要移植。

3. Débridement: a) Débridement is the removal of eschar or necrotic tissue to prevent bacterial proliferation under the eschar and to promote wound healing. b) Débridement may be mechanical, enzymatic, or surgical. c) Deep partial- or full-thickness burns: Wound is cleansed and débrided, and topical antimicrobial agents are applied once or twice daily.

3.清创术： a）清创是除去焦痂或坏死组织，以防止焦痂下细菌增殖和促进伤口愈合。 b）清创术可以是机械的，酶的或外科的。 c）深部或全层深度烧伤：清洗伤口并进行清创术，每天局部应用抗菌剂一次或两次。

5. Maintain NPO status, as prescribed, until bowel sounds return. 6. Monitor for continuous urine flow (30-60 mL/hour). 7. The RN is notified if the urine output is less than 30 mL/hour or if there is no urine output for more than 15 minutes. 8. Ureteral stents or catheters may be in place for 2 to 3 weeks or until healing occurs; maintain the stability of catheters to prevent dislodgment. 12. Monitor for hematuria. 13. Monitor for signs of peritonitis. 14. Monitor for bladder distention after a partial cystectomy. 15. Monitor for shock, hemorrhage, thrombophlebitis, and lower-extremity lymphedema after a radical cystectomy. 16. Monitor the urinary drainage pouch for leaks, and check the skin integrity. 17. Monitor urine pH (do not place the dipstick into the stoma), because highly alkaline or acidic urine can cause skin irritation and facilitate crystal formation. 18. Reinforce instructions to the client regarding the potential for urinary tract infection or the development of calculi. 19. Reinforce instructions to the client to check the skin for irritation and to monitor the urinary drainage pouch for any leakage.

5.按照规定保持NPO状态，直到肠鸣音恢复。 6.监测持续的尿液流量（30-60 mL /小时）。 7.如果尿量少于30毫升/小时或超过15分钟无尿量，则通知RN。 8.输尿管支架或导管可放置2至3周或直到愈合。保持导管的稳定性，防止移位。 12.监测血尿。 13.监测腹膜炎的体征。 14.进行部分膀胱切除术后监测膀胱膨胀。 15.根治性膀胱切除术后监测休克，出血，血栓性静脉炎和下肢淋巴水肿。 16.监测尿液引流袋是否泄漏，并检查皮肤完整性。 17.监测尿液的pH值（不要将量油尺放入造口中），因为高度碱性或酸性的尿液会刺激皮肤并促进晶体形成。 18.加强对患者的指示，说明其可能引起尿路感染或结石。 19.加强对服务对象的指示，以检查皮肤是否有刺激性，并监测尿液引流袋是否有渗漏。

6. Turn and reposition the immobile client every 2 hours, or more frequently if necessary; provide active and passive range-of-motion exercises at least every 8 hours. 7. If a pressure injury is present, record the location and size of the wound (length, width, depth), monitor and record the type and amount of exudates (a culture of the exudate may be prescribed), and check for undermining and tunneling. 8. Serosanguineous exudate (blood-tinged amber fluid) is expected for the first 48 hours; purulent exudates indicate colonization of the wound with bacteria. 9. Use agency protocols for skin assessment and management of a wound. 10. Treatment may include wound dressings and débridement procedures; skin grafting may be necessary. 11. Other treatments may include electrical stimulation to the wound area (increases blood vessel growth and stimulates granulation), vacuum-assisted wound closure (removes infectious material from the wound and promotes granulation), hyperbaric oxygen therapy (administration of oxygen under high pressure raises tissue oxygen concentration), and the use of topical growth factors (biologically active substances that stimulate cell growth).

6.每2小时或在必要时更频繁地转动不动的客户并重新定位。至少每8小时提供一次主动和被动的运动范围练习。 7.如果存在压力伤害，请记录伤口的位置和大小（长度，宽度，深度），监控并记录渗出液的类型和数量（可以规定渗出液的培养方法），并检查是否破坏和隧道。 8.预计头48小时会出现浆液性渗出液（琥珀色的血液）。化脓性渗出液表明细菌在伤口上定植。 9.使用代理协议进行皮肤评估和伤口处理。 10.治疗方法可能包括伤口敷料和清创术。可能需要植皮。 11.其他治疗方法可能包括对伤口区域进行电刺激（增加血管生长并刺激肉芽形成），真空辅助伤口闭合（从伤口中清除感染性物质并促进肉芽形成），高压氧疗法（在高压下施用氧气）组织氧浓度），以及使用局部生长因子（刺激细胞生长的生物活性物质）。

7▪ Discontinue continuous bladder irrigation and indwelling urinary catheter as prescribed, usually 24 to 48 hours after surgery. 8▪ Monitor for continence and urinary retention when the catheter is removed; inform the client that some burning, frequency, and dribbling may occur after catheter removal. 9▪ Inform the client that he should be voiding 150 mL to 200 mL of clear yellow urine every 3 to 4 hours by 3 days after surgery. 10▪ Inform the client that he may pass small clots and tissue debris for several days. 11▪ Instruct the client, as prescribed, to avoid heavy lifting, stressful exercise, driving, the Valsalva's maneuver, and sexual intercourse for 2 to 6 weeks to prevent strain. 12▪ Instruct the client to call the PHCP if bleeding occurs or if there is a decrease in the urinary stream. 13▪ Encourage the client to drink 2400 to 3000 mL of fluid each day, preferably before 8:00 pm to prevent nocturia. 14▪ Instruct the client to avoid alcohol, caffeinated beverages, and spicy foods to prevent the overstimulation of the bladder. 15▪ Reinforce instructions to the client that if the urine becomes bloody, he should rest and increase the fluid intake; if the bleeding does not subside, he should notify the PHCP.

7▪通常在手术后24至48小时，按规定停止连续膀胱冲洗和留置导尿管。 8■取下导管后，监测尿失禁和尿retention留；告知服务对象在移开导管后可能会发生灼伤，发声和盘带。 9▪告知服务对象，他应在手术后3天每3至4小时排空150 mL至200 mL透明黄色尿液。 10▪告知服务对象，他可能会连续几天通过小块和组织碎屑。 11▪按规定指示服务对象，避免沉重的举重，压力大的运动，驾驶，Valsalva的动作和性交，持续2至6周，以防止劳累。 12▪如果发生出血或尿流减少，指示服务对象致电PHCP。 13■鼓励服务对象每天喝2400到3000 mL液体，最好是在晚上8:00之前喝以预防夜尿。 14▪指导服务对象避免饮酒，含咖啡因的饮料和辛辣食物，以防止膀胱过度刺激。 15■加强对服务对象的指示，即如果尿液带血，应休息并增加液体摄入量；如果出血没有缓解，他应通知PHCP。

8. Provide the use of a pressure sleeve, as prescribed if edema is severe. 9. Maintain fluid and electrolyte balance; administer diuretics and provide a low-salt diet, as prescribed, for severe lymphedema. 10. Consult with the RN and the physical therapist regarding prescribed exercise. 11. Reinforce instructions regarding home-care measures. 12. No IVs, no injections, no blood pressure measurements, and no venipunctures should be done on the arm on the side of the mastectomy. The arm on the side of the mastectomy is protected, and any intervention that could traumatize the affected arm is avoided because of the risk for lymphedema.

8.如果水肿严重，则按规定使用压力套筒。 9.保持体液和电解质平衡； 遵医嘱使用利尿剂并提供低盐饮食，以应对严重的淋巴水肿。 10.有关规定的锻炼，请咨询RN和物理治疗师。 11.加强有关家庭护理措施的说明。 12.不应在乳房切除术一侧的手臂上进行静脉注射，不打针，不进行血压测量和静脉穿刺。 乳房切除术一侧的手臂受到了保护，并且避免了可能使患处受伤的任何干预措施，因为存在淋巴水肿的风险。

8. Monitor for hypovolemia and prepare to administer fluids intravenously to maintain the fluid balance. 9. Monitor the vital signs closely. j) Insert a Foley catheter as prescribed and maintain urine output at 30 mL to 50 mL per hour. 10. Maintain NPO (nothing by mouth) status. 11. Insert a nasogastric tube as prescribed to remove gastric secretions and prevent aspiration. 12. Administer tetanus prophylaxis as prescribed. 13. Administer pain medication, as prescribed, via the IV route. 14. Administer pain medication before dressings changes and procedures. 15. Prepare the client for an escharotomy or fasciotomy as prescribed.

8.监测血容量不足并准备静脉内输液以维持体液平衡。 9.密切监视生命体征。 j）按规定插入Foley导管，并保持每小时30 mL至50 mL的尿量。 10.保持NPO（无口腔）状态。 11.按规定插入鼻胃管以清除胃液分泌并防止误吸。 12.按规定管理预防破伤风。 13.按照规定，通过静脉注射途径使用止痛药。 14.在更换敷料和程序之前，先服用止痛药。 15.按照规定，为委托人准备切开或筋膜切开术。

A) Metastasis: 1. Cancer cells move from their original location to other sites. 2. Routes of metastasis a) Local seeding: Distribution of shed cancer cells occurs in the local area of the primary tumor. b) Blood-borne metastasis: Tumor cells enter the blood; this is the most common cause of cancer spread. c) Lymphatic spread: Primary sites rich in lymphatics are more susceptible to early metastatic spread. B) Cancer classification 1. Solid tumors: Associated with the organs from which they develop, such as breast cancer or lung cancer 2. Hematologic cancers: Originate from blood cell-forming tissues, such as the leukemias, lymphomas, and multiple myeloma C) Grading and staging: 1. Grading and staging are methods used to describe the tumor. 2. These methods describe the extent of the tumor, the extent to which malignancy has increased in size, the involvement of regional nodes, and metastatic development. 3. Grading a tumor classifies the cellular aspects of the cancer and is an indicator of tumor growth rate and spread. 4. Staging classifies the clinical aspects of the cancer and degree of metastasis at diagnosis.

A）转移： 1.癌细胞从其原始位置移动到其他位置。 2.转移途径 a）局部播种：脱落的癌细胞分布在原发肿瘤的局部区域。 b）血源性转移：肿瘤细胞进入血液；这是癌症扩散的最常见原因。 c）淋巴扩散：富含淋巴的原发部位更容易发生早期转移扩散。 B）癌症分类 1.实体瘤：与它们发生发展的器官相关，例如乳腺癌或肺癌 2.血液系统癌症：起源于血细胞形成组织，例如白血病，淋巴瘤和多发性骨髓瘤 C）分级和分期： 1.分级和分期是用来描述肿瘤的方法。 2.这些方法描述了肿瘤的范围，恶性肿瘤增大的程度，区域淋巴结的累及和转移的发展。 3.肿瘤分级对癌症的细胞方面进行分类，是肿瘤生长速率和扩散的指标。 4.分期对癌症的临床方面和诊断时的转移程度进行分类。

B) Carbon monoxide poisoning 1. Description a) Carbon monoxide is a colorless, odorless, and tasteless gas that has an affinity for hemoglobin 200 times greater than that of oxygen. b) Oxygen molecules are displaced and carbon monoxide reversibly binds to hemoglobin to form carboxyhemoglobin. c) Tissue hypoxia occurs.

B）一氧化碳中毒 1.说明 a）一氧化碳是一种无色，无味和无味的气体，对血红蛋白的亲和力是氧气的200倍。 b）氧分子被置换，一氧化碳可逆地与血红蛋白结合形成羧基血红蛋白。 c）发生组织缺氧。

B) Topical antibiotic products 1. Benzoyl peroxide a) Can produce drying and peeling b) Severe local irritation (burning, blistering, scaling, swelling) may require reducing the frequency of application. c) Some products may contain sulfites; monitor for serious allergic reactions. 2. Clindamycin and erythromycin a) Both products are antibiotics that suppress the growth of P. acnes. b) Combination therapy with benzoyl peroxide prevents the emergence of resistant bacteria; fixed-dose combinations include clindamycin/benzoyl peroxide and erythromycin/benzoyl peroxide. 3. Dapsone: Side and adverse effects include oiliness, peeling, dryness, and erythema of the skin (oral form of medication is used to treat leprosy). C) Topical retinoids: 1. Tretinoin a) A derivative of vitamin A (vitamin A supplements should be discontinued during therapy). b) In addition to treating acne, it may be prescribed to reduce fine wrinkles, skin roughness, and mottled hyperpigmentation as with age spots. c) Can cause localized adverse effects such as blistering, peeling, crusting, burning, and swelling of the skin. d) Abrasive products and keratolytic products are discontinued before using tretinoin to decrease localized adverse effects. e) Instruct the client to apply a sunscreen with an SPF of 15 or greater and to wear protective clothing when outdoors because of sensitivity to UV light.

B）外用抗生素产品 1.过氧化苯甲酰 a）会产生干燥和脱皮 b）严重的局部刺激（燃烧，起泡，结垢，肿胀）可能需要减少使用频率。 c）有些产品可能含有亚硫酸盐；监测严重的过敏反应。 2.克林霉素和红霉素 a）两种产品都是抑制痤疮丙酸杆菌生长的抗生素。 b）与过氧化苯甲酰联合使用可防止耐药菌的出现；固定剂量组合包括克林霉素/过氧化苯甲酰和红霉素/过氧化苯甲酰。 3.氨苯砜：副作用包括油腻，脱皮，干燥和皮肤红斑（口服药物用于治疗麻风病）。 C）外用维甲酸： 1.维甲酸 a）维生素A的衍生物（治疗期间应停用维生素A补充剂）。 b）除治疗痤疮外，还可以减少皱纹，皮肤粗糙和斑驳的色素沉着。 c）可能引起局部不良影响，例如皮肤起泡，脱皮，结s，灼热和肿胀。 d）在使用维甲酸之前减少磨料产品和角质蛋白产品以减少局部不良影响。 e）指示客户在户外使用SPF为15或更高的防晒霜，并由于对紫外线敏感而穿着防护服。

B) Data collection 1. Bone (skeletal) pain, especially in the pelvis, spine, and ribs. 2. Weakness and fatigue 3. Recurrent infection 4. Anemia 5. Urinalysis shows Bence Jones proteinuria and elevated total serum protein level 6. Osteoporosis (bone loss and the development of pathological fractures) 7. Thrombocytopenia and leukopenia 8. Elevated calcium and uric acid levels 9. Kidney failure 10. Spinal cord compression and paraplegia 11. Bone marrow aspiration shows an abnormal number of immature plasma cells. 12. The client with multiple myeloma is at risk for pathological fractures. Therefore, provide skeletal support during moving, turning, and ambulating, and provide a hazard-free environment.

B）数据收集 1.骨（骨骼）疼痛，特别是骨盆，脊柱和肋骨。 2.虚弱和疲劳 3.反复感染 4.贫血 5.尿液分析显示Bence Jones蛋白尿和总血清蛋白水平升高 6.骨质疏松症（骨质流失和病理性骨折的发展） 7.血小板减少症和白细胞减少症 8.钙和尿酸水平升高 9.肾衰竭 10.脊髓压迫和截瘫 11.骨髓抽吸显示异常数量的未成熟浆细胞。 12.多发性骨髓瘤患者有发生病理性骨折的风险。 因此，在移动，转弯和移动时应提供骨骼支撑，并提供无危险的环境。

B) Nonbiological 1. Artificial Skin ▪ Artificial skin consists of two layers: a Silastic epidermis and a porous dermis made from bovine hide collagen and shark cartilage. ▪ After application, fibroblasts move into the collagen part of the artificial skin and create a structure that is similar to that of normal dermis. ▪ The artificial dermis then dissolves and is replaced with normal blood vessels and connective tissue called neodermis. ▪ The neodermis supports a standard autograft that is placed over it when the Silastic layer is removed. 2. Biosynthetic ▪ This type of covering is made of a combination of biosynthetic and synthetic materials. ▪ It is placed in contact with the wound surface and it forms an adherent bond until epithelialization has occurred. ▪ Its porous substance allows exudate to pass through it. ▪ Monitor for wound exudate and signs of infection. 3. Synthetic ▪ Synthetic coverings are applied directly to the surface of a clean or surgically prepared wound and they remain in place until they fall off or are removed. ▪ The covering is transparent or translucent; therefore, the wound can be inspected without removing the dressing. ▪ Pain at the wound site is reduced because the covering prevents the contact of the wound with air.

B）非生物 1.人造皮肤 ▪人造皮肤包括两层：硅橡胶表皮和由牛皮革胶原蛋白和鲨鱼软骨制成的多孔真皮。 ▪涂抹后，成纤维细胞进入人造皮肤的胶原蛋白部分，并形成与正常真皮相似的结构。 ▪然后，人造真皮溶解并被正常血管和称为新生真皮的结缔组织代替。 ▪去除硅橡胶层后，新真皮支持标准的自体移植物。 2.生物合成 ▪这种覆盖物是由生物合成材料和合成材料制成的。 ▪将其放置在与伤口表面接触的位置，并形成粘附键，直到发生上皮形成。 ▪其多孔物质使渗出液通过。 ▪监测伤口渗出液和感染迹象。 3.合成的 ▪合成覆盖物直接应用于干净或手术准备的伤口表面，并保持在原位，直到掉落或取下。 ▪覆盖物是透明或半透明的；因此，无需移除敷料即可检查伤口。 ▪伤口处的疼痛得以减轻，因为覆盖物可防止伤口与空气接触。

C. Interventions 1. Assist with the administration of chemotherapy as prescribed. 2. Provide supportive care to control symptoms and prevent complications, especially bleeding, bone fractures, kidney failure, and infections. 3. Maintain neutropenic and bleeding precautions, as necessary. 4. Monitor for signs of bleeding, infection, and skeletal fractures. 5. Encourage the consumption of at least 2 L of fluid per day to offset potential problems associated with hypercalcemia, hyperuricemia, and proteinuria, and encourage additional fluid intake as indicated and tolerated. 6. Monitor for signs of kidney failure. Collect 24- hour urine as prescribed. 7. Encourage ambulation to prevent renal problems and slow down bone resorption. 8. IV fluids and diuretics may be prescribed to increase the renal excretion of calcium. 9. Blood transfusions may be prescribed for anemia. 10. Administer analgesics, as prescribed, and provide nonpharmacological therapies to control pain. 11. Administer antibiotics for the infection, as prescribed. 12. Bisphosphonate medications may be prescribed to slow bone damage and reduce pain and risk of fractures. 13. Prepare the client for local radiation therapy, if prescribed. 14. Reinforce instructions to the client regarding homecare measures and the signs and symptoms of infection.

C.干预 1.按照规定协助进行化学疗法。 2.提供支持性护理，以控制症状并预防并发症，尤其是出血，骨折，肾衰竭和感染。 3.必要时保持中性粒细胞减少和出血的预防措施。 4.监测是否有出血，感染和骨骼骨折的迹象。 5.鼓励每天至少消耗2 L的液体以抵消与高钙血症，高尿酸血症和蛋白尿有关的潜在问题，并鼓励按指示并耐受额外的液体摄入。 6.监测肾脏衰竭的迹象。按规定收集24小时尿液。 7.鼓励下床活动以防止肾脏问题并减慢骨骼吸收。 8.可以开IV液和利尿剂以增加钙的肾脏排泄。 9.可以规定输血治疗贫血。 10.按照规定使用镇痛药，并提供非药物疗法来控制疼痛。 11.按照规定管理用于感染的抗生素。 12.可以开具双膦酸盐类药物以减缓骨骼损伤并减轻疼痛和骨折风险。 13.如果有规定，请准备好接受者进行局部放射治疗。 14.加强对客户的指示，说明其家庭护理措施以及感染的体征和症状。

C. Interventions: 1. Avoid direct massage to a reddened skin area because massage can damage the capillary beds and cause tissue necrosis. 2. Institute measures to prevent pressure injuries such as appropriate positioning, using pressure relief devices, ensuring adequate nutrition, and developing a plan for skin cleansing and care. 3. Check the skin frequently and monitor for an alteration in skin integrity. 4. Keep the client's skin dry and the sheets wrinkle-free; if the client is incontinent, check him or her frequently and change pads or any items placed under them immediately after they are soiled. 5. Use creams and lotions to lubricate the skin and a barrier protection ointment for the incontinent client.

C.干预： 1.避免直接按摩到发红的皮肤区域，因为按摩 会损坏毛细血管床并引起组织坏死。 2.制定预防压力伤害的措施，例如适当的定位，使用压力释放装置，确保足够的营养以及制定皮肤清洁和护理计划。 3.经常检查皮肤，并监测皮肤完整性的变化。 4.保持服务对象的皮肤干燥，床单无皱纹；如果服务对象大小便失禁，请经常检查他或她，并在弄脏后立即更换垫子或放置在其下面的任何物品。 5.使用乳膏和乳液润滑皮肤，并为失禁患者提供屏障保护药膏。

C) Data collection 1. Mass felt during breast self-examination (BSE) (usually felt in the upper outer quadrant, beneath the nipple, or in axilla) 2. Presence of the lesion on mammography. 3. A fixed, irregular nonencapsulated mass; typically painless except in the late stages 4. Asymmetry, with the affected breast being higher. 5. Nipple retraction or elevation 6. Bloody or clear nipple discharge 7. Skin dimpling, retraction, or ulceration 8. Skin edema or peau d'orange skin, which may indicate lymphatic involvement (blocked skin drainage causes skin edema and an "orange peel" appearance). 9. Axillary lymphadenopathy 10. Lymphedema of the affected arm 11. Symptoms of bone or lung metastasis in late-stage D) Early Detection: Regular BSE 1. Perform regularly 7 to 10 days after menses 2. Postmenopausal clients or clients who have had a hysterectomy should also perform a BSE regularly.

C）数据收集 1.乳房自我检查（BSE）时感觉到肿块（通常在上象限，乳头下或腋窝感觉到） 2.乳房X光检查上是否存在病变。 3.固定的，不规则的未封装质量； 除后期外，通常无痛 4.不对称，患处较高。 5.乳头内陷或抬高 6.血性或乳头清澈 7.皮肤凹陷，回缩或溃疡 8.皮肤水肿或橙红色皮肤，这可能表示淋巴受累（皮肤排泄障碍导致皮肤水肿和"橙皮"外观）。 9.腋窝淋巴结肿大 10.受累手臂的淋巴水肿 11.晚期骨或肺转移的症状 d）早期检测：普通BSE 1.月经后7至10天定期进行 2.绝经后客户或进行子宫切除的客户也应定期进行BSE。

C) Data collection 1. Abnormal bleeding, especially in postmenopausal women 2. Vaginal discharge 3. Low back, pelvic, or abdominal pain (pain occurs late in the disease process) 4. Enlarged uterus (in advanced stages) D) Nonsurgical interventions 1. External radiation or internal radiation (intracavitary radiation), used alone or in combination with surgery, depending on the stage of cancer 2. Chemotherapy to treat advanced or recurrent disease 3. Progesterone therapy with medication for estrogen-dependent tumors may be prescribed. 4. Antiestrogen medication may also be prescribed. E) Surgical interventions: Total abdominal hysterectomy and bilateral salpingo-oophorectomy

C）数据收集 1.异常出血，尤其是绝经后妇女 2.阴道分泌物 3.下背部，骨盆或腹痛（疼痛发生在疾病过程的后期） 4.子宫扩大（晚期） D）非手术干预 1.外部放射线或内部放射线（腔内放射线），可以单独使用，也可以与手术结合使用，具体取决于癌症的阶段 2.化学疗法治疗晚期或复发性疾病 3.可以开具治疗雌激素依赖性肿瘤的孕激素疗法。 4.也可以开抗雌激素药物。 E）外科手术：全腹子宫切除术和双侧输卵管卵巢切除术

C) Data collection 1. Painless vaginal bleeding, postmenstrually, and postcoitally (after sexual intercourse). 2. Foul-smelling or serosanguineous vaginal discharge. 3. Pelvic, lower back, leg, or groin pain 4. Anorexia and weight loss 5. Leakage of urine and feces from the vagina 6. Dysuria (painful urination) 7. Hematuria 8. Cytological changes on Pap test D) Cryosurgery 1. Involves freezing of the tissues by a probe with subsequent necrosis. 2. No anesthesia is required, although cramping may occur during the procedure. 3. A heavy, watery discharge will occur for several weeks after the procedure. 4. Reinforce instructions to the client to avoid intercourse and the use of tampons while the discharge is present. E) Laser therapy 1. Used when all boundaries of the lesion are visible during a colposcopic examination 2. Energy from the beam is absorbed by fluid in the tissues, which causes them to vaporize. 3. Minimal bleeding is associated with the procedure. 4. Slight vaginal discharge is expected after the procedure; healing occurs in 6 to 12 weeks.

C）数据收集 1.月经后和性交后（性交后）无痛阴道出血。 2.恶臭或血清白带。 3.骨盆，下背部，腿部或腹股沟疼痛 4.厌食和体重减轻 5.尿液和粪便从阴道漏出 6.排尿困难（排尿疼痛） 7.血尿 8.巴氏试验的细胞学变化 D）冷冻手术 1.涉及用探针冷冻组织并随后坏死。 2.尽管手术过程中可能会出现抽筋，但无需麻醉。 3.手术后数周，大量的水样会排出。 4.加强对服务对象的指示，避免在有排出物的情况下进行性交和使用棉塞。 E）激光疗法 1.在阴道镜检查时可见病灶的所有边界时使用 2.光束中的能量被组织中的流体吸收，从而使它们蒸发。 3.与手术相关的出血最少。 4.手术后预期会有少量白带；愈合发生在6到12周内。

C) Preoperative interventions 1. Reinforce instructions about preoperative, operative, and postoperative management, including diet, medications, nasogastric tube placement, IV lines, NPO status, pain control, coughing and deep breathing, leg exercises, and postoperative activity. 2. Assist the RN to demonstrate appliance application and use for those clients who will have a stoma. 3. Arrange an enterostomal nurse consult and for a visit with a person who has had urinary diversion. 4. Antimicrobials for bowel preparation are administered as prescribed. 5. Encourage discussion of feelings, including the effects on sexual activities. D) Postoperative interventions 1. Monitor urinary output closely following bladder surgery. Assist the RN with the irrigation of the ureteral catheter (if present and prescribed) gently to prevent obstruction. 2. Check the stoma (it should be red and moist) every hour for the first 24 hours. 3. If the stoma appears dark and dusky, notify the RN and the PHCP immediately, because this indicates necrosis. 4. Monitor for the return of bowel function; monitor for peristalsis, which will return in 3 to 4 days.

C）术前干预 1.加强有关术前，术中和术后管理的说明，包括饮食，药物，鼻胃管放置，静脉输液管，NPO状态，疼痛控制，咳嗽和深呼吸，腿部锻炼以及术后活动。 2.协助RN为有气孔的客户演示设备的应用和使用。 3.安排一名肠口护士咨询并拜访有尿流改道的人。 4.按规定使用肠道准备用抗菌剂。 5.鼓励讨论感情，包括对性活动的影响。 D）术后干预 1.膀胱手术后应密切监测尿量。协助RN轻轻冲洗输尿管导管（如果存在且有处方），以防止阻塞。 2.在最初的24小时内每小时检查一次造口（应该是红色和潮湿的）。 3.如果气孔显得暗淡和阴暗，请立即通知RN和PHCP，因为这表明坏死。 4.监测肠功能的恢复；监测蠕动，蠕动将在3到4天内恢复。

C) Burn depth 1. Superficial-thickness burn: a) Involves injury to the epidermis; the blood supply to the dermis is still intact. b) Mild to severe erythema (pink to red) is present, but no blisters. c) The skin blanches with pressure. d) Burn is painful, with a tingling sensation, and the pain is eased by cooling. e) Discomfort lasts about 48 hours; healing occurs in about 3 to 6 days. f) No scarring occurs and skin grafts are not required. 2. Superficial partial-thickness burn: a) Involves injury deeper into the dermis; the blood supply is reduced b) Large blisters may cover an extensive area. c) Edema is present. d) Mottled pink to red base and a broken epidermis, with a wet, shiny, and weeping surface is characteristic. e) Burn is painful and sensitive to cold air. f) Heals in 10 to 21 days with no scarring, but some minor pigment changes may occur. g) Grafts may be used if the healing process is prolonged.

C）烧录深度 1.浅层烧伤： a）伤害表皮；真皮的血液供应仍然完好无损。 b）存在轻度至严重的红斑（粉红色至红色），但没有水泡。 c）皮肤因压力而变白。 d）烧伤很痛，有刺痛感，并且通过冷却减轻疼痛。 e）不适持续约48小时；愈合大约需要3到6天。 f）没有疤痕发生，不需要植皮。 2.浅层局部烧伤： a）使伤害更深地进入真皮；血液供应减少 b）大水泡可能覆盖大面积区域。 c）出现水肿。 d）特征是斑驳的粉红色到红色基部和表皮破裂，表面湿润，有光泽和垂泪。 e) 烧伤很痛，对冷空气很敏感。 F) 可在10到21天之内愈，无疤痕，但可能会发生一些轻微的色素变化。 G) 如果愈合过程延长，可以使用嫁接。

C) direct thermal heat injury: 1. description: a) Thermal heat injury can occur to the lower airways by the inhalation of steam or explosive gases, or the aspiration of scalding liquids. b) Injury can occur to the upper airways, which appear erythematous and edematous, with mucosal blisters and ulcerations. c) Mucosal edema can lead to upper airway obstruction, especially during the first 24 to 48 hours. d) All clients with head or neck burns should be monitored closely for the development of airway obstruction and are considered immediately for endotracheal intubation if obstruction occurs. 2. data collection: a) Erythema and edema of the upper airways b) Mucosal blisters and ulcerations

C）直接热损伤： 1.说明： a）吸入蒸汽或爆炸性气体或吸入烫伤液体，可能会对下呼吸道造成热损伤。 b）上呼吸道可能会受伤，表现为红斑和水肿，并伴有粘膜水泡和溃疡。 c）粘膜水肿可导致上呼吸道阻塞，尤其是在最初的24至48小时内。 d）应密切监测所有头部或颈部烧伤的患者的气道阻塞情况，如果发生阻塞，应立即考虑进行气管插管。 2.数据收集： a）上呼吸道红斑和水肿 b）黏膜水泡和溃疡

C) Nonsurgical interventions 1. Prepare the client for hormone manipulation therapy (androgen suppression therapy) as prescribed or active surveillance with prostate- specific antigen (PSA and digital rectal examination (DRE). 2. Luteinizing hormone may be prescribed to slow the rate of growth of the tumor. 3. Medication adverse effects include reduced libido, hot flashes, breast tenderness, osteoporosis, loss of muscle mass, and weight gain. The client should be informed of these effects. 4. Pain medication, radiation therapy, corticosteroids, and bisphosphonates may be prescribed for palliation of advanced prostate cancer. 5. Prepare the client for external beam radiation or brachytherapy, which may be prescribed alone or with surgery, preoperatively or postoperatively, to reduce the lesion and limit metastasis. 6. Prepare the client for the administration of chemotherapy in cases of hormone-resistant tumors. D. Surgical interventions 1. Prepare the client for orchiectomy (palliative), if prescribed, which will limit the production of testosterone. 2. Prepare the client for prostatectomy if prescribed. 3. The radical prostatectomy can be performed via a retropubic, perineal, or suprapubic approach, and may involve minimally invasive robotic surgery. 4. Cryosurgical ablation is a minimally invasive procedure that may be an alternative to radical prostatectomy; liquid nitrogen freezes the gland, and the dead cells are absorbed by the body.

C）非手术干预 1.为患者准备按处方进行的激素操纵疗法（雄激素抑制疗法）或使用前列腺特异抗原（PSA和直肠指检（DRE））进行主动监护。 2.可能开具促黄体激素以减慢肿瘤的生长速度。 3.药物不良反应包括性欲减退，潮热，乳房胀痛，骨质疏松，肌肉量减少和体重增加。应将这些影响告知服务对象。 4.可以处方镇痛药，放疗，糖皮质激素和双膦酸盐治疗晚期前列腺癌。 5.为服务对象准备外部束放射或近距离放射疗法，可以在手术前或术后单独或配合手术处方，以减少病变并限制转移。 6.在出现激素抵抗性肿瘤的情况下，准备好接受化疗的服务对象。 D.手术干预 1.如果有处方，则为客户准备睾丸切除术（姑息性），这将限制睾丸激素的产生。 2.如果有处方，请准备好患者进行前列腺切除术。 3.可以通过耻骨后，会阴或耻骨上方法进行前列腺癌根治术，并且可能涉及微创机器人手术。 4.冷冻消融术是一种微创手术，可以替代前列腺癌根治术。液氮使腺体冻结，死细胞被人体吸收。

D) Systemic adverse effects 1. Growth retardation in children 2. Adrenal suppression 3. Cushing's syndrome 4. Striae, skin atrophy 5. Ocular effects (glaucoma and cataracts) E) Interventions 1. Monitoring plasma cortisol levels may be prescribed if prolonged therapy is necessary. 2. Wash the area just before application to increase medication penetration. 3. Apply sparingly in a thin film, rubbing gently. 4. Avoid use of a dry occlusive dressing unless specifically prescribed by the primary health care provider (PHCP). 5. Instruct client to report signs of adverse effects to the PHCP. 6. In the adult, intact skin is generally impermeable to most topical medications. However, medications should not be applied to denuded areas unless prescribed because undesired absorption can occur.

D）全身不良反应 1.儿童发育迟缓 2.肾上腺抑制 3.库欣综合症 4.条纹，皮肤萎缩 5.眼部影响（青光眼和白内障） E）干预 1.如果需要长期治疗，可以开处方监测血浆皮质醇水平。 2.刚使用前要清洗该区域，以增加药物渗透性。 3.少量涂抹于薄膜上，轻轻摩擦。 4.除非基层医疗服务提供者（PHCP）明确规定，否则请避免使用干燥的闭塞敷料。 5.指示客户向PHCP报告不良影响的迹象。 6.在成年人中，大多数局部药物通常不能渗透完整的皮肤。 但是，除非有规定，否则不应在裸露区域使用药物，因为会发生不希望的吸收。

D) Postoperative interventions 1. Monitor for signs of bleeding and wound infection; antibiotics may be administered to prevent wound infection. 2. Monitor intake and output. 3. Provide and explain pain management methods; to reduce swelling in the first 48 hours, an ice pack may be prescribed (wrap in a protective layer of cloth). 4. Notify the RN if chills, fever, increasing pain or tenderness at the incision site, or drainage from the incision occurs. 5. After the orchiectomy, the client will be instructed to avoid heavy lifting and strenuous activity for the length of time prescribed by the PHCP. 6. Instruct the client to perform a monthly testicular self-examination on the remaining testicle. 7. Inform the client that sutures will be removed approximately 7 to 10 days after surgery.

D）术后干预 1.监测出血和伤口感染的迹象； 抗生素可用于 防止伤口感染。 2.监视进气和排气。 3.提供并解释疼痛管理方法； 为了减少头48小时内的肿胀，可开具冰袋（用布套保护层包裹）。 4.如果在切口部位发冷，发烧，疼痛或压痛加剧或切口引流，请通知RN。 5.睾丸切除术后，应指示服务对象在PHCP规定的时间内避免沉重的举重和剧烈的活动。 6.指导服务对象每月对剩余的睾丸进行睾丸自我检查。 7.告知服务对象手术后约7至10天将删除缝合线。

D) Colostomy, ileostomy 1. Preoperative interventions a) Consultation with the enterostomal therapist may be necessary to assist with identifying the optimal placement of the ostomy. b) Instruct the client in the prescribed preoperative diet; bowel preparation (laxatives and enemas) may be prescribed. c) Intestinal antiseptics and antibiotics may be prescribed (per surgeon's preference) to decrease the bacterial content of the colon and to reduce the risk of infection from the surgical procedure. 2. Postoperative: Colostomy a) If a pouch system is not in place, apply a petroleum jelly gauze over the stoma to keep it moist, and keep it covered by a dry sterile dressing; place a pouch system on the stoma as soon as possible. b) Monitor the pouch system for proper fit and signs of leakage; empty the pouch when one-third full. c) Monitor the stoma for size, unusual bleeding, and necrotic tissue. d) Note that the normal stoma color is red or pink, which indicates high vascularity. e) Note that a pale pink stoma indicates low hemoglobin and hematocrit levels. f) Monitor the functioning of the colostomy. g) Expect that stool will be liquid postoperatively, but that it will become more solid, depending on the area of the colostomy.

D）结肠造口术，回肠造口术 1.术前干预 a）可能需要咨询肠胃治疗师，以帮助确定最佳的造口术位置。 b）指导患者进行术前处方饮食；可以规定肠准备（泻药和灌肠剂）。 c）（根据外科医生的喜好）可以开处方肠道杀菌剂和抗生素，以减少结肠的细菌含量并降低手术过程中感染的风险。 2.术后：结肠造口术 a）如果没有安装囊袋系统，则在气孔上涂抹凡士林纱布以使其保持湿润，并用干燥的无菌敷料覆盖它；尽快将小袋系统放在造口上。 b）监测袋系统的正确安装和泄漏迹象；当三分之一装满时，将袋子清空。 c）监测造口的大小，异常出血和坏死组织。 d）注意，正常的造口颜色为红色或粉红色，表明血管高。 e）注意淡粉红色的气孔表明血红蛋白和血细胞比容水平较低。 f）监测结肠造口术的功能。 g）期望粪便在术后会呈液态，但是会变得更坚实，这取决于结肠造口术的面积。

E) Age and general health: 1. Mortality rate is higher for children younger than 4 years old, particularly for children from birth to 1 year of age, and for clients older than 65 years. 2. Debilitating disorders, such as cardiac, respiratory, endocrine, and renal disorders, negatively influence the client's response to injury and treatment. 3. Mortality rate is higher when the client has a preexisting disorder at the time of the burn injury. F) Burn location 1. Burns of the head, neck, and chest are associated with pulmonary complications. 2. Burns of the face are associated with corneal abrasion. 3. Burns of the ear are associated with auricular chondritis. 4. Hands and joints require intensive therapy to prevent disability. 5. The perineal area is prone to auto-contamination by urine and feces. 6. Circumferential burns of the extremities can produce a tourniquet-like effect and lead to vascular compromise (compartment syndrome). 7. Circumferential thorax burns lead to inadequate chest wall expansion and pulmonary insufficiency.

E）年龄和总体健康： 1. 4岁以下儿童的死亡率较高，特别是从出生到1岁的儿童以及65岁以上的客户的死亡率。 2.虚弱的疾病，例如心脏，呼吸系统，内分泌和肾脏疾病，会对服务对象对伤害和治疗的反应产生负面影响。 3.如果客户在烧伤时患有既往疾病，死亡率会更高。 F）烧录位置 1.头部，颈部和胸部的灼伤与肺部并发症有关。 2.面部烧伤与角膜磨损有关。 3.烧伤与耳性软骨炎有关。 4.手和关节需要强化治疗以防止残疾。 5.会阴区容易被尿液和粪便自动污染。 6.四肢的周围烧伤可产生类似止血带的效果，并导致血管受损（房室综合征）。 7.胸廓周围烧伤导致胸壁扩张不足和肺功能不全。

E) Isotretinoin 1. Derivative of vitamin A (vitamin A supplements should be discontinued during therapy); in addition, the use of tetracyclines can increase the risk of adverse effects and should be discontinued before use of isotretinoin. 2. Used to treat severe cystic acne; reserved for persons who have not responded to other therapies, including systemic antibiotics 3. Adverse effects include nosebleeds; inflammation of the lips or eyes; dryness or itching of the skin, nose, or mouth; pain, tenderness, or stiffness in the joints, bones, or muscles; and back pain. 4. Less common adverse effects include rash, hair loss, peeling of the skin, headache, and reduction in night vision. 5. Causes sensitization of the skin to UV light 6. The medication elevates triglyceride levels, which should be measured before and during therapy; alcohol consumption should be eliminated during therapy because alcohol could potentiate elevation of serum triglyceride levels. 7. The medication may cause depression in some clients; if depression occurs, the medication should be discontinued. 8. Isotretinoin is highly teratogenic and can cause fetal abnormalities. If prescribed, the client needs to follow strict rules of the iPLEDGE program. It must not be used if the client is pregnant.

E）异维A酸 1.维生素A的衍生物（治疗期间应停用维生素A补充剂）；此外，使用四环素会增加不良反应的风险，应在使用异维A酸之前停止使用。 2.用于治疗严重的囊性痤疮；保留给对其他疗法（包括全身性抗生素）无反应的人 3.不良反应包括流鼻血；嘴唇或眼睛发炎；皮肤，鼻子或嘴巴干燥或发痒；关节，骨骼或肌肉的疼痛，压痛或僵硬；和背部疼痛。 4.较少见的不良反应包括皮疹，脱发，皮肤脱皮，头痛和夜视力下降。 5.引起皮肤对紫外线敏感。6.药物会升高甘油三酸酯水平， 应该在治疗之前和治疗期间进行测量；治疗期间应避免饮酒，因为饮酒可增强血清甘油三酯水平。 7.药物可能会使某些患者抑郁。如果发生抑郁，应停止用药。 8.异维A酸具有很高的致畸性，可引起胎儿畸形。如果有规定，客户需要遵循iPLEDGE计划的严格规则。如果服务对象怀孕，则不得使用此功能。

E) Postoperative interventions : 1. Monitor vital signs. 2. Position the client in a semi-Fowler's position; turn her from the back to the unaffected side, with the affected arm elevated above the level of the heart to promote drainage and prevent lymphedema. 3. Encourage coughing and deep breathing. 4. If a suction-type of drain (such as a Jackson-Pratt) is in place, maintain suction and record the amount of drainage and the drainage characteristics; reinforce instructions to the client about home management of the drain (Figure 41-3). 5. Monitor operative site for infection, swelling, or the presence of fluid collection under the skin flaps or in the arm. 6. Monitor incision site for constriction from the dressings, impaired sensation, or color changes of the skin. 7. If breast reconstruction was performed, the client will return from surgery with a surgical support garment and the temporary prosthesis in place.

E）术后干预： 1.监视生命体征。 2.将客户置于半福勒位置；将她从背部转到未受影响的一侧，患病的手臂抬高到心脏水平以上，以促进引流并防止淋巴水肿。 3.鼓励咳嗽和深呼吸。 4.如果有抽吸式排水装置（例如Jackson-Pratt），则保持吸力并记录排水量和排水特性。加强对客户的排水沟家庭管理说明（图41-3）。 5.监测手术部位是否有感染，肿胀或皮瓣下或手臂内积液。 6.监测切口部位是否有敷料收缩，感觉受损或皮肤颜色变化。 7.如果进行了乳房再造，服务对象将带着手术支持服从手术中恢复并放置临时假体。

E) Transurethral resection of the prostate (TURP): may be performed for palliation in prostate cancer clients. 1. The procedure involves the insertion of a scope into the urethra to excise prostatic tissue. 2. Monitor for hemorrhage; bleeding is common following TURP. 3. Postoperative continuous bladder irrigation (CBI) may be prescribed, which prevents catheter obstruction from clots. 4. Monitor for signs of transurethral resection syndrome, which include signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbance, and nausea and vomiting; notify the RN immediately. 5. Antispasmodics may be prescribed for bladder spasm. 6. Inform the client to monitor and report dribbling or incontinence postoperatively and teach perineal exercises. 7. Sterility is possible following the surgical procedure. F) Suprapubic prostatectomy 1. Suprapubic prostatectomy is removal of the prostate gland by an abdominal incision with a bladder incision. 2. The client will have an abdominal dressing that may drain copious amounts of urine, and the abdominal dressing will need to be changed frequently. 3. Severe hemorrhage is possible, and monitoring for blood loss is an important nursing intervention. 4. Antispasmodics may be prescribed for bladder spasms. 5. Continuous bladder irrigation (CBI) is prescribed and carried out to keep the urine pink. 6. Sterility occurs with this procedure.

E）经尿道前列腺切除术（TURP）：可对前列腺癌患者进行缓解。 1.该手术包括将尿道镜插入尿道以切除前列腺组织。 2.监测出血情况； TURP后出血是常见的。 3.可能需要进行术后连续膀胱冲洗（CBI），以防止导管阻塞而引起凝块。 4.监测经尿道切除综合征的体征，包括脑水肿和颅内压升高的体征，例如血压升高，心动过缓，精神错乱，神志不清，肌肉抽搐，视觉障碍，恶心和呕吐；立即通知RN。 5.可以规定镇痉药用于膀胱痉挛。 6.告知服务对象术后要监测并报告运球或失禁，并教会阴运动。 7.手术后可能会出现无菌状态。 F）耻骨上前列腺切除术 1.耻骨上前列腺切除术是通过腹部切口和膀胱切口切除前列腺。 2.服务对象的腹部敷料可能会排出大量尿液，因此需要经常更换腹部敷料。 3.可能会发生严重的出血，监测失血是一项重要的护理干预措施。 4.可能为膀胱痉挛开了解痉药。 5.规定并进行连续膀胱冲洗（CBI），以保持尿液呈粉红色。 6.此过程不育。

F) Hysterectomy 1. Description a) Hysterectomy is performed for micro-invasive cancer if childbearing is not desired. b) A vaginal approach is most commonly performed. c) A radical hysterectomy and bilateral lymph node dissection may be performed for cancer that has spread beyond the cervix but not to the pelvic wall. 2. Postoperative interventions a) Monitor vital signs. b) Assist with coughing and deep- breathing exercises. c) Assist with range-of-motion (ROM) exercises and provide early ambulation. d) Apply anti-embolism stockings, as prescribed. e) Monitor intake and output, urinary catheter drainage, and hydration status. f) Monitor bowel sounds. g) Monitor the incision site for signs of infection. h) Administer pain medication, as prescribed. i) Reinforce postoperative instructions to avoid tub baths, sitting for long periods, and stair climbing for 1 month; avoid strenuous activity or lifting anything weighing more than 10 to 20 pounds; consume foods that aid in healing, including protein, fruits, and vegetables; avoid sexual intercourse for 3 to 6 weeks, as prescribed; and about the signs/symptoms associated with complications. j) Monitor vaginal bleeding following a hysterectomy. More than 1 saturated pad per hour may indicate excessive bleeding; report this occurrence to the RN.

F）子宫切除术 1.说明 a）如果不需要分娩，则对微浸润性癌行子宫切除术。 b）最常采用阴道入路。 c）对于已经扩散到子宫颈以外但未扩散到骨盆壁的癌症，可以进行彻底的子宫切除术和双侧淋巴结清扫术。 2.术后干预 a）监测生命体征。 b）协助咳嗽和深呼吸练习。 c）协助进行运动范围（ROM）锻炼并提供早期行走。 d）按照规定使用防栓袜。 e）监测摄入量和输出量，导尿管引流和水合状态。 f）监测肠鸣音。 g）监测切口部位是否有感染迹象。 h）服用止痛药 规定的。 i）加强术后指导，避免浴缸洗澡，长时间坐着和爬楼梯1个月；避免剧烈运动或举起重于10到20磅的东西；食用有助于康复的食物，包括蛋白质，水果和蔬菜；按规定避免性交3至6周；以及与并发症相关的体征/症状。 j）子宫切除术后监测阴道出血。每小时超过1个饱和垫可能表示出血过多；向RN报告这种情况。

G. Perineal prostatectomy 1. The prostate gland is removed through an incision made between the scrotum and anus. 2. Minimal bleeding occurs with this procedure. 3. The client needs to be monitored closely for infection because the risk of infection is increased with this type of prostatectomy. 4. Urinary incontinence is common. 5. The procedure causes sterility. 6. Reinforce teaching to the client on how to perform perineal exercises. H. Postoperative interventions 1. Monitor vital signs. 2. Monitor urinary output and urine for hemorrhage or clots. 3. Increase fluids to 2400 to 3000 mL/day, unless contraindicated. 4. Monitor for arterial bleeding as evidenced by bright red urine with numerous clots; if it occurs, increase CBI and notify the RN immediately. 5. Monitor for venous bleeding as evidenced by burgundy-colored urine output; if it occurs, notify the RN; the surgeon may apply traction on the catheter. 6. Monitor hemoglobin and hematocrit levels. 7. Expect red to light pink urine for 24 hours, turning to amber in 3 days. 8. Ambulate the client as early as possible and as soon as urine begins to clear in color. 9. Inform the client that a continuous feeling of an urge to void is normal. 10. Reinforce instructions to the client to avoid attempts to void around the catheter because this will cause bladder spasms. 11. Administer antibiotics, analgesics, stool softeners, and antispasmodics as prescribed. 12. Monitor the three-way indwelling urinary catheter, which usually has a 30 mL- to 45-mL retention balloon. 13. Maintain CBI with sterile bladder irrigation solution as prescribed to keep the catheter free of obstruction and keep the urine pink in color. 14. Following TURP, monitor for transurethral resection syndrome or severe hyponatremia (water intoxication) caused by the excessive absorption of bladder irrigation during surgery (altered mental status, bradycardia, increased blood pressure, and confusion).

G.会阴前列腺切除术 1.通过在阴囊和肛门之间切开切口来切除前列腺。 2.通过此程序可以使出血最少。 3.需要密切监测患者的感染情况，因为这种前列腺切除术会增加感染的风险。 4.尿失禁很常见。 5.程序导致无菌。 6.加强对服务对象的会阴锻炼的教学。 H.术后干预 1.监视生命体征。 2.监测尿量和尿液 出血或血块。 3.除非禁忌，否则将液体增加至2400至3000 mL /天。 4.监测动脉出血，如鲜红色的尿液和许多凝块所证明；如果发生，请增加CBI并立即通知RN。 5.监测静脉出血，以勃艮第色的尿量为证据；如果发生，通知RN；外科医生可以在导管上施加牵引力。 6.监测血红蛋白和血细胞比容水平。 7.尿液呈红色至浅粉红色持续24小时，三天内变为琥珀色。 8.尽早为服务对象走动，并在尿液开始变色时尽快走动。 9.告知服务对象持续不断的渴望作废的感觉是正常的。 10.加强对服务对象的指示，避免尝试在导管周围排空，因为这会引起膀胱痉挛。 11.按规定管理抗生素，止痛药，粪便软化剂和解痉剂。 12.监测三向留置尿 导管，通常为30 mL至45 mL 保留气球。 13.按照规定用无菌膀胱冲洗液维护CBI，以保持导管畅通无阻，并使尿液保持粉红色。 14. TURP术后，监测因手术过程中过度吸收膀胱冲洗（精神状态改变，心动过缓，血压升高和精神错乱）而引起的经尿道切除综合征或严重低钠血症（水中毒）。

J. Postoperative interventions: Suprapubic prostatectomy 1. Monitor suprapubic and indwelling urinary catheter drainage. 2. Monitor CBI if prescribed. 3. Note that the indwelling urinary catheter will be removed 2 to 4 days postoperatively if the client has a suprapubic catheter. 4. If prescribed, clamp the suprapubic catheter after the indwelling urinary catheter is removed, and instruct the client to attempt to void; after the client has voided, assess the residual urine in the bladder by unclamping the suprapubic catheter and measuring the output. 5. Prepare for removal of the suprapubic catheter when the client consistently empties the bladder and residual urine is 75 mL or less. 6. Monitor the suprapubic incision dressing, which may become saturated with urine, until the incision heals; dressing may need to be changed frequently.

J.术后干预：耻骨上前列腺切除术 1.监测耻骨上和留置导尿管的引流。 2.如果有规定，请监视CBI。 3.请注意，如果患者使用耻骨上导管，则术后2至4天将取出留置导尿管。 4.如果有规定，在移开留置导尿管后夹住耻骨上导管，并指示服务对象尝试排空；服务对象排空后，通过松开耻骨上导管并测量输出量来评估膀胱中的残留尿液。 5.当患者持续排空膀胱且残余尿量为75 mL或更少时，准备移除耻骨上导管。 6.监测耻骨上切口的敷料，该敷料可能会被尿液浸透，直至切口愈合；敷料可能需要经常更换。

h) Expect liquid stool from an ascending colon colostomy, loose to semiformed stool from a transverse colon colostomy, or close to normal stool from a descending colon colostomy. i) Fecal matter should not be allowed to remain on the skin. j) Administer analgesics and antibiotics, as prescribed. k) Irrigate the perineal wound, if present and if prescribed, and monitor for signs of infection. l) Inform the client to avoid foods that cause excessive gas formation and odor. m) Reinforce instructions about stoma care and irrigations, as prescribed. n) The client is instructed on how to resume normal activities, including work, travel, and sexual intercourse, as prescribed; provide psychosocial support. 3. Postoperative: Ileostomy a) Healthy stoma is red b) Postoperative drainage will be dark green and progress to yellow as the client begins to eat. c) Stool is liquid. d) The risk for dehydration and electrolyte imbalance exists. e) Monitor stoma color: A dark blue, purple, or black stoma indicates compromised circulation, requiring RN and PHCP notification.

h）结肠结肠造口术需要粪便，横结肠结肠造口术可以松弛到半粪便，结肠结肠造口术可以使粪便接近正常粪便。 i）不允许粪便残留在皮肤上。 j）按规定使用镇痛药和抗生素。 k）冲洗会阴伤口（如果存在且有处方），并监测感染迹象。 l）告知服务对象避免食物引起过多的气体形成和气味。 m）按照规定加强有关造口护理和灌溉的说明。 n）指示客户如何按照规定恢复正常活动，包括工作，旅行和性交；提供社会心理支持。 3.术后：回肠造口术 a）健康的造口是红色的 b）术后引流将呈深绿色，并随着服务对象开始进食而逐渐变为黄色。 c）凳子是液体。 d）存在脱水和电解质不平衡的风险。 e）监测气孔颜色：深蓝色，紫色或黑色的气孔表示血液循环不良，需要RN和PHCP通知。

o) Monitor IV fluids and hourly intake and output to determine the adequacy of fluid replacement therapy; notify the PHCP if urine output is less than 30 mL/hour or greater than 50 mL/hour. p) Elevate circumferential burns of the extremities on pillows above the level of the heart to reduce dependent edema if no obvious fractures are present; diuretics increase the risk of hypovolemia and are generally avoided as a means of decreasing edema. q) Monitor pulses and capillary refill of the affected extremities, and check the perfusion of the distal extremity with a circumferential burn. r) Prepare for chest and other radiographs to rule out fractures or associated trauma. s) Keep the room temperature warm. t) Place the client on an air- fluidized bed or other special mattress and use a bed cradle to keep the sheets off the client's skin.

o）监测静脉输液以及每小时的进出量，以确定补液疗法是否足够；如果尿量少于30 mL /小时或大于50 mL /小时，请通知PHCP。 p）如果没有明显的骨折，将枕头四肢的圆周烧伤升高到高于心脏水平的位置，以减少依赖的水肿；利尿剂会增加血容量不足的风险，通常应避免将其用作减少水肿的一种方法。 q）监测患肢的脉搏和毛细血管充盈，并检查远端肢端的血流灌注情况。 r）为胸部和其他X光片做准备，以排除骨折或相关创伤。 s）保持室温温暖。 t）将服务对象放在空气流化床或其他特殊床垫上，并使用床架将床单保持在服务对象的皮肤上。

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank. Answer: _____%. 36% Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This totals 36%.

一个成年客户因爆炸而被烧死。最初，烧伤影响了服务对象的整个脸部（头部的前半部分）和躯干的上半部分，并且手臂的下半部分被圆周烧伤。服务对象的衣服着火了，服务对象跑了，造成头部后表面和后躯干上半部烧伤。根据九分法则，这个客户的烧伤程度是多少？填空。答案：_____％。 36％ 基本原理：根据九分法则，在初次烧伤时，头部的前半部分等于4.5％，躯干的上半部分等于9％，而手臂的下半部分等于9％。随后的烧伤包括头部的后半部（占4.5％）和躯干的后半部（占9％）。总计36％。

Major burns: 1. Evaluate the degree and extent of the burn, and treat life-threatening conditions. 2. Ensure a patent airway and administer 100% oxygen as prescribed. 3. Monitor for respiratory distress and determine the need for intubation. 4. Check the oropharynx for blisters and erythema. 5. Monitor arterial blood gases and carboxyhemoglobin levels. 6. For an inhalation injury, administer 100% oxygen via a tight-fitting nonrebreather face mask, as prescribed until the carboxyhemoglobin level falls below 15%. 7. Initiate peripheral IV access to unburned skin proximal to any extremity burn or prepare for the insertion of a central venous line as prescribed.

严重烧伤： 1.评估烧伤的程度和程度，并处理危及生命的状况。 2.确保呼吸道通畅，并按规定使用100％的氧气。 3.监测呼吸窘迫并确定是否需要插管。 4.检查口咽部是否有水泡和红斑。 5.监测动脉血气和羧基血红蛋白水平。 6.对于吸入性伤害，按照规定，通过紧身的无呼吸器面罩给予100％的氧气，直到羧基血红蛋白水平降至15％以下。 7.在任何四肢烧伤附近开始向未烧伤的皮肤进行外周静脉通路，或按规定准备插入中央静脉线。

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. Does the nurse determine which client complaint may be associated with the use of this medication? 1. Itching 2. Euphoria 3. Drowsiness 4. Frequent urination 1 Rationale: Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication.

临床护士正在对客户进行入院评估，并指出该客户正在服用壬二酸。护士是否确定与该药物使用有关的服务对象投诉？ 1.瘙痒 2.欣快感 3.睡意 4.尿频 1个 理由：壬二酸是一种用于治疗轻度至中度痤疮的局部药物。不良反应包括皮肤黝黑的客户灼痛，瘙痒，刺痛，发红和皮肤色素沉着。其他选项中注明的效果与该药物没有特别关联。

Client Instructions after Mastectomy: 1▪ Avoid overuse of the arm during the first few months. 2▪ To prevent lymphedema, keep the affected arm elevated; consultation with lymphedema specialist may be prescribed. 3▪ Provide incision care with an emollient, as prescribed, to soften and prevent wound contracture. 4▪ Encourage use of Reach to Recovery volunteers. 5▪ Encourage the client to perform breast self-examination on the remaining breast. 6▪ Protect the affected hand and arm. 7▪ Avoid strong sunlight on the affected arm. 8▪ Do not let the affected arm hang dependent. 9▪ Do not carry a pocketbook or anything heavy over the affected arm. 10▪ Avoid trauma, cuts, bruises, or burns to the affected side. 11▪ Avoid wearing constricting clothing or jewelry on the affected side. 12▪ Wear gloves when gardening. 13▪ Use thick oven mitts when cooking. 14▪ Use a thimble when sewing. 15▪ Apply hand cream several times daily. 16▪ Use cream cuticle remover. 17▪ Call the PHCP if signs of inflammation occur in the affected arm. 18▪ Wear a Medic-Alert bracelet stating which arm is lymphedematous.

乳房切除术后的客户说明： 1■在开始的几个月中，避免过度使用手臂。 2■为防止淋巴水肿，使患病手臂保持抬高；可能需要咨询淋巴水肿专家。 3■按照规定，在切口护理处使用润肤剂，以软化并防止伤口挛缩。 4▪鼓励使用"到达灾区"志愿者。 5■鼓励服务对象对剩余的乳房进行乳房自我检查。 6■保护受影响的手和手臂。 7■避免在受影响的手臂上照射强烈的阳光。 8▪不要让受影响的手臂悬垂。 9▪请勿将皮夹或重物放在受影响的手臂上。 10▪避免受伤，割伤，擦伤或烧伤患侧。 11▪避免在患侧穿紧身的衣服或珠宝。 12▪园艺时戴手套。 13▪烹饪时请使用厚的烤箱手套。 14■缝制时请使用顶针。 15■每天涂几次护手霜。 16▪使用去角质霜。 17▪如果受影响的手臂出现炎症迹象，请致电PHCP。 18▪佩戴Medic-Alert手镯，指出手臂淋巴水肿。

The nurse is caring for a client after a mastectomy. Which finding would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery? 1. Pain at the incisional site 2. Arm edema on the operative side 3. Sanguineous drainage in the Jackson Pratt drain 4. Complaints of decreased sensation near the operative site 2 Rationale: Clients who undergo mastectomy for breast cancer, especially those with axillary node resection, may develop chronic lymphedema or excessive swelling in the arm and hand. Lymphedema is a complication that may develop immediately after mastectomy, months, or even years after surgery. Slight edema may occur in the immediate postoperative period, but should decrease especially if the client rests with the arm supported on a pillow. Women should avoid injury to the arm on the affected side and not allow venipunctures or blood pressures to be taken in that arm. Pain and numbness near the incision and drainage from the surgical site are expected occurrences after mastectomy and are not indicative of a complication.

乳房切除术后，护士正在照顾病人。哪个发现表明服务对象正在经历可能会成为与手术相关的慢性问题的并发症？ 1.切口处疼痛 2.手术侧手臂水肿 3.杰克逊·普拉特排水渠中的大排水 4.手术部位感觉减退的投诉 2 理由：接受乳腺癌乳房切除术的患者，特别是腋窝淋巴结切除的患者，可能会出现慢性淋巴水肿或手臂和手部过度肿胀。淋巴水肿是一种并发症，可能在乳房切除术后，几个月甚至几年后立即发展。术后即刻可能会出现轻度水肿，但应减少，​​尤其是当服务对象将手臂放在枕头上休息时。妇女应避免对患侧的手臂造成伤害，并且不允许在该手臂上进行静脉穿刺或血压测量。切开术后切口和引流附近的疼痛和麻木是乳房切除术后的预期发生，并不表示并发症。

Breast self-examination and client instructions: 1. While in the shower or bath, when the skin is slippery with soap and water, examine your breasts. Use the pads of your second, third, and fourth fingers to firmly press every part of the breast. Use your right hand to examine your left breast and your left hand to examine your right breast. Using the pads of the fingers on your left hand, examine the entire breast with the use of small circular motions in a spiral or in an up-and-down motion so that the entire breast area is examined. Repeat the procedure using your right hand to examine your left breast. Repeat the pattern of palpation under the arm. Check for any lump, hard knot, or thickening of the tissue. 2. Look at your breasts in a mirror. Stand with your arms at your side. 3. Raise your arms overhead and check for any changes in the shape of your breasts, any dimpling of the skin, or any changes in the nipple. 4. Place your hands on your hips and press down firmly, tightening the pectoral muscles. Observe for asymmetry or changes, keeping in mind that your breasts probably do not match exactly. 5. While lying down, feel your breasts as described in step 1. When examining your right breast, place a folded towel under your right shoulder, and put your right hand behind your head. Repeat the procedure when examining your left breast. Mark on your calendar that you have completed your breast self-examination; note any changes or unique characteristics that you want to discuss with your primary health care provider.

乳房自我检查和客户指示： 1.在淋浴或沐浴中，用肥皂和水使皮肤光滑时，请检查您的乳房。用第二，第三和第四根手指的垫子稳固地按压乳房的每个部位。用右手检查左乳房，用左手检查右乳房。使用左手的手指垫，以螺旋或上下运动的小圆周运动检查整个乳房，以便检查整个乳房区域。用右手重复该过程以检查左乳房。重复手臂下方的触诊模式。检查是否有肿块，硬结或组织变厚。 2.照镜子看你的乳房。双臂站立在身边。 3.抬起头顶的手臂，检查乳房形状是否有任何变化，皮肤是否凹陷或乳头是否有变化。 4.将手放在臀部上并用力向下按，收紧胸肌。注意是否存在不对称或变化，请记住您的乳房可能不完全匹配。 5.躺下时，按照步骤1所述感觉乳房。检查右乳房时，在右肩下方放一条折叠的毛巾，然后将右手放在头后面。检查左乳房时，请重复该步骤。在您的日历上标记您已经完成了乳房自我检查；请注意您要与您的主要医疗保健提供者讨论的任何更改或独特特征。

Breast Cancer: A) Description 1. Breast cancer is classified as invasive when it penetrates the tissue that surrounds the mammary duct and grows in an irregular pattern. 2. Metastasis occurs via lymph nodes. 3. Common sites of metastasis are the bone and lungs; metastasis may also occur to the brain and liver. 4. Diagnosis is made by needle aspiration breast biopsy or by the surgical removal of the tumor with a microscopic examination looking for malignant cells. B) Risk factors 1. Age 2. Family history of breast cancer 3. Early menarche and late menopause 4. Previous cancer of the breast, uterus, or ovaries 5. Nulliparity, the late first birth 6. Obesity 7. High-dose radiation exposure of the chest

乳腺癌： 说明 1.乳腺癌如果渗入围绕乳腺导管的组织并以不规则的方式生长，则被分类为浸润性的。 2.转移通过淋巴结发生。 3.转移的常见部位是骨骼和肺部；转移也可能发生在大脑和肝脏。 4.通过穿刺穿刺活检或显微镜下检查恶性细胞的手术切除肿瘤来进行诊断。 B）危险因素 1.年龄 2.乳腺癌家族史 3.初潮早期和更年期晚期 4.先前的乳房，子宫或卵巢癌 5.胎唇早产 6.肥胖 7.胸部大剂量放射线照射

Wound care: 1. Description: The cleansing, débridement, and dressing of the burn wounds 2. Hydrotherapy: a) Wounds are cleansed by immersion, showering, or spraying. b) Hydrotherapy occurs for 30 minutes or less to prevent increased sodium loss through the burn wound, heat loss, pain, and stress. c) Client should be medicated before the procedure. d) Hydrotherapy is generally not used for clients who are hemodynamically unstable or those with new skin grafts. e) Care is taken to minimize bleeding and to maintain body temperature during the procedure. f) If hydrotherapy is not used, wounds are washed and rinsed while the client is in bed before the application of antimicrobial agents.

伤口护理： 1.描述：烧伤创面的清洁，清创和敷料 2.水疗： a）通过浸泡，淋浴或喷洒清洁伤口。 b）水疗持续30分钟或更短时间，以防止由于烧伤创口而造成的钠流失增加，热量流失，疼痛和压力增加。 c）手术前应给客户服药。 d）对于血流动力学不稳定或新植皮的患者，一般不使用水疗。 e）在手术过程中要注意减少出血并保持体温。 f）如果不使用水疗，则在患者躺在床上之前，应先使用抗菌剂清洗并冲洗伤口。

Types of Exudate from Wounds: A) Serous 1▪ Clear or straw-colored 2▪ Occurs as a normal part of the healing process B) Serosanguineous 1▪ Pink-colored as a result of the presence of a small amount of blood cells mixed with serous drainage 2▪ Occurs as a normal part of the healing process C) Sanguineous 1▪ Red drainage from trauma to a blood vessel 2▪ May occur with wound cleansing or other trauma to the wound bed 3▪ Sanguineous drainage is uncommon in wounds D) Hemorrhaging 1▪ Frank blood from a leaking blood vessel 2▪ May require emergency treatment to control bleeding 3▪ Hemorrhage is an abnormal wound exudate E) Purulent 1▪ Yellow, gray, or green drainage as a result of an infection in the wound

伤口渗出液的类型： A）浆液 1■透明或稻草色 2■在康复过程中正常发生 B）血清型 1■由于存在少量血细胞和浆液性排泄物而变成粉红色 2■在康复过程中正常发生 C）血腥的 1■从创伤到血管的红色引流 2■可能会因伤口清洁或伤口床受到其他创伤而发生 3■伤口流血不常见 D）出血 1■血管泄漏的弗兰克血 2■可能需要紧急治疗以控制出血 3■出血是伤口渗出液的异常 E）化脓 1■伤口感染导致黄色，灰色或绿色引流

Wound Coverings: A) Biological 1. Amniotic Membranes ▪ Amniotic membranes from human placentas are used to adhere to the wound. ▪ This is effective as a dressing until epithelial cell regrowth occurs. ▪ Frequent changes are required, because amnion does not develop a blood supply, and it disintegrates in about 48 hours. 2. Allograft or Homograft (Human Tissue) ▪ Donated human cadaver skin is provided through a skin bank. ▪ Monitor for wound exudate and signs of infection. ▪ Rejection can occur within 24 hours. ▪ The risk of transmitting a blood-borne infection exists with the use of this covering. 3. Xenograft or Heterograft (Animal Tissue) ▪ Pigskin is harvested after slaughter and preserved for storage. ▪ Monitor for infection and wound adherence. ▪ Rejection can occur within 24 to 72 hours. ▪ This tissue is placed over granulation tissue and replaced every 2 to 5 days until the wound heals naturally or until closure with an autograft is complete. 4. Cultured Skin ▪ Cultured skin is grown in a laboratory from a small specimen of epidermal cells from an unburned portion of the client's body. ▪ Cell sheets are grafted onto the client to generate a permanent skin surface. ▪ Cell sheets are not durable; care must be taken when applying them to ensure adherence and prevent sloughing. 5. Autograft ▪ Skin is taken from a remote, unburned area of the client's own body and transplanted to cover the burn wound. ▪ The graft is placed either on a clean granulated bed or over a surgically excised area of the burn. ▪ Autograft provides for permanent skin coverage.

伤口覆盖物： A）生物 1.羊膜 ▪人类胎盘的羊膜被用于粘附伤口。 ▪这是一种有效的敷料，直到上皮细胞再生。 ▪需要经常更换，因为羊膜不会产生血液供应，并且会在约48小时内分解。 2.同种异体移植或同种异体移植（人类组织） ▪通过皮肤库提供捐赠的人体尸体皮肤。 ▪监测伤口渗出液和感染迹象。 ▪拒绝可能会在24小时内发生。 ▪使用该覆盖物会存在传播血源性感染的风险。 3.异种移植或异种移植（动物组织） ▪屠宰后将猪皮收割并保存以供储存。 ▪监测感染和伤口粘连。 ▪拒绝可能会在24到72小时内发生。 ▪将该组织放在肉芽组织上，每2至5天更换一次，直到伤口自然愈合或用自体移植完成闭合为止。 4.培养皮肤 ▪培养的皮肤是在实验室中从客户身体未燃烧的部分表皮细胞的小样本中生长出来的。 ▪将细胞片移植到客户身上，以产生永久的皮肤表面。 ▪电池片不耐用；使用它们时必须小心以确保附着力并防止脱落。 5.自体移植 ▪皮肤取自客户自己身体的未烧过的较远区域，然后移植以覆盖烧伤伤口。 ▪将移植物放置在干净的颗粒床上或烧伤的手术切除区域上。 ▪自体移植可永久覆盖皮肤。

Care of the Client with a Sealed Radiation Implant: 1▪ Place the client in a private room with a private bath. 2▪ Place a caution sign on the client's door. 3▪ Organize nursing tasks to minimize exposure to the radiation source. 4▪ Nursing assignments to a client with a radiation implant should be rotated. 5▪ Limit exposure time to 30 minutes per care provider per 8-hour shift. 6▪ Wear a dosimeter film badge to measure radiation exposure. 7▪ Wear a lead shield to reduce the transmission of radiation. 8▪ The nurse should never care for more than one client with a radiation implant at one time. 9▪ Do not allow a pregnant nurse to care for the client. 10▪ Do not allow children who are younger than 16 years of age or pregnant women to visit the client. 11▪ Limit visitors to 30 minutes per day; visitors should be at least 6 feet from the source. 12▪ Save the bed linens and dressings until the source is removed, and then dispose of the linens and dressings in the usual manner. 13▪ Other equipment can be removed from the room at any time.

使用密封的放射植入物来护理客户： 1▪将服务对象放在带私人浴室的私人房间中。 2▪在服务对象的门上放置警告标志。 3▪组织护理任务，以最大程度地减少辐射源的暴露。 4▪应轮换使用放射植入物的客户的护理工作。 5▪每8小时轮班，每位护理人员的暴露时间限制为30分钟。 6▪佩戴剂量计胶片徽章以测量辐射暴露。 7■佩戴铅罩以减少辐射的传播。 8▪护士一次不要植入放射物来照顾一个以上的服务对象。 9▪请勿让怀孕的护士照顾服务对象。 10▪不允许16岁以下的儿童或孕妇来访。 11▪每天限制访客30分钟；访客应该离来源至少6英尺。 12▪保存床单和敷料，直到将其取下为止，然后按通常方式处理床单和敷料。 13■其他设备可以随时从房间移开。

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Avoid sun exposure in the late afternoon and early evening hours. 5. Examine your body monthly for any lesions that may be suspicious. 2, 3, 5 Rationale: The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 AM to 4 PM. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

健康教育护士向一组客户提供有关有助于预防皮肤癌的措施的指导。护士应提供哪些指示？选择所有符合条件的。 1.应每8小时涂一次防晒霜。 2.参加户外活动时要使用防晒霜。 3.在阳光下戴帽子，不透明的衣服和太阳镜。 4.避免在午后和傍晚暴露在阳光下。 5.每月检查您的身体是否有可疑的病变。 2 3 5 理由：应指示客户避免在最亮的日照时间（上午10点至下午4点）之间晒太阳。户外活动时应戴防晒霜，帽子，不透明的衣服和太阳镜。应指导服务对象每月检查身体是否有任何癌性或癌前病变的外观。游泳或出汗后，应每2至3小时重新涂一次防晒霜；否则，保护时间会缩短。

Burn Products: A. Silver sulfadiazine 1. Has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast 2. Silver is released slowly from the cream, which is selectively toxic to bacteria. 3. Used primarily to prevent sepsis in clients with burns 4. Not a carbonic anhydrase inhibitor; does not cause acidosis 5. Apply 1/16-inch film (keep burn covered at all times with silver sulfadiazine). 6. Adverse effects include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. 7. Monitor complete blood cell count, particularly the white blood cells, frequently; if leukopenia develops, the PHCP is notified (medication is usually discontinued). B) Mafenide acetate 1. Water-soluble cream that is bacteriostatic for gram-negative and gram-positive organisms. 2. Used to treat burns to reduce bacteria present in avascular tissues. 3. Diffuses through the devascularized areas of the skin and may precipitate metabolic acidosis with the client displaying hyperventilation; monitor blood gases and electrolytes. 4. Apply 1/16-inch film directly to the burn. 5. Adverse effects can include local pain and rash. Medicate for pain before application. 6. Adverse effects include bone marrow depression, hemolytic anemia, and metabolic acidosis. 7. Keep burn covered with mafenide acetate at all times. 8. Notify the PHCP if hyperventilation occurs; if acidosis develops, mafenide acetate is washed off the skin and usually discontinued for 1 to 2 days.

刻录产品： A.磺胺嘧啶银 1.对革兰氏阴性菌，革兰氏阳性菌和酵母具有广泛的活性 2.银从乳膏中缓慢释放，对细菌有选择性地毒性。 3.主要用于预防烧伤患者的败血症 4.不是碳酸酐酶抑制剂；才不是 引起酸中毒 5.涂上1/16英寸的薄膜（始终用磺胺嘧啶银覆盖灼伤）。 6.不良反应包括皮疹和瘙痒，皮肤蓝绿色或灰色变色，白细胞减少症和间质性肾炎。 7.经常监测全血细胞计数，尤其是白细胞；如果发生白细胞减少症，会通知PHCP（通常会停药）。 B）醋酸马芬尼 1.对革兰氏阴性和革兰氏阳性生物具有抑菌作用的水溶性乳膏。 2.用于治疗烧伤，减少血管组织中存在的细菌。 3.扩散穿过皮肤的无血管区域，并可能导致代谢性酸中毒，使患者显示过度换气；监测血液中的气体和电解质。 4.直接将1/16英寸的胶片涂在刻录上。 5.不良反应可能包括局部疼痛和皮疹。服药前要止痛。 6.不良反应包括骨髓抑制，溶血性贫血和代谢 酸中毒。 7.始终在烧伤处覆盖乙酸马芬尼。 8.如果过度换气，请通知PHCP。如果发生酸中毒，则将醋酸马芬尼从皮肤上洗掉，通常停药1至2天。

Prostate Cancer: A) Description 1. Prostate cancer, a slow-growing malignancy of the prostate gland, is a common cancer in American men; most prostate tumors are adenocarcinomas arising from androgen- dependent epithelial cells. 2. The risk increases in men with each decade after the age of 50 years. 3. Prostate cancer can spread via direct invasion of surrounding tissues or by metastasis, through the bloodstream and lymphatics, to the bony pelvis and spine. 4. Bone metastasis is a concern, as is may spread to the lungs, liver, and kidneys. 5. The cause of prostate cancer is unclear, but advancing age, heavy metal exposure, smoking, and history of sexually transmitted infection are contributing factors; it is more common among men of African American descent. B) Data collection 1. Asymptomatic during the early stages 2. Hard, pea-sized nodule palpated on rectal examination 3. Gross, painless hematuria 4. Late symptoms include weight loss, urinary obstruction, and pain radiating from the lumbosacral area down the leg. 5. Prostate-specific antigen (PSA) level is elevated in various noncancerous conditions and therefore should not be used as a screening test without a digital rectal examination; it is routinely used to monitor response to therapy. 6. Diagnosis is made through biopsy of the prostate gland.

前列腺癌： 说明 1.前列腺癌是前列腺癌的一种缓慢增长的恶性肿瘤，在美国男性中很常见。大多数前列腺肿瘤是雄激素依赖性上皮细胞引起的腺癌。 2. 50岁以后的每十年，男性的风险增加。 3.前列腺癌可通过直接侵入周围组织或通过转移，通过血流和淋巴管扩散到骨盆和脊柱而扩散。 4.骨转移是一个问题，可能扩散到肺，肝和肾。 5.前列腺癌的病因尚不清楚，但年龄增长，重金属暴露，吸烟和性传播感染史是促成因素；在非裔美国人中更常见。 B）数据收集 1.早期无症状 2.直肠检查触诊到硬的豌豆大小的结节 3.肉眼无痛性血尿 4.晚期症状包括体重减轻，尿路梗阻和腰腿部腰部放射的疼痛。 5.在各种非癌性疾病中，前列腺特异性抗原（PSA）水平升高，因此，未经数字直肠检查，不应将其用作筛查试验；它通常用于监视对治疗的反应。 6.通过前列腺活检进行诊断。

Ovarian Cancer A. Description: 1. Ovarian cancer grows rapidly, spreads quickly, and is often bilateral. 2. Metastasis occurs by direct spread to the organs in the pelvis, by distal spread through lymphatic drainage, or by peritoneal seeding. 3. In its early stages, ovarian cancer is often asymptomatic; because most women are diagnosed in advanced stages, ovarian cancer has a higher mortality rate than any other cancer of the female reproductive system, particularly among white women between 55 and 65 years of age of North American or European descent. 4. An exploratory laparotomy is performed to diagnose and stage the tumor. 5. A transvaginal ultrasound can also be used; however, this screening does not decrease mortality. B) Data collection 1. Abdominal discomfort or swelling 2. GI disturbances 3. Dysfunctional vaginal bleeding 4. Abdominal mass 5. Elevated tumor marker C) Interventions 1. External radiation is used if the tumor has invaded other organs. 2. Chemotherapy is used postoperatively for all stages of ovarian cancer. 3. Intraperitoneal chemotherapy, which involves the installation of chemotherapy into the abdominal cavity, may be prescribed. 4. Total abdominal hysterectomy and bilateral salpingo-oophorectomy may be necessary.

卵巢癌 说明： 1.卵巢癌生长迅速，扩散迅速，并且经常是双边的。 2.转移是通过直接扩散到骨盆的器官，通过淋巴引流的远端扩散或通过腹膜播种而发生的。 3.在早期，卵巢癌通常是无症状的。由于大多数女性被诊断为处于晚期，因此卵巢癌的死亡率高于女性生殖系统的任何其他癌症，尤其是在北美或欧洲裔55至65岁的白人女性中。 4.进行探索性剖腹术以诊断和分期肿瘤。 5.还可以使用经阴道超声检查；但是，这种筛查并不能降低死亡率。 B）数据收集 1.腹部不适或肿胀 2.胃肠道干扰 3.阴道功能失调 4.腹部肿块 5.肿瘤标志物升高 C）干预 1.如果肿瘤侵犯了其他器官，则使用外部辐射。 2.化疗用于卵巢癌的所有阶段。 3.可能需要进行腹膜内化疗，其中涉及将化学疗法安装到腹腔中。 4.可能需要进行全腹子宫切除术和双侧输卵管卵巢切除术。

Pressure Injury: A) Description 1. A pressure injury is an impairment of skin integrity. 2. A pressure injury can occur anywhere on the body; tissue damage results when the skin and underlying tissue are compressed between a bony prominence and an external surface for an extended period of time. 3. The tissue compression restricts blood flow to the skin and this can result in tissue ischemia, inflammation, and necrosis; once a pressure injury develops, it is difficult to heal. 4. Prevention of skin breakdown in any part of the body is a major role for the nurse. B) Risk factors 1. Skin pressure 2. Skin shearing and friction 3. Immobility 4. Malnutrition 5. Incontinence 6. Decreased sensory perception

压力伤害： 说明 1.压力伤害是皮肤完整性的损害。 2.身体任何地方都可能发生压力伤害；当皮肤和下面的组织在骨隆起和外表面之间被压缩较长时间时，会导致组织损伤。 3.组织受压限制了血液流向皮肤，这可能导致组织缺血，发炎和坏死。一旦出现压力伤害，就很难he愈。 4.防止身体任何部位的皮肤破裂是护士的主要职责。 B）危险因素 1.皮肤压力 2.皮肤剪切和摩擦 3.不动 4.营养不良 5.失禁 6.感觉知觉下降

Stevens-Johnson Syndrome: A) A medication-induced skin reaction that occurs through an immunological response; common medications causing the reaction include antibiotics (especially sulfonamides), antiseizure medications and nonsteroidal antiinflammatory drugs (NSAIDs). B) Similar to toxic epidermal necrolysis (TEN), another medication-induced skin reaction that results in diffuse erythema and large blister formation on the skin and mucous membranes C) May be mild or severe and cause vesicles, erosions, and crusts on the skin; if severe, systemic reactions occur that involve the respiratory system, renal system, and eyes, resulting in blindness, and it can be fatal. Initial clinical manifestations include flu-like symptoms and erythema of the skin and mucous membranes. Serious systemic symptoms and complications occur when the ulcerations involve the larynx, bronchi, and esophagus. D) Most commonly occurs in clients with cancer who are receiving chemotherapy or immunotherapy or who have an impaired immune system E) Treatment includes immediate discontinuation of the medication causing the syndrome; antibiotics, corticosteroids, and supportive therapy may be necessary.

史蒂文斯-约翰逊综合症： A）通过免疫反应发生的药物引起的皮肤反应；引起该反应的常见药物包括抗生素（尤其是磺胺类药物），抗癫痫药和非甾体抗炎药（NSAIDs）。 B）与毒性表皮坏死（TEN）类似，另一种药物引起的皮肤反应导致皮肤和粘膜弥漫性红斑和大水疱形成 C）可能是轻度或严重的，并引起皮肤上的囊泡，糜烂和结c；如果发生严重的全身性反应，涉及呼吸系统，肾脏系统和眼睛，导致失明，这可能是致命的。最初的临床表现包括流感样症状以及皮肤和粘膜红斑。当溃疡累及喉，支气管和食道时，会出现严重的全身症状和并发症。 D）最常见于接受化疗或免疫疗法或免疫系统受损的癌症患者 E）治疗包括立即停止引起综合症的药物治疗；可能需要使用抗生素，皮质类固醇和支持疗法。

Inhalation Injuries: A) Smoke inhalation injury: 1. Description: Respiratory injury that occurs when the victim inhales products of combustion during a fire. (Airway is a priority concern in an inhalation injury.) 2. Data collection a) Facial burns b) Erythema c) Swelling of the oropharynx and nasopharynx d) Singed nasal hairs e) Flaring nostrils f) Stridor, wheezing, and dyspnea g. Hoarse voice h) Sooty (carbonaceous) sputum and cough i) Tachycardia j) Agitation and anxiety

吸入伤害： A）吸入烟雾伤害： 1.描述：受害者在火灾中吸入燃烧产物时发生呼吸道伤害。 （呼吸道是吸入性伤害的优先考虑因素。） 2.数据收集 a）面部烧伤 b）红斑 c）口咽和鼻咽肿胀 d）鼻毛 e）鼻孔张大 f）骑乘者，喘息和呼吸困难g。沙哑的声音 h）煤烟（含碳）和咳嗽 i）心动过速 j）躁动和焦虑

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? 1. A staff member who has never had roseola 2. A staff member who has never had mumps 3. An unlicensed assistive personnel who has never had chickenpox 4. An unlicensed assistive personnel who has never had German measles 3 Rationale: Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox.

在长期护理机构工作的护士正在计划当天的临床任务。护士知道不分配哪位职员来诊断带状疱疹吗？ 1.从来没有吃过玫瑰茄的工作人员 2.从未有腮腺炎的工作人员 3.从未感染过水痘的无牌辅助人员 4.从未患过德国麻疹的无牌辅助人员 3 理由：带状疱疹是由水痘带状疱疹病毒的再激活引起的，水痘带状疱疹病毒是水痘的致病性病毒。尚未暴露于水痘带状疱疹病毒的个体容易感染水痘。

Resuscitative phase: 1. Fluid resuscitation a) The amount of fluid administered depends on how much IV fluid per hour is required to maintain a urinary output of 30 mL/hour to 50 mL/hour. b) Successful fluid resuscitation is evaluated by stable vital signs, an adequate urine output, palpable peripheral pulses, and an intact level of consciousness and thought processes. c) IV fluid replacement may be titrated (adjusted) on the basis of urinary output plus serum electrolyte levels to meet the perfusion needs of the client with burns. d) If the hemoglobin and hematocrit levels decrease or if the urinary output exceeds 50 mL/hour, the rate of IV fluid administration may be decreased. e) Urinary output is the most reliable and most sensitive noninvasive assessment parameter for cardiac output and tissue perfusion.

复苏阶段： 1.液体复苏 a）输液量取决于每小时保持30 mL /小时至50 mL /小时的尿量需要多少静脉输液。 b）通过稳定的生命体征，充足的尿液排出量，可察觉的外周脉搏以及完整的意识和思维过程来评估液体复苏是否成功。 c）可以根据尿量加上血清电解质水平来滴定（调整）静脉补液，以满足烧伤患者的灌注需求。 d）如果血红蛋白和血细胞比容水平降低或尿量超过50毫升/小时，则静脉输液的速率可能会降低。 e）尿量是心输出量和组织灌注的最可靠，最敏感的非侵入性评估参数

Topical Glucocorticoids: A) Description 1. Antiinflammatory, antipruritic, and vasoconstrictive actions. 2. Preparations vary in potency and depend on the concentration and type of preparation, and method of application (occlusive dressings enhance absorption, increasing the effects). 3. Systemic effects are more likely to occur with prolonged therapy and when extensive skin surfaces are treated. 4. Topical glucocorticoids can be absorbed into the systemic circulation; absorption is greater in permeable skin areas (scalp, axilla, face and neck, eyelids, perineum) and less in areas where permeability is poor (palms, soles, back). B) Contraindications 1. Clients demonstrating previous sensitivity to corticosteroids. 2. Clients with current systemic fungal, viral, or bacterial infections. 3. Clients with current complications related to glucocorticoid therapy. C) Local adverse effects 1. Burning, dryness, irritation, itching 2. Skin atrophy 3. Thinning of the skin, striae, purpura, telangiectasia 4. Acneiform eruptions 5. Hypopigmentation 6. Overgrowth of bacteria, fungi, and viruses

外用糖皮质激素： 说明 1.抗炎，止痒和血管收缩作用。 2.制剂的效力各不相同，取决​​于制剂的浓度和类型以及使用方法（封闭的敷料可增加吸收，增加效果）。 3.长时间治疗和治疗大量皮肤表面后，更可能发生全身作用。 4.局部糖皮质激素可被吸收进入体循环；在渗透性皮肤区域（头皮，腋窝，面部和颈部，眼睑，会阴）的吸收较大，而在渗透性较差的区域（手掌，鞋底，背部）吸收较少。 B）禁忌症 1.客户证明以前对皮质类固醇敏感。 2.当前患有全身性真菌，病毒或细菌感染的客户。 3.患有糖皮质激素治疗相关并发症的患者。 C）局部不良影响 1.燃烧，干燥，刺激，瘙痒 2.皮肤萎缩 3.皮肤，皮纹，紫癜，毛细血管扩张的变薄 4.痤疮样爆发 5.色素沉着 6.细菌，真菌和病毒的过度生长

Multiple Myeloma: A) Description 1. A malignant proliferation of plasma cells and tumors within the bone. 2. Excessive number of abnormal plasma cells invade the bone marrow, develop into tumors, and ultimately destroy the bone; invasion of the lymph nodes, spleen, and liver occurs. 3. The abnormal plasma cells produce an abnormal antibody (myeloma protein or the Bence Jones protein) that is found in the blood and urine. 4. Multiple myeloma causes the decreased production of immunoglobulin and antibodies and increased levels of uric acid and calcium, which can lead to kidney failure. 5. The disease typically develops slowly and the cause is unknown.

多发性骨髓瘤： 说明 1.骨内浆细胞和肿瘤的恶性增殖。 2.过多的异常浆细胞侵入骨髓，发展成肿瘤，最终破坏骨骼；发生淋巴结，脾脏和肝脏浸润。 3.异常浆细胞产生一种在血液和尿液中发现的异常抗体（骨髓瘤蛋白或Bence Jones蛋白）。 4.多发性骨髓瘤会导致免疫球蛋白和抗体的产生减少，以及尿酸和钙的水平升高，从而导致肾功能衰竭。 5.疾病通常发展缓慢，病因不明。

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area? 1. Intact skin 2. The presence of tunneling 3. A deep, crater-like appearance 4. Partial-thickness skin loss of the epidermis 4 Rationale: With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and it may look like an abrasion, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3 and tunneling develops during stage 4.

夜班护士查看了服务对象图表中的护理文档，并注意到，日间护士已经记录了服务对象在area骨区域发生了2级压力损伤。护士在检查服务对象的s骨区域时会期望找到什么？ 1.完整的皮肤 2.隧道的存在 3.深深的坑状外观 4.表皮部分厚度的皮肤脱落 4 理由：患有第2阶段的压力伤害，皮肤并不完整。表皮或真皮有部分厚度的皮肤损失。溃疡是浅表的，可能看起来像擦伤，水泡或浅坑。皮肤完好无损，处于第1阶段的压力伤害。在第3阶段会出现深坑状外观，在第4阶段会出现隧道现象。

Endometrial (Uterine) Cancer A) Description 1. Endometrial cancer is a slow-growing tumor arising from the endometrial mucosa of the uterus, associated with the menopausal years. 2. Metastasis occurs through the lymphatic system to the ovaries and pelvis and via the blood to the lungs, liver, and bone, or intra-abdominally to the peritoneal cavity. B) Risk factors 1. Use of estrogen replacement therapy (ERT) 2. Nulliparity 3. Polycystic ovary disease 4. Increased age 5. Late menopause 6. Family history of uterine cancer or hereditary nonpolyposis colorectal cancer 7. Obesity 8. Hypertension 9. Diabetes mellitus

子宫内膜癌 说明 1.子宫内膜癌是由子宫内膜粘膜引起的，与绝经年有关的缓慢生长的肿瘤。 2.转移通过淋巴系统转移到卵巢和骨盆，并通过血液转移到肺，肝和骨，或者通过腹腔转移到腹膜腔。 B）危险因素 1.雌激素替代疗法（ERT）的使用 2. Nulliparity 3.多囊卵巢疾病 4.年龄增加 5.更年期晚 6.子宫癌或遗传性非息肉性大肠癌的家族史 7.肥胖 8.高血压 9.糖尿病

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color of the skin which is insensitive to touch 4 Rationale: The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.

客户到达急诊室，右手遇到冻伤。护士在检查服务对象的手时应该期望找到什么？ 一只粉红色的水肿的手 2.指甲床呈火红色皮肤浮肿 3.黑色指尖被红斑皮疹包围 4.皮肤白色，对触摸不敏感 4 原理：与冻伤相关的发现包括皮肤为白色或蓝色，皮肤坚硬，寒冷且对触摸不敏感。融化时，皮肤潮红，水泡或小气泡的发展或组织水肿也发生。坏疽可在9至15天内发育。

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action? 1. Reinsert the implant into the vagina. 2. Call the primary health care provider (PHCP). 3. Pick up the implant with gloved hands and flush it down the toilet. 4. Pick up the implant with long-handled forceps and place into a lead container. 4 Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. Lead is an element that has a high density and high atomic number and is used to shield persons from radiation. If dislodged, the implant must be handled carefully to limit radiation exposure to the client and all persons in the environment. If the implant becomes dislodged, the nurse should pick up the implant with long- handled forceps and place it into the lead container. The radiation safety officer of the institution should be notified. Although the PHCP needs to be notified, this is not the immediate action. The nurse cannot reinsert the implant. A radioactive implant is specifically placed inside the client to kill the cancer while limiting damage to adjacent tissues and organs. Touching the implant with gloves and flushing this down the toilet exposes the nurse and the environment to unsafe levels of radiation.

客户因插入内部宫颈放射植入物而住院。护理时，护士在床上发现了辐射植入物。哪些是即时护理措施？ 1.将植入物重新插入阴道。 2.致电初级卫生保健提供者（PHCP）。 3.戴手套的双手捡起植入物，并冲洗到马桶上。 4.用长柄镊子拾取植入物，并将其放入铅容器中。 4 理由：内部放射治疗期间，应始终将铅制容器和长柄镊子放在服务对象房间。铅是一种具有高密度和高原子序数的元素，可用于屏蔽人的辐射。如果脱落，必须小心处理植入物，以限制对客户和环境中所有人的辐射暴露。如果植入物脱落，护士应使用长柄镊子捡起植入物，并将其放入引线容器中。应当通知该机构的辐射安全官员。尽管需要通知PHCP，但这不是立即采取的措施。护士无法重新插入植入物。放射性植入物专门放置在客户体内，以杀死癌症，同时限制对相邻组织和器官的损害。用手套触摸植入物并将其冲入马桶，会使护士和环境暴露于不安全的辐射水平。

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? 1. Oxygen via nasal cannula at 10 L 2. Oxygen via nasal cannula at 15 L 3. 100% oxygen via an aerosol mask 4. 100% oxygen via a tight-fitting, nonrebreather face mask 4 Rationale: If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined.

客户在其家庭地下室发生烧伤并怀疑有吸入伤害后，便到达急诊室。护士应为客户开哪些处方药？ 1.经由鼻导管的氧气为10 L 2. 15 L时通过鼻导管供氧 3.通过气溶胶面罩提供100％的氧气 4.通过紧密贴合的无呼吸面罩提供100％的氧气 4 理由：如果怀疑有吸入性伤害，则建议通过紧身的非呼吸式面罩施用100％的氧气，直到羧基血红蛋白水平降至15％以下。吸入伤后，检查口咽部是否有红斑，水泡或溃疡的迹象。还确定是否需要气管插管。

Client Education Guide: Radiation Therapy for Cancer: 1▪ Wash the irradiated area gently each day with either water alone or with a mild soap and water. 2▪ Use the hand rather than a washcloth to wash the area. 3▪ Rinse the soap thoroughly from the skin. 4▪ Take care not to remove the markings that indicate exactly where the beam of radiation is to be focused. 5▪ Dry the irradiated area with patting motions rather than rubbing motions; use a clean, soft towel or cloth. 6▪ Use no powders, ointments, lotions, or creams on the skin at the radiation site unless they are prescribed by the radiologist. 7▪ Wear soft clothing over the skin at the radiation site. 8▪ Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at the radiation site. 9▪ Avoid exposure to the irradiated area to the sun. 10▪ Avoid heat exposure.

客户教育指南：癌症放射疗法： 1▪每天仅用水或用温和的肥皂水轻轻地清洗受辐照的区域。 2■用手而不是毛巾擦洗该区域。 3■从皮肤彻底冲洗肥皂。 4▪注意不要去除标记，该标记准确地指出了辐射束的聚焦位置。 5■以拍打动作而不是摩擦动作擦干照射区域； 使用干净的软毛巾或布。 6▪除非放射线医生规定，否则不得在放射部位的皮肤上使用粉末，药膏，乳液或乳霜。 7■在辐射部位的皮肤上穿柔软的衣服。 8▪避免在辐射现场穿皮带，皮带扣，皮带或任何会束缚或摩擦皮肤的衣服。 9▪避免暴露在阳光下。 10避免高温。

The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply. 1. Dyspnea 2. Diarrhea 3. Sore throat 4. Constipation 5. Red and dry skin over neck 3, 5 Rationale: External radiation is used to treat cancer in a specific area by emission of ionizing radiation beams that destroy cancer cells and have minimal damage to the surrounding normal cells. The client receiving external radiation experiences both general side/adverse effects such as fatigue, nausea, anorexia and localized side/adverse effects in the specific area receiving radiation. A client who is receiving radiation to the larynx is most likely to experience a sore throat and dry, reddened skin in the throat area. Diarrhea or constipation occur with radiation to the gastrointestinal (GI) tract. Dyspnea may occur with lung involvement.

客户正在接受颈部的外部辐射，以治疗喉癌。护士会监视服务对象，知道外部辐射有哪些副作用？选择所有符合条件的。 1.呼吸困难 2.腹泻 3.喉咙痛 4.便秘 5.颈部皮肤干燥干燥 3 5 原理：外部辐射用于通过辐射电离辐射束来治疗特定区域的癌症，这些辐射束会破坏癌细胞并使对周围正常细胞的损害降至最低。接受外部辐射的客户在接受辐射的特定区域中会遇到一般的副作用（例如疲劳，恶心，厌食症）和局部副作用。正在接受喉部辐射的服务对象最有可能出现喉咙痛和喉咙区域干燥变红的皮肤。腹泻或便秘是通过胃肠道（GI）辐射发生的。肺受累可能会导致呼吸困难

Cervical Cancer: A) Description 1. Preinvasive cancer is limited to the cervix. 2. Invasive cancer is in the cervix and other pelvic structures. 3. Metastasis is usually confined to the pelvis, but distant metastasis occurs through the lymphatic spread. 4. Premalignant changes are described on a continuum from dysplasia, which is the earliest premalignancy change, to carcinoma in situ, which is the most advanced premalignant change. B) Risk factors 1. Human papillomavirus (HPV) infection (vaccination against HPV is effective to avoid HPV infection, and thus cervical cancer). 2. Cigarette smoking, both active and passive 3. Reproductive behavior, including early first intercourse (before the age of 17 years), multiple sex partners, or male partners with multiple sex partners. 4. Screening via regular gynecological examinations and Pap test, with the treatment of precancerous abnormalities, decreases the incidence and mortality of cervical cancer.

宫颈癌： 说明 1.浸润前癌仅限于子宫颈。 2.浸润性癌在子宫颈和其他骨盆结构中。 3.转移通常局限于骨盆，但远处转移通过淋巴扩散发生。 4.恶变前的变化描述为从发育异常（这是最早的恶变前的变化）到原位癌（其是最晚期的恶变前的变化）的连续过程。 B）危险因素 1.人乳头瘤病毒（HPV）感染（预防HPV疫苗有效避免 HPV感染，进而子宫颈癌）。 2.主动和被动吸烟 3.生殖行为，包括初次性交（在17岁之前），多个性伴侣或具有多个性伴侣的男性伴侣。 4.通过常规的妇科检查和Pap试验进行筛查，并通过治疗癌前异常，可以降低子宫颈癌的发病率和死亡率。

Acne Vulgaris: A) Description 1. Acne is a chronic skin disorder that usually begins during puberty and is more common in males; lesions develop on the face, neck, chest, shoulders, and back. 2. Acne requires active treatment for control until it resolves. 3. The types of lesions include comedones (open and closed), pustules, papules, and nodules. 4. The exact cause is unknown, but may include androgenic influence on the sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes (the enzymes that reduce lipids to irritating fatty acids). 5. Exacerbations coincide with the menstrual cycle because of hormonal activity; oily skin and a genetic predisposition may be contributing factors. B） Data collection 1. Closed comedones are whiteheads and noninflamed lesions that develop as follicles and enlarge with the retention of horny cells. 2. Open comedones are blackheads that result from the continuing accumulation of horny cells and sebum, which dilates the follicles. 3. Pustules and papules result as the inflammatory process progresses. 4. Nodules result from the total disintegration of a comedone and subsequent collapse of the follicle. 5. Deep scarring can result from nodules.

寻常痤疮： 说明 1.痤疮是一种慢性皮肤病，通常在青春期开始，在男性中更为常见；病变在面部，颈部，胸部，肩膀和背部形成。 2.痤疮需要积极治疗才能得到控制，直至消退。 3.病变类型包括粉刺（开放和闭合），脓疱，丘疹和结节。 4.确切原因尚不清楚，但可能包括对皮脂腺的雄激素影响，皮脂产生增加和痤疮丙酸杆菌（将脂质还原为刺激性脂肪酸的酶）的增殖。 5.由于荷尔蒙的活动，月经周期加重。油性皮肤和遗传易感性可能是促成因素。 B）资料收集 1.闭合的粉刺是白头和非炎症性病变，形成为卵泡并随着角质细胞的保留而扩大。 2.开放的粉刺是由于角质细胞和皮脂不断积聚而形成的黑头粉刺，使卵泡扩张。 3.脓疱和丘疹随着炎症过程的进行而产生。 4.结节是由于粉刺完全崩解和随后的卵泡塌陷所致。 5.结节可导致深层瘢痕形成。

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1. Potassium level 2. Triglyceride level 3. Hemoglobin ĀC 4. Total cholesterol level 2 Rationale: Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on triglycerides has been evaluated. There is no indication that isotretinoin affects potassium, hemoglobin ĀC, or total cholesterol levels.

异维A酸适用于患有严重痤疮的患者。在服用这种药物之前，护士预计将开出哪种实验室检查处方？ 1.钾水平 2.甘油三酸酯水平 3.血红蛋白ĀC 4.总胆固醇水平 2 理由：异维A酸可以提高甘油三酸酯水平。在治疗前应测量血液中甘油三酸酯的水平，此后应定期测量，直到评估了对甘油三酸酯的影响为止。没有迹象表明异维A酸会影响钾，血红蛋白ĀC或总胆固醇水平。

When reinforcing teaching about signs and symptoms of ovarian cancer with a community group of women, the nurse emphasizes which sign/symptom as being a typical manifestation of the disease recognized by persons diagnosed with the condition? 1. Pelvic cramping 2. Sharp abdominal pain 3. Abdominal distention or fullness 4. Postmenopausal vaginal bleeding 3 Rationale: Ovarian cancer is the leading cause of death from gynecological cancers and occurs in women older than 50 years. The most common sign and symptom of ovarian cancer is abdominal distention or fullness. Less common are vague symptoms of urinary frequency and urgency, and GI symptoms such as a change in bowel habits. Pelvic cramping, sharp abdominal pain, or postmenopausal vaginal bleeding are not the most typical signs and symptoms.

当与社区妇女共同加强关于卵巢癌的体征和症状的教学时，护士强调哪种体征/症状是被诊断为该病的人所识别的疾病的典型表现？ 1.骨盆抽筋 2.剧烈的腹痛 3.腹胀或饱胀 4.绝经后阴道出血 3 理由：卵巢癌是导致妇科癌症死亡的主要原因，其发病年龄超过50岁。卵巢癌最常见的体征和症状是腹胀或饱胀。较少见的是尿频和尿急的模糊症状，以及胃肠道症状，例如排便习惯的改变。盆腔绞痛，剧烈的腹痛或绝经后阴道出血不是最典型的体征和症状。

The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions may be prescribed to treat the SIADH? Select all that apply. 1. Increase fluid intake 2. Decreased sodium intake 3. Institute safety measures 4. Frequent monitoring of sodium blood levels 5. Gather data about the neurological status frequently 6. Medication that is antagonistic to antidiuretic hormone (ADH) 3, 4, 5, 6 Rationale: Syndrome of inappropriate ADH (SIADH) is a condition in which excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is a potential complication associated with cancer, especially small cell lung cancer. SIADH is managed by treating the condition and its cause. The SIADH induces low sodium blood levels and results in altered neurological states, including confusion and unresponsiveness. Treatment of SIADH includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH, such as demeclocycline. Sodium blood levels and neurological status are monitored closely and safety interventions must be instituted. The client should not be treated with an increase in fluid intake or a decrease in the sodium intake.

患有肺癌的病人发展为抗利尿激素不适当综合征（SIADH），这是癌症的并发症。除了治疗肺癌外，护士还期望可以开出哪些干预措施来治疗SIADH？选择所有符合条件的。 1.增加液体摄入量 2.钠摄入量减少 3.研究所的安全措施 4.经常监测钠血水平 5.经常收集有关神经系统状况的数据 6.对抗抗利尿激素（ADH）的药物 3、4、5、6 理由：不适当的ADH综合征（SIADH）是肾脏吸收大量水并进入全身循环的疾病。水分增加会引起低钠血症（血清钠水平降低）和一定程度的体液retention留。 SIADH是与癌症特别是小细胞肺癌相关的潜在并发症。 SIADH是通过治疗病情及其原因来管理的。 SIADH诱导低钠血水平并导致神经系统状态改变，包括混乱和无反应性。 SIADH的治疗包括限制体液，增加钠的摄入以及具有对ADH拮抗作用的作用机理的药物，如地氯环素。钠血水平和神经系统状态受到密切监测，必须采取安全干预措施。不应以增加液体摄入量或减少钠摄入量的方式对待服务对象。

Surgical Breast Procedures 1. Lumpectomy ▪ The tumor is excised and removed. ▪ Lymph node dissection may also be performed. 2. Simple Mastectomy ▪ Breast tissue and the nipple are removed. ▪ The lymph nodes are left intact. 3. Modified Radical Mastectomy ▪ Breast tissue, the nipple, and the lymph nodes are removed. ▪ The muscles are left intact.

手术乳房程序 1.乳房切除术 ▪切除肿瘤并切除。 ▪也可以进行淋巴结清扫术。 2.单纯乳房切除术 ▪去除乳房组织和乳头。 ▪淋巴结完好无损。 3.改良根治性乳房切除术 ▪去除乳房组织，乳头和淋巴结。 ▪肌肉保持完整。

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? 1. "I need to wear sunscreen when participating in outdoor activities." 2. "I need to avoid sun exposure before 10:00 am and after 4:00 pm." 3. "I need to wear a hat, opaque clothing, and sunglasses when in the sun." 4. "I need to examine my body monthly for any lesions that may be suspicious." 2 Rationale: The client should be instructed to avoid sun exposure between the hours of approximately 10:00 am and 4:00 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

护士加强了对一组客户的指示，说明有助于预防皮肤癌的措施。客户的哪个陈述表明需要进一步的教学？ 1."参加户外活动时需要戴防晒霜。" 2."我需要避免在上午10:00之前和下午4:00之后晒太阳。" 3."在阳光下，我需要戴帽子，不透明的衣服和太阳镜。" 4."我需要每月检查身体是否有可疑的病变。" 2 理由：应指示服务对象避免在上午10:00到下午4:00之间的时间晒太阳。户外活动时应戴防晒霜，帽子，不透明的衣服和太阳镜。应指导服务对象每月检查身体是否有任何癌变或癌前病变的外观。

The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement by the client indicates the need for further teaching? Select all that apply. 1. "I will handle the area gently." 2. "I will wear loose-fitting clothing." 3. "I will avoid the use of deodorants." 4. "I will limit sun exposure to 1 hour daily." 5. "I will apply moisturizer with a cotton tipped applicator for itching. " 4, 5 Rationale: The client needs to be instructed to avoid exposure to the sun because of the risk of burns, resulting in altered tissue integrity. No lotions, ointments, or medications should be applied to the skin unless prescribed by the radiologist.

护士向接受外部放射治疗的服务对象提供皮肤护理说明。客户的哪个陈述表明需要进一步的教学？选择所有符合条件的。 1."我将轻柔地处理该区域。" 2."我会穿宽松的衣服。" 3."我将避免使用除臭剂。" 4."我将日照时间限制为每天1小时。" 5."我将用棉签涂抹保湿剂，以止痒。 " 4、5 理由：由于烧伤的危险，需要指示服务对象避免暴露在阳光下，从而改变组织的完整性。除非放射线医师规定，否则不得在皮肤上使用洗剂，药膏或药物。

The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction? Select all that apply. 1. Avoid driving a car for 1 week. 2. Restrict fluid intake to prevent incontinence. 3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks. 5. Inspect the incision on the scrotum every day for any redness. 6. Notify the primary health care provider (PHCP) if small blood clots are noticed during urination. 3, 4 Rationale: A suprapubic approach involves a lower abdominal incision to remove the prostate to treat prostate cancer. The nurse will reinforce instructions about the incision activity, medications, and when to contact the urologist. The client should take the prescribed stool softener because constipation will lead to straining and cause pain and tension on the surgical site. The client should avoid lifting more than 20 pounds for 6 weeks to avoid tension on the surgical site. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A daily fluid intake of 2 L to 2.5 L per day (unless contraindicated) should be maintained to limit clot formation and prevent infection. The incision is not on the scrotum but in the lower abdominal area. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery and do not need to be reported.

护士在耻骨上前列腺切除术后加强对患有前列腺癌的病人的出院指导。护士应加强哪种出院指导？选择所有符合条件的。 1.避免开车1周。 2.限制液体摄入以防止失禁。 3.每天服用规定的粪便柔软剂。 4.避免举起重于20磅的物体6周。 5.每天检查阴囊上的切口是否发红。 6.如果在排尿过程中发现小血块，请通知初级卫生保健提供者（PHCP）。 3 4 理由：耻骨上方法包括下腹部切口以切除前列腺以治疗前列腺癌。护士将加强有关切口活动，用药以及何时联系泌尿科医师的指导。服务对象应服用规定的粪便软化剂，因为便秘会导致劳损，并在手术部位引起疼痛和紧张。服务对象应避免在6周内举起20磅以上的重物，以免在手术部位产生拉力。禁止开车和长时间坐至少3周。除非禁忌，否则每天应保持每天2 L至2.5 L的液体摄入量，以限制血块形成并防止感染。切口不在阴囊上，而是在下腹部。小便的组织或血块可在排尿过程中通过，直至手术后最多2周，无需报告。

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? 1. Oily skin 2. Silvery-white scaly lesions 3. Patchy hair loss and round, red macules with scales 4. The presence of wheal patches scattered about the trunk 2 Rationale: Psoriatic patches are covered with silvery-white scales. There is no patchy hair loss or round, red macules with scales. The skin is dry and there is no presence of wheal patches scattered about the trunk.

护士检查怀疑患有牛皮癣的服务对象的皮肤。如果存在这种疾病，护士应注意哪个发现？ 1.油性皮肤 2.银白色鳞状病变 3.脱发，鳞片状，圆形红斑 4.躯干周围散布着鲸鱼斑块 2 基本原理：银屑病斑块覆盖着银白色的鳞片。没有斑驳的脱发或有鳞片的圆形红斑。皮肤干燥，在躯干周围没有散布的鲸鱼斑块。

The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action? Select all that apply. 1. Eat a high-protein diet. 2. Avoid exposure to sunlight. 3. Wash the skin with mild soap and pat it dry. 4. Apply pressure on the radiated area to prevent bleeding. 5. Avoid standing within 6 feet of persons under the age of 18 years. 4, 5 Rationale: The client should avoid pressure on the radiated area and wear loose-fitting clothing to prevent a disruption in the skin integrity. A client receiving external radiation is not radioactive and does not need to avoid other persons, including young people. A diet high in protein assists in the healing process. Avoiding sunlight and washing the skin with gentle soap and patting dry will assist with preventing skin disruption.

护士正在加强对接受外部放射治疗的服务对象的指示。如果服务对象声明要采取哪种行动，则护士会确定服务对象需要进一步的教学？选择所有符合条件的。 1.多吃高蛋白饮食。 2.避免暴露在阳光下。 3.用温和的肥皂洗净皮肤并拍干。 4.在辐射区域上施加压力以防止流血。 5.避免站立在18岁以下人员的6英尺内。 4、5 理由：服务对象应避免对辐射区域施加压力，并穿宽松的衣服以防止皮肤完整性受到破坏。接收外部辐射的客户没有放射性，因此无需避开其他人，包括年轻人。高蛋白饮食有助于愈合过程。避免阳光直射，并用柔和的肥皂洗净皮肤并拍干，有助于防止皮肤破裂。

The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse should suggest including which in the plan of care? Select all that apply. 1. Restricting all visitors 2. Restricting fluid intake 3. Restricting fresh fruits and vegetables in the diet 4. Apply pressure on the radiated area to prevent bleeding. 5. Inserting an indwelling urinary catheter to prevent skin breakdown 3, 4 Rationale: A client who is experiencing pancytopenia (decrease in all blood cells types: red, white, and platelets) is at high risk for infection because of significantly low immunity. The client should not eat fresh fruits and vegetables because they are at a potential for ingesting bacteria. All foods should be cooked thoroughly. The client should wear a mask when outside of the room to avoid potential infection spread from persons in the hallways. Not all visitors are restricted, but the client is protected from people with known infections. Fluids should be encouraged because dehydration increases the risk for infection. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infection.

护士正在协助制定因化疗导致全血细胞减少症患者的护理计划。护士应建议在护理计划中包括哪些？选择所有符合条件的。 1.限制所有访客 2.限制液体摄入 3.饮食中限制新鲜水果和蔬菜 4.在辐射区域上施加压力以防止流血。 5.插入留置导尿管以防止皮肤破裂 3 4 理由：患有全血细胞减少症（所有血细胞类型减少：红，白和血小板减少）的服务对象由于免疫力明显较低而处于感染的高风险中。服务对象不应吃新鲜的水果和蔬菜，因为它们可能会吸收细菌。所有食物都应彻底煮熟。服务对象在房间外面时应该戴上口罩，以免潜在的感染从走廊上的人传播。并非所有访客都受到限制，但是可以保护客户免受已知感染者的侵害。应鼓励输液，因为脱水会增加感染的风险。应避免侵入性措施，例如留置导尿管，以防止感染。

The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention should be included to prevent renal failure for this client? Select all that apply. 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count 5. Monitoring serum calcium and uric acid levels 1, 5 Rationale: In order to prevent renal failure in the client with multiple myeloma, the nurse should encourage fluids and monitor serum calcium and uric acid levels. Hypercalcemia secondary to bone destruction is a priority concern in the client with multiple myeloma. The nurse should encourage fluids in adequate amounts to maintain an output of 1.5 L to 2 L a day. Clients require about 3 L of fluid per day. The fluid is needed not only to dilute the calcium and uric acid, but also to prevent protein from precipitating in the renal tubules. Oral care, encouraging coughing and deep breathing, and monitoring the red blood cell count are important for clients with cancer, but these interventions are not specific to prevention of renal failure.

护士正在协助制定多发性骨髓瘤患者的护理计划。应包括哪种护理干预措施以防止该患者发生肾功能衰竭？选择所有符合条件的。 1.鼓励液体 2.经常提供口腔护理 3.咳嗽和深呼吸 4.监测红细胞计数 5.监测血清钙和尿酸水平 1、5 理由：为了预防多发性骨髓瘤患者的肾衰竭，护士应鼓励输液并监测血清钙和尿酸水平。继发于骨破坏的高钙血症是多发性骨髓瘤患者的优先考虑事项。护士应鼓励摄入足够量的液体，以保持每天1.5升至2升的输出量。客户每天需要大约3 L的液体。不仅需要稀释钙和尿酸的液体，而且还需要防止蛋白质在肾小管中沉淀的液体。口腔护理，鼓励咳嗽和深呼吸以及监测红细胞计数对癌症患者很重要，但这些干预措施并非专门针对预防肾衰竭

The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. Does the nurse determine that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply: 1. Alopecia 2. Back pain 3. Painless testicular swelling 4. A heavy sensation in the scrotum 5. Elevation in prostate specific antigen (PSA) levels 1, 5 Rationale: Alopecia is not a sign/symptom of testicular cancer. However, it may occur as a result of radiation or chemotherapy. Elevated PSA levels are associated with prostate cancer. Testicular swelling without pain and a feeling of heaviness in the scrotum occur with testicular cancer as a result of the tumor growing. Back pain may indicate metastasis to the retroperitoneal lymph nodes.

护士正在协助社区成员开展有关睾丸癌的健康促进计划。如果社区成员声明睾丸癌的体征/症状，护士是否确定需要进一步的教学？选择所有符合条件的： 1.脱发 2.背痛 3.无痛的睾丸肿胀 4.阴囊有强烈的感觉 5.前列腺特异性抗原（PSA）水平升高 1、5 理由：脱发不是睾丸癌的体征/症状。但是，它可能由于放疗或化学疗法而发生。 PSA水平升高与前列腺癌有关。睾丸癌是肿瘤生长的结果，在睾丸癌中会出现无痛的睾丸肿胀和阴囊沉重的感觉。背痛可能表明转移至腹膜后淋巴结。

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with chemotherapy? 1. Anemia 2. Decreased platelets 3. Increased uric acid level 4. Decreased leukocyte count 3 Rationale: Hyperuricemia, elevated levels of uric acid, is especially common after treatment for leukemias and lymphomas, because the therapy results in massive cell destruction and the release of uric acid. Anemia (low red blood cell count), low platelet levels, and low white blood cell counts are associated with the bone marrow abnormalities that are a part of the leukemias and lymphoma disease process.

护士正在审查接受化疗方案的白血病患者的实验室检查结果。哪个实验室发现表明化学疗法会导致大量细胞破坏？ 1.贫血 2.血小板减少 3.尿酸水平升高 4.白细胞计数减少 3 理由：高尿酸血症，尿酸水平升高，在治疗白血病和淋巴瘤后尤为常见，因为该疗法会导致大量细胞破坏和尿酸释放。贫血（红细胞计数低），血小板水平低和白细胞计数低与骨髓异常有关，而骨髓异常是白血病和淋巴瘤疾病过程的一部分。

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm3 (10 × 109/L). On the basis of this laboratory value, the nurse should perform which intervention? Select all that apply. 1. Monitor stools for occult blood. 2. Keep away from persons who have colds or feel ill. 3. Instruct the client not to bend over at the waist or lift. 4. Floss teeth and rinse the mouth with mouthwash after every meal. 5. Instruct the client to blow nose very gently without blocking either nostril. 1, 3, 5 Rationale: Platelets or thrombocytes are necessary for a client to clot. A high risk of hemorrhage exists when the platelet count drops below 20,000 mm3 (20 × 109/L). Fatal central nervous system hemorrhage or massive GI hemorrhage can occur when the platelet count is less than 10,000 mm3 (10 × 109/L). The client may be treated with medications or platelet or blood transfusions to improve the platelet count. The nurse should monitor the client's stools for blood, both obvious and occult. The client should be very gentle if blowing the nose and not cause any pressure to build up in the head. The client also needs to avoid starting bleeding from epistaxis (nosebleed). The client should not bend over at the waist because this action would increase the pressure within the head and increase the risk for an intracerebral bleed. Clients with decreased immunity, which is not stated in the question, should avoid ill persons. The client should not floss the teeth and only use a soft toothbrush to avoid bleeding in the mouth.

护士正在审查接受化疗的服务对象的实验室检查结果，并注意到血小板计数为10,000 mm3（10×109 / L）。根据此实验室值，护士应采取哪种干预措施？选择所有符合条件的。 1.监测粪便中是否有隐血。 2.远离感冒或生病的人。 3.指示服务对象不要弯腰或抬起腰。 4.每顿饭后用牙线洁牙并用漱口水漱口。 5.指导服务对象轻轻吹鼻，不要阻塞鼻孔。 1 3 5 理由：病人凝结血小板或血小板是必需的。当血小板计数降至20,000 mm3（20×109 / L）以下时，存在出血的高风险。当血小板计数低于10,000 mm3（10×109 / L）时，可能会发生致命的中枢神经系统出血或大量GI出血。可以用药物或血小板或输血治疗服务对象以改善血小板计数。护士应监测服务对象的粪便中是否有明显的和隐匿的血液。 blowing鼻子时，服务对象应非常温柔，不要在头部造成任何压力。服务对象还需要避免从鼻出血开始流鼻血（鼻出血）。服务对象不应在腰部弯腰，因为该动作会增加头部的压力并增加发生脑出血的风险。免疫力下降的患者（问题中未提及）应避免生病。服务对象不应使用牙线清洁牙线，只能使用柔软的牙刷来避免口腔出血。

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. 1. Lesion has a waxy border 2. An irregularly shaped lesion 3. Papule, with a red, central crater 4. A small papule with a dry, rough scale 5. A firm nodular lesion topped with a crust 1, 2 Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

护士正在检查被诊断为基底细胞癌的病灶患者的医疗记录。护士应该期望这种病灶的哪些特征要记录在服务对象的记录中？选择所有符合条件的。 1.病变边界蜡质 2.不规则形状的病变 3.丘疹，中央有红色环形山 4.小丘疹，干燥，粗糙 5.结实的结节性病变，外皮结top 一二 原理：基底细胞癌表现为珍珠状丘疹，中央凹陷，边缘呈蜡状。黑色素瘤是具有红色，白色或蓝色的不规则形状的色素丘疹或斑块。鳞状细胞癌是结实的结节性病变，上面有硬皮或溃疡中央部位。光化性角化病是一种癌前病变，表现为小黄斑或丘疹，干燥，粗糙，附着的黄色或棕色鳞片。

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make? 1. The client is hypotensive. 2. Pain is present from the burn injury. 3. The burn has probably caused laryngeal edema, which has occluded the airway. 4. The client is afraid and is having a panic attack as a result of the unfamiliar surroundings. 3 Rationale: The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness.

护士正在照料刚被脸部和胸部灼伤后刚被送进护理室的病人。护士咳嗽嘶哑，服务对象排痰时出现黑色斑点。客户突然变得焦躁不安，他的肤色也变得暗淡。根据这些数据，护士应该做出哪种解释？ 1.病人血压低。 2.烧伤有疼痛感。 3.烧伤可能引起喉头水肿，阻塞了气道。 4.由于不熟悉的环境，服务对象感到害怕，并且感到恐慌。 3 理由：服务对象表现出几种吸入性伤害的警告信号：有脸部火焰灼伤，声音嘶哑，咳嗽，碳质痰，烧过的面部毛发，面部浮肿和变色的病史。另外，低氧的主要症状之一是躁动。

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? 1. A dependent position 2. Elevation of the knees 3. Flat, without elevation 4. Elevation above the level of the heart 4 Rationale: Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation.

护士正在照顾双腿周围烧伤的病人。哪种腿部位置适合这种烧伤？ 1.附属职位 2.膝盖抬高 3.平坦，无高程 4.海拔高于心脏水平 4 理由：四肢的周围烧伤可能会损害血液循环。将受伤的肢体抬高到心脏水平以上并进行积极的运动有助于减少依赖性水肿的形成。

The nurse is caring for a client with an internal radiation implant. The nurse should observe which principle? Select all that apply. 1. Pregnant women are not allowed into the client's room. 2. Limit the time with the client to 1 hour per 8-hour shift. 3. Wear a lead apron while delivering bedside care to the client. 4. Remove the dosimeter badge when entering the client's room. 5. Individuals less than 16 years old are allowed in the room if they stay 6 feet away from the client. 1, 3 Rationale: A client receiving treatment for cancer with internal radioactive implant is emitting radioactive beams and others in the environment must take precautions to avoid injury. Pregnant persons are not allowed in the room. Nurses delivering bedside care must wear a lead apron which will stop the radioactive beams. The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client's room. Children less than 16 years old and pregnant women are not allowed in the client's room. These guidelines protect individuals from radiation exposure.

护士正在用内部放射植入物照顾病人。护士应遵循哪些原则？选择所有符合条件的。 1.孕妇不得进入服务对象房间。 2.将与客户的时间限制为每8小时轮班1小时。 3.在为患者提供床边护理时，请穿着铅围裙。 4.进入客户房间时，请取下剂量计徽章。 5.如果未满16岁的人士与服务对象保持6英尺的距离，则允许他们进入房间。 一三 理由：使用内部放射性植入物接受癌症治疗的客户正在发射放射性射线，环境中的其他人必须采取预防措施以避免伤害。不允许孕妇进入房间。提供床边护理的护士必须戴铅皮围裙，该围裙会阻止放射性束。护士在带有内部辐射植入物的服务对象的房间中度过的时间为每8小时轮班30分钟。在客户房间时必须佩戴剂量计徽章。未满16岁的儿童和孕妇不得进入服务对象的房间。这些准则可保护个人免于辐射暴露。

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. 1. Back 2. Axilla 3. Eyelids 4. Soles of the feet 5. Palms of the hands 1, 4, 5 Rationale: Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

护士正在给患有湿疹的病人使用外用皮质类固醇激素。护士应在哪个身体部位使用药物？ 选择所有符合条件的。 1.返回 2.腋窝 3.眼皮 4.脚底 5.手掌 一四五 理由：外用皮质类固醇可以被吸收到体循环中。皮肤特别容易渗透的区域（头皮，腋窝，面部，眼睑，颈部，会阴，生殖器）的吸收较高，而皮肤特别易渗透的区域（背部，手掌，脚底）的吸收较低。护士应避免高吸收区域，以防止全身吸收。

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? 1. Wear gloves only. 2. Wear a mask and gloves. 3. Wear a gown and gloves. 4. Avoid touching the client's clothes. 3 Rationale: The Centers for Disease Control and Prevention recommends the wearing of gowns and gloves when in close contact with a person who has methicillin-resistant Staphylococcus aureus (MRSA). Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Methicillin-resistant Staphylococcus aureus (MRSA) is contagious and is spread to others by direct contact with infected skin or infected articles.

护士被告知，指定的服务对象被怀疑患有耐甲氧西林的金黄色葡萄球菌（MRSA）。在照顾客户期间，护士应采取哪些预防措施？ 1.仅戴手套。 2.戴上口罩和手套。 3.穿礼服和手套。 4.避免碰客户的衣服。 3 理由：疾病控制与预防中心建议在与耐甲氧西林金黄色葡萄球菌（MRSA）的人密切接触时穿礼服和手套。口罩不是必需的。通过衣服和其他无生命物体传播的情况很少见。耐甲氧西林金黄色葡萄球菌（MRSA）具有传染性，可通过直接接触受感染的皮肤或受感染的物品而传播给他人。

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Positive patch test 2. Positive culture results 3. Abnormal biopsy results 4. Wood's light examination indicative of infection 2 Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

护士被指派照顾带状疱疹的病人。 基于对这种疾病的病因的理解，护士确定这种明确的诊断是通过哪种诊断测试进行的？ 1.阳性斑贴试验 2.积极的文化成果 3.活检结果异常 4.伍德的光检查表明有感染 2 理由：带状疱疹的经典表现，临床检查是诊断性的。 但是，病变的病毒培养可以提供明确的诊断。 带状疱疹（带状疱疹）是由水痘带状疱疹病毒（一种引起水痘的病毒）的再激活引起的。 斑贴测试是一种皮肤测试，涉及将过敏原施用于皮肤表面以识别特定的过敏。 活检将提供组织的细胞学检查。 在伍德的光检查中，在紫外线下观察皮肤，以识别皮肤的浅表感染。

Care of the donor site: a) Method of care varies, depending on the PHCP's preference. b) A non-adherent gauze dressing may be applied at the time of surgery to maintain pressure and to stop any oozing; always check the surgeon's preference. c) The PHCP may prescribe site treatment with gauze impregnated with petrolatum or with a biosynthetic dressing. d) Keep the donor site clean, dry, and free from pressure. e) Prevent the client from scratching the donor site. f) Apply lubricating lotions to soften the area and to reduce the itching after the donor site is healed. g) Donor site can be reused after healing has occurred (heals spontaneously within 7-14 days with proper care).

捐助者部位的护理： a）护理方法会有所不同，具体取决于PHCP的偏好。 b）手术时可使用非粘性纱布敷料以保持压力并阻止渗血； 始终检查外科医生的偏好。 c）PHCP可能规定用浸有凡士林或生物合成敷料的纱布进行现场治疗。 d）保持供体部位清洁，干燥且无压力。 e）防止客户刮擦供体部位。 f）在施主部位愈合后，涂抹润滑液以软化该区域并减少瘙痒。 g）治愈后供体部位可重复使用（在适当护理下7至14天内自愈）。

Poison Ivy Treatment: A. Treatment of lesions includes calamine lotion and commercial products that soothe lesions, aluminum acetate compresses, and solutions that are astringent and antiseptic, and/or colloidal oatmeal baths to relieve discomfort. B. Topical corticosteroids are effective to prevent or relieve inflammation, especially when used before blisters form. C. Oral corticosteroids may be prescribed for severe reactions and an antihistamine such as diphenhydramine may be prescribed. D. Poison Ivy Treatment Products 1▪ Bentoquatam—for preventive use 2▪ Calamine lotion 3▪ Hydrocortisone 4▪ Zinc acetate; isopropanol; benzyl alcohol

毒藤治疗： A.损伤的治疗包括炉甘石洗剂和舒缓损伤的商业产品，醋酸铝压缩物，收敛剂和防腐剂的溶液和/或胶体燕麦浴以缓解不适。 B.外用皮质类固醇有效预防或减轻炎症，尤其是在水疱形成之前使用时。 C.可能开具严重反应的口服皮质类固醇，并开具苯海拉明等抗组胺药。 D.常春藤毒理产品 1■Bentoquatam-预防性使用 2■炉甘石洗剂 3■氢化可的松 4■醋酸锌； 异丙醇 苯甲醇

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations 1 Rationale: Salicylic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.

水杨酸被处方用于诊断牛皮癣的病人。护士监视服务对象，知道哪个发现表明该药存在全身毒性？ 1.耳鸣 2.腹泻 3.便秘 4.呼吸减少 1个 理由：水杨酸很容易通过皮肤吸收，会导致全身毒性（水杨酸）。症状包括耳鸣，头晕，呼吸过快和心理障碍。便秘和腹泻与水杨酸无关。

Medications to Treat Atopic Dermatitis: A) Systemic Immunosuppressants 1▪ Azathioprine 2▪ Cyclosporine 3▪ Methotrexate 4▪ Oral glucocorticoids B)Topical Immunosuppressants 1▪ Pimecrolimus 1% cream 2▪ Tacrolimus

治疗特应性皮炎的药物： A）全身性免疫抑制剂 1■硫唑嘌呤 2■环孢菌素 3■甲氨蝶呤 4■口服糖皮质激素 B）局部免疫抑制剂 1■吡美莫司1％乳霜 2■他克莫司

Débridement: A) Mechanical 1▪ Performed during hydrotherapy; involves use of washcloths or sponges to cleanse and débride eschar and the use of scissors and forceps to lift and trim away loose eschar 2▪ May include wet-to-dry or wet-to-wet dressing changes 3▪ Painful procedure; may cause bleeding B) Enzymatic 1▪ Application of topical enzyme agents directly to the wound; the agent digests collagen necrotic tissue C) Surgical 1▪ Excision of eschar or necrotic tissue via a surgical procedure in the operating room D) Tangential Technique 1▪ Very thin layers of the necrotic burn surface are excised until bleeding occurs (bleeding indicates that a healthy dermis or subcutaneous fat has been reached). E) Fascial Technique 1▪ The burn wound is excised to the level of superficial fascia; this technique is usually reserved for very deep and extensive burns.

清创术： A）机械 1■在水疗期间进行； 涉及使用毛巾或海绵清洁和清除焦char，并使用剪刀和镊子提起并修剪散焦的焦trim 2■可能包括从干到湿或从湿到湿的敷料更换 3■痛苦的过程； 可能导致出血 B）酶的 1■将局部酶制剂直接涂在伤口上； 该剂可消化胶原坏死组织 C）手术 1■在手术室中通过外科手术切除焦or或坏死组织 D）切线技术 1■切除坏死的烧伤表面非常薄的一层，直到出血为止（出血表明已达到健康的真皮或皮下脂肪）。 E）筋膜技术 1■烧伤创面切至浅筋膜水平； 此技术通常用于非常深而广泛的烧伤。

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing which finding indicates the occurrence of a systemic effect? 1. Hyperventilation 2. Elevated blood pressure 3. Local rash at the burn site 4. Local pain at the burn site 1 Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 2 and 4 describe local rather than systemic effects. Elevated blood pressure may be expected from the pain that occurs with a burn injury.

烧伤患者正在接受局部用乙酸多芬尼酯治疗至受伤部位。护士监视服务对象，知道哪个发现表明发生了全身性影响？ 1.换气过度 2.血压升高 3.烧伤部位的局部皮疹 4.烧伤部位局部疼痛 1个 理由：醋酸马芬奈德是一种碳酸酐酶抑制剂，可抑制肾脏肾脏排酸，从而引起酸中毒。应监测接受此治疗的客户是否存在酸碱失衡（换气过度）的迹象。如果发生这种情况，药物可能会停药1至2天。选项2和4描述的是局部效应，而不是全身效应。烧伤引起的疼痛可能会导致血压升高。

Pathophysiology of Burns: A) Following a burn, vasoactive substances are released from the injured tissue and cause an increase in the capillary permeability, allowing the plasma to seep into the surrounding tissues. B) The direct injury to the vessels increases capillary permeability (capillary permeability decreases 18-26 hours after the burn, but it does not normalize until 2-3 weeks after the injury). C) Extensive burns result in generalized body edema and a decrease in circulating intravascular blood volume. D) The fluid losses result in a decrease in organ perfusion. E) The heart rate increases, cardiac output decreases, and the blood pressure drops. F) Initially, hyponatremia and hyperkalemia occur. G) The hematocrit level increases as a result of plasma loss; this initial increase falls to below normal on the third to fourth day after the burn as a result of red blood cell damage and loss at the time of injury. H) Initially, the body shunts blood from the kidneys, causing oliguria; then the body begins to reabsorb fluid and diuresis of the excess fluid occurs over the next days to weeks. I) Blood flow to the gastrointestinal tract is diminished, which leads to intestinal ileus and gastrointestinal dysfunction. J) Immune system function is depressed, which results in immunosuppression and thus increases the risk of infection and sepsis. K) Pulmonary hypertension can develop, resulting in a decrease in the arterial oxygen tension level and a decrease in lung compliance. L) Evaporative fluid losses through the burn wound are greater than normal, and the losses continue until complete wound closure occurs. M) If the intravascular space is not replenished with intravenously administered fluids, hypovolemic shock and ultimately death occur.

烧伤的病理生理学： A）烧伤后，血管活性物质从受伤的组织中释放出来，并导致毛细血管渗透性增加，从而使血浆渗入周围组织。 B）对血管的直接伤害增加了毛细血管的通透性（烧伤后18-26小时毛细血管的通透性降低，但直到受伤后2-3周才恢复正常）。 C）广泛的烧伤导致全身水肿和循环血管内血容量减少。 D）液体流失导致器官灌注减少。 E）心率增加，心输出量减少，血压下降。 F）最初，发生低钠血症和高钾血症。 G）由于血浆损失，血细胞比容水平增加；由于烧伤后红细胞的损失和损失，烧伤后第三至第四天的初始增加量降至正常水平以下。 H）最初，人体从肾脏分流血液，引起少尿；然后身体开始重新吸收液体，多余的液体利尿在接下来的几天至几周内发生。 I）胃肠道的血流减少，导致肠梗阻和胃肠道功能障碍。 J）免疫系统功能下降，导致免疫抑制，从而增加感染和败血症的风险。 K）可能发展为肺动脉高压，导致动脉血氧张力水平降低和肺顺应性降低。 L）通过烧伤创口蒸发的液体流失量大于正常值，并且这种流失一直持续到伤口完全闭合为止。 M）如果不给静脉内液体补充血管内空间，则会发生低血容量性休克并最终导致死亡。

Burn Injuries: A) Description: Cell destruction of the layers of the skin caused by heat, friction, electricity, radiation, or chemicals B) Burn size 1. Small burns: The response of the body to injury is localized to the injured area. 2. Large or extensive burns: a) Major or extensive burns consist of 25% or more of the total body surface area for an adult and 10% or more of the total body surface area for a child. b) The response of the body to the injury is systemic. c) The burn affects all the major systems of the body.

烧伤： A）说明：由热，摩擦，电，辐射或化学物质引起的皮肤层细胞破坏 B）烧伤尺寸 1.小灼伤：身体对受伤的反应仅限于受伤部位。 2.大块或大块烧伤： a）对于成年人，大面积或大面积烧伤占人体总表面积的25％或以上，对儿童而言，占总体表面积的10％或以上。 b）身体对受伤的反应是全身性的。 c）灼伤会影响身体的所有主要系统。

Escharotomy: a) A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve circulation. b) Escharotomy is performed for circulatory compromise caused by circumferential burns. c) Escharotomy is performed at the bedside without anesthesia because nerve endings have been destroyed by the burn injury. d) Escharotomy can be performed on the thorax to improve ventilation. e) Following escharotomy, check pulses, color, movement, and sensation of the affected extremity, and control any bleeding with pressure. f) Pack the incision gently with fine-mesh gauze as prescribed after escharotomy. g) Apply topical antimicrobial agents to the area as prescribed.

焦痂切开术： a）通过烧焦焦A作纵向切口，以减轻收缩和压力并改善循环。 b）进行切开切开术以消除因周向烧伤引起的循环损害。 c）由于在烧伤中神经末梢已被破坏，因此在没有麻醉的情况下在床边进行了麻醉。 d）可以在胸腔进行直肠切开术以改善通气。 e）进行切开手术后，检查患肢的脉搏，颜色，运动和感觉，并用压力控制出血。 f）切开后，按规定用细网纱轻轻包裹切口。 g）在规定的区域使用局部抗菌剂。

Physical therapy: 1. Perform range-of-motion exercises as prescribed to reduce edema and to maintain strength and joint function. 2. Ambulate the client as prescribed to maintain the strength of the lower extremities. 3. Apply splints as prescribed to maintain proper joint position and prevent contractures: a) Static splints immobilize the joint and are applied for periods of immobilization, during sleeping, and for clients who cannot maintain proper positioning. b) Dynamic splints exercise the affected joint. c) Avoid pressure to skin areas when applying splints, which could lead to further tissue and nerve damage. 4. Scarring is controlled by elastic wraps and bandages that apply continuous pressure to the healing skin during the period of time when the skin is vulnerable to shearing. 5. Antiburn scar support garments are usually worn 23 hours a day until the burn scar tissue has matured, which takes 18 months to 2 years.

物理疗法： 1.按照规定进行运动幅度训练，以减轻水肿并保持力量和关节功能。 2.按照规定步行，以保持下肢的力量。 3.按照规定使用夹板以保持正确的关节位置并防止挛缩： a）静态夹板固定关节，并在固定期间，睡眠期间和无法保持正确姿势的客户使用。 b）动态夹板锻炼受影响的关节。 c）夹板时避免对皮肤区域施加压力，否则可能导致进一步的组织和神经损伤。 4.疤痕是由弹性包裹物和绷带控制的，这些包裹物在皮肤易受剪力作用的期间会不断向愈合的皮肤施加压力。 5.烧伤疤痕支持服通常每天穿着23个小时，直到烧伤疤痕组织成熟为止，这需要18个月至2年。

Acne Products: A) Description 1. Acne lesions that are mild may be treated with nonpharmacological measures, such as gentle cleansing 2 or 3 times daily (oil-based moisturizing products need to be avoided), dermabrasion, or comedo extraction. 2. Mild acne is usually treated pharmacologically with topical agents (antimicrobials and retinoids). 3. Moderate acne is usually treated with oral antibiotics and comedolytics. 4. Severe acne is usually treated with isotretinoin. 5. Hormonal medications such as oral contraceptives and spironolactone may be prescribed to treat acne in female clients. 6. Combination therapy may be prescribed to treat acne. 7. Actions of the medications may include suppressing the growth of Propionibacterium acnes, reducing inflammation, promoting keratolysis, unplugging existing comedones and preventing their development, and normalizing hyperproliferation of epithelial cells within the hair follicles; some medications cause thinning of the skin, which facilitates penetration of other medications. 8. For topical applications: Site should be washed and allowed to dry completely before application; hands should be washed after application. 9. All topical products are kept away from the eyes, inside the nose, lips, mucous membranes, hair, and inflamed or denuded skin.

痤疮产品： 说明 1.轻度痤疮病变可以用非药理学方法治疗，例如每天轻柔清洁2或3次（需要避免油性保湿产品），磨皮或粉刺提取。 2.轻度痤疮通常用局部用药（抗微生物剂和类维生素A）进行药理治疗。 3.中度痤疮通常用口服抗生素和粉刺溶解剂治疗。 4.严重痤疮通常用异维A酸治疗。 5.可以开具口服避孕药和螺内酯等激素类药物来治疗女性客户的痤疮。 6.可以开联合疗法治疗痤疮。 7.药物的作用可能包括抑制痤疮丙酸杆菌的生长，减少炎症，促进角质层溶解，拔除现有的粉刺并阻止其发育，并使毛囊内的上皮细胞过度增殖正常化；一些药物会导致皮肤变薄，从而促进其他药物的渗透。 8.对于局部应用：应用前应清洗场地并使其完全干燥；应用后应洗手。 9.所有外用产品均应远离眼睛，鼻子，嘴唇，粘膜，头发和发炎或裸露的皮肤。

Premalignant Cancers: Stages of Cervical Intraepithelial Neoplasia: 1▪ Stage I: Mild dysplasia 2▪ Stage II: Moderate dysplasia 3▪ Stage III: Severe dysplasia to carcinoma in situ

癌前癌：宫颈上皮内瘤变的阶段： 1■第一阶段：轻度不典型增生 2▪第二阶段：中度不典型增生 3▪第三阶段：严重的不典型增生到原位癌

Grading and Staging of cancer: A) Grading 1▪ Grade I: Cells differ slightly from normal cells and are well differentiated (mild dysplasia). 2▪ Grade II: Cells are more abnormal and are moderately differentiated (moderate dysplasia). 3▪ Grade III: Cells are very abnormal and are poorly differentiated (severe dysplasia). 4▪ Grade IV: Cells are immature (anaplasia) and undifferentiated; cell of origin is difficult to determine. B) Staging 1▪ Stage 0: Carcinoma in situ 2▪ Stage I: Tumor limited to the tissue of origin; localized tumor growth 3▪ Stage II: Limited local spread 4▪ Stage III: Extensive local and regional spread 5▪ Stage IV: Distant metastasis

癌症的分级和分期： A）评分 1■I级：细胞与正常细胞略有不同，并且分化良好（轻度不典型增生）。 2▪II级：细胞更加异常且中等分化（中度发育不良）。 3■III级：细胞非常异常且分化较差（严重发育不良）。 4■IV级：细胞不成熟（发育不良）且未分化； 起源细胞很难确定。 B）分期 1▪0期：原位癌 2▪第一阶段：肿瘤仅限于起源组织。 局部肿瘤生长 3■第二阶段：本地传播有限 4▪第三阶段：广泛的本地和区域传播 5▪第四阶段：远处转移

Warning Signs of Cancer—CAUTION: 1▪ Change in bowel or bladder habits 2▪ Any sore that does not heal 3▪ Unusual bleeding or discharge 4▪ Thickening or lump in the breast or elsewhere 5▪ Indigestion 6▪ Obvious change in wart or mole 7▪ Nagging cough or hoarseness

癌症的警告信号—注意： 1■排便或膀胱习惯的改变 2■任何无法治愈的疮 3■异常出血或分泌物 4■乳房或其他部位增厚或肿块 5■消化不良 6■疣或痣的明显变化 7■咳嗽或声音嘶哑

Classification of Leukemia: 1. Acute Lymphocytic Leukemia ▪ Mostly lymphoblasts present in the bone marrow ▪ The age of onset is usually younger than 15 years 2. Acute Myelogenous Leukemia ▪ Mostly myeloblasts present in the bone marrow ▪ The age of onset is usually between 15 and 39 years 3. Chronic Myelogenous Leukemia ▪ Mostly granulocytes present in the bone marrow ▪ Age of onset is usually in the fourth decade 4. Chronic Lymphocytic Leukemia ▪ Mostly lymphocytes present in the bone marrow ▪ Age of onset is usually older than 50 years

白血病分类： 1.急性淋巴细胞白血病 ▪骨髓中存在淋巴母细胞 ▪发病年龄通常小于15岁 2.急性骨髓性白血病 ▪骨髓中大多数存在成肌细胞 ▪发病年龄通常在15至39岁之间 3.慢性粒细胞性白血病 ▪骨髓中主要存在粒细胞 ▪发病年龄通常在第四个十年 4.慢性淋巴细胞性白血病 ▪骨髓中大多数存在淋巴细胞 ▪发病年龄通常大于50岁

Pelvic exenteration: 1. Description: a) Pelvic exenteration, the removal of all pelvic contents, including bowel, vagina, and bladder, is a radical surgical procedure performed for recurrent cancer if no evidence of tumor outside the pelvis and no lymph node involvement exist. b) When the bladder is removed, an ileal conduit is created and located on the right side of the abdomen to divert urine. c) A colostomy may need to be created on the left side of the abdomen for the passage of feces. 2. Postoperative interventions: a) Similar to postoperative interventions following a hysterectomy. b) Monitor for signs of altered respiratory status. c) Monitor incision site for infection. d) Monitor intake and output and for signs of dehydration. e) Monitor for hemorrhage, shock, and deep vein thrombosis. f) Apply anti-embolism stockings or sequential compression devices as prescribed. g) Administer prophylactic heparin as prescribed. h) Administer perineal irrigations and sitz baths as prescribed. i) Instruct the client to avoid strenuous activity for 6 months. j) Instruct the client that the perineal opening, if present, may drain for several months. k) Reinforce instructions to the client in the care of the ileal conduit and colostomy, if created. l) Provide sexual counseling because vaginal intercourse is not possible after anterior and total pelvic exenteration. m) Internal radiation therapy is used for clients for whom surgery is not an option.

盆腔引流： 1.说明： a）如果没有骨盆外肿瘤的迹象并且没有淋巴结受累，则盆腔引流术是清除复发性癌症的一种根本性外科手术，包括切除肠，阴道和膀胱等所有盆腔内容物。 b）取出膀胱后，会在回肠右侧建立回肠导管，以转移尿液。 c）可能需要在腹部左侧进行结肠造口术以使粪便通过。 2.术后干预： a）类似于子宫切除术后的干预措施。 b）监测呼吸状态是否改变。 c）监测切口部位是否感染。 d）监控进水和出水以及是否有脱水迹象。 e）监测出血，休克和深静脉血栓形成。 f）按照规定使用防栓袜或顺序压缩装置。 g）按规定服用预防性肝素。 h）按规定进行会阴冲洗和坐浴。 i）指导服务对象避免剧烈运动六个月。 j）告知服务对象会阴开口（如果存在）可能会流失数月。 k）加强对客户的回肠导管和结肠造口术（如果创建）的说明。 l）提供性咨询，因为在前盆和盆腔完全浸透后无法进行阴道性交。 m）内部放射疗法用于无法进行手术的患者。

Testicular Cancer: A) Description 1. Testicular cancer arises from germinal epithelium from the sperm-producing germ cells or from nongerminal epithelium from other structures in the testicles. 2. Testicular cancer most often occurs between the ages of 15 and 40 years. 3. The cause of testicular cancer is unknown, but a history of an undescended testicle (cryptorchidism) and genetic predisposition have been associated with testicular tumor development. 4. Metastasis occurs to the lung, liver, bone, and adrenal glands via the blood, and to the retroperitoneal lymph nodes via lymphatic channels. B) Early detection: Perform monthly testicular self-examination. 1. Performing testicular self-examination: Perform monthly; a day of the month is selected and the examination is performed on the same day each month. 2. Client instructions C) Data Collection 1. Painless testicular swelling occurs. 2. "Dragging" or "pulling" sensation is experienced in the scrotum. 3. Palpable lymphadenopathy, abdominal masses, and gynecomastia may indicate metastasis. 4. Late signs include back or bone pain and respiratory symptoms.

睾丸癌： 说明 1.睾丸癌源自产生精子的生殖细胞的生殖上皮或睾丸中其他结构的非生殖上皮。 2.睾丸癌最常发生在15至40岁之间。 3.睾丸癌的病因尚不清楚，但睾丸未降史（隐睾症）和遗传易感性与睾丸肿瘤的发展有关。 4.转移通过血液转移到肺，肝，骨和肾上腺，并通过淋巴道转移到腹膜后淋巴结。 B）早期发现：每月进行一次睾丸自我检查。 1.进行睾丸自我检查：每月进行一次；选择一个月中的某一天，并在每个月的同一天进行检查。 2.客户说明 C）资料收集 1.发生无痛的睾丸肿胀。 2.阴囊出现"拖拉"或"拉扯"的感觉。 3.触及的淋巴结肿大，腹部肿块和男性乳房发育可能预示转移。 4.晚期症状包括背部或骨骼疼痛和呼吸道症状。

Testicular self-examination and client instructions: 1. The best time to perform this examination is right after a shower when your scrotal skin is moist and relaxed, thus making the testicles easy to feel. 2. Gently lift each testicle. Each one should feel like an egg; it should be firm but not hard, and smooth with no lumps. 3. Using both hands, place your middle fingers on the underside of each testicle and your thumbs on top. 4. Gently roll each testicle between the thumb and fingers to feel for any lumps, swellings, or masses. 5. If you notice any changes from 1 month to the next, notify your primary health care provider.

睾丸自我检查和客户指示： 1.进行此项检查的最佳时间是在洗完澡后，阴囊皮肤湿润和放松，从而使睾丸易于感觉。 2.轻轻提起每个睾丸。 每个人都应该像个鸡蛋。 它应该坚固但不硬，并且光滑且无结块。 3.用双手将中指放在每个睾丸的下侧，将拇指放在顶部。 4.在拇指和手指之间轻轻滚动每个睾丸，以感觉是否有肿块，肿胀或肿块。 5.如果您注意到从1个月到下个月的任何变化，请通知您的主要医疗保健提供者。

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication is likely to cause stinging initially." 4. "The medication should be applied directly to the wound." 3 Rationale: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

磺胺嘧啶银处方用于患有部分厚度烧伤的患者，护士会提供有关药物的教学。客户的哪项陈述表明需要进一步了解治疗方法？ 1."药物是一种抗菌药。" 2."药物将帮助治愈烧伤。" 3."药物最初可能会引起刺痛。" 4."药物应直接用于伤口。" 3 原理：磺胺嘧啶银是一种抗菌药，对革兰氏阴性菌，革兰氏阳性菌和酵母菌具有广泛的活性。它直接应用于伤口以帮助愈合。使用时不会引起刺痛。

Care of the graft site: a) Elevate and immobilize the graft site. b) Keep the site free from pressure. c) Avoid weight-bearing. d) When the graft takes, if prescribed, roll a cotton-tipped applicator over the graft to remove exudate, because exudate can lead to infection and prevent graft adherence. f) Monitor for foul-smelling drainage, increased temperature, increased white blood cell count, hematoma formation, and fluid accumulation. g) Reinforce instructions to the client to avoid using fabric softeners and harsh detergents in the laundry. h) Reinforce instructions to the client to lubricate the healing skin with prescribed agents. i) Reinforce instructions to the client to protect the affected area from sunlight. j) Reinforce instructions to the client to use splints and support garments as prescribed.

移植部位的护理： a）升高并固定移植部位。 b）保持场地不受压力。 c）避免承重。 d）如果采取了移植物的规定（如果有规定），则将棉签涂在移植物上以去除渗出液，因为渗出液会导致感染并阻止移植物的粘附。 f）监测是否有恶臭的引流，温度升高，白细胞计数增加，血肿形成和液体积聚。 g）加强对客户的指示，避免在衣物中使用织物柔软剂和刺激性洗涤剂。 h）加强对服务对象的说明，以使用指定的药剂润滑愈合的皮肤。 i）加强对客户的指示，以保护受影响的区域免受阳光照射。 j）加强对客户的指示，以按照规定使用夹板和支撑服。

Fasciotomy: a) An incision is made that extends through the subcutaneous tissue and fascia. b) The procedure is performed if adequate tissue perfusion does not return following an escharotomy. c) Fasciotomy is performed in the operating room with the client under general anesthesia. d) After the procedure, check the pulse, color, movement, and sensation of the affected extremity, and control any bleeding with pressure. e) Apply topical antimicrobial agents and dressings to the area, as prescribed.

筋膜切开术： a）切开穿过皮下组织和筋膜的切口。 b）如果在进行切开切开术后仍未再进行足够的组织灌注，则执行该程序。 c）筋膜切开术是在手术室中由委托人在全身麻醉下进行的。 d）手术后，检查患肢的脉搏，颜色，运动和感觉，并用压力控制出血。 e）按规定在该部位使用局部抗菌剂和敷料。

Intestinal Tumors A. General interventions 1. Monitor for signs of complications, which include bowel perforation with peritonitis, abscess and/or fistula formation (fever associated with pain), hemorrhage (signs of shock), and complete intestinal obstruction. 2. Monitor for signs of bowel perforation, which include low blood pressure, rapid and weak pulse, distended abdomen, and elevated temperature. 3. Monitor for signs of intestinal obstruction, which include vomiting (maybe fecal contents), pain, constipation, and abdominal distention. 4. Note that an early sign of intestinal obstruction is increased peristaltic activity, which produces an increase in bowel sounds; as the obstruction progresses, hypoactive sounds are heard. 5. Prepare for radiation preoperatively if prescribed to facilitate surgical resection and postoperatively to decrease the risk of recurrence or to reduce pain, hemorrhage, bowel obstruction, or metastasis. B) Nonsurgical interventions 1. Preoperative radiation for local control and postoperative radiation for palliation may be prescribed. 2. Postoperative chemotherapy to control symptoms and the spread of disease C) Surgical interventions: Bowel, local lymph node resection, and creation of a colostomy or ileostomy.

肠肿瘤 A.一般干预 1.监测是否有并发症迹象，包括肠道穿孔伴腹膜炎，脓肿和/或瘘管形成（伴有疼痛发烧），出血（休克迹象）和肠梗阻。 2.监测肠穿孔的迹象，包括血压低，脉搏快而弱，腹部胀大和体温升高。 3.监测肠梗阻的迹象，包括呕吐（可能是粪便），疼痛，便秘和腹胀。 4.请注意，肠梗阻的早期迹象是蠕动增加，肠鸣音增加。随着障碍物的进展，会听到过动的声音。 5.如果开了处方以利于手术切除，则应在术前做好放射准备，并在术后减少放射的风险或减轻疼痛，出血，肠梗阻或转移。 B）非手术干预 1.术前放疗可局部控制，术后放疗可减轻疼痛 规定的。 2.术后化疗以控制症状和疾病传播 C）手术干预：肠，局部淋巴结切除，并进行结肠造口术或回肠造口术。

Surgical Interventions for Gastric Cancer 1. Subtotal Gastrectomy 1) Billroth I a)▪ Also called gastroduodenostomy b)▪ Partial gastrectomy; the remaining segment is anastomosed to the duodenum 2) Billroth II a)▪ Also called gastrojejunostomy b)▪ Partial gastrectomy; the remaining segment is anastomosed to the jejunum 2. Total Gastrectomy a)▪ Also called esophagojejunostomy b)▪ Removal of the stomach, with the attachment of the esophagus to the jejunum or the duodenum

胃癌的外科手术干预 1.胃大部切除术 1）比罗罗斯一世 a）■也称为胃十二指肠吻合术 b）■部分胃切除术； 其余节段与十二指肠吻合 2）Billroth II a）■也称为胃空肠吻合术 b）■部分胃切除术； 其余部分吻合到空肠 2.全胃切除术 a）■也称为食管空肠造口术 b）■切除胃，将食道连接至空肠或十二指肠

Gastric Cancer: A) Description 1. Gastric cancer is a malignant growth of the mucosal cells in the inner lining of the stomach, with invasion to the muscle and beyond in advanced disease. 2. No single causative agent has been identified, but it is believed that H. pylori infection and a diet of smoked, highly salted, processed, or spiced foods have carcinogenic effects; other risk factors include smoking, alcohol and nitrate ingestion, and a history of gastric ulcers. 3. Complications include GI hemorrhage, obstruction, metastasis, and dumping syndrome. 4. The goal of treatment is to remove the tumor and provide a nutritional program. B) Postoperative interventions 1. Monitor vital signs. 2. Place in Fowler's position for comfort. 3. Administer analgesics, antiemetics, as prescribed. 4. Monitor intake and output; fluids and electrolyte replacement by IV will be prescribed; parenteral nutrition may also be necessary. 5. Maintain NPO (nothing by mouth) status, as prescribed, for 1 to 3 days until peristalsis returns; monitor bowel sounds. 6. Monitor nasogastric suction. Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours, changes to brown-tinged then yellow or clear. 7. Do not irrigate the nasogastric tube (follow agency procedures); assist the PHCP with irrigation or removal. 8. Advance the diet from NPO to sips of clear water to six small bland meals a day, as prescribed. 9. Monitor for complications such as hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency.

胃癌： 说明 1.胃癌是胃内壁粘膜细胞的恶性生长，在晚期疾病中会侵袭肌肉及其他部位。 2.尚未发现任何单一的致病因素，但是据信幽门螺杆菌感染和烟熏，高盐，加工或加香料的食物的饮食具有致癌作用；其他危险因素包括吸烟，酒精和硝酸盐摄入以及胃溃疡史。 3.并发症包括胃肠道出血，阻塞，转移和倾倒综合征。 4.治疗的目的是切除肿瘤并提供营养计划。 B）术后干预 1.监视生命体征。 2.放在福勒的位置以保持舒适。 3.按规定使用止痛药，止吐药。 4.监控进气和出气；将规定用IV代替液体和电解质；肠胃外营养也可能是必需的。 5.保持规定的NPO（无口腔）状态1到3天，直到蠕动恢复。监视肠鸣音。 6.监测鼻胃抽吸。胃切除术后，通常从鼻胃管引流的血液会持续24小时流血，变为棕褐色，然后变为黄色或透明。 7.请勿冲洗鼻胃管（遵循代理程序）；协助PHCP进行灌溉或清除。 8.按照规定，每天从NPO进食，每天喝一口清水，再吃六顿平淡无味的饭菜。 9.监测是否有并发症，例如出血，倾倒综合征，腹泻，低血糖和维生素B12缺乏症。

Pancreatic Cancer A) Description 1. Most pancreatic tumors are highly malignant, rapidly growing adenocarcinomas that originate from the epithelium of the ductal system. 2. Pancreatic cancer is associated with increased age, a history of diabetes mellitus, alcohol use, a history of previous pancreatitis, smoking, the ingestion of a high-fat diet, and exposure to environmental chemicals. 3. Symptoms usually do not occur until the tumor is large; therefore, the prognosis is poor. 4. Endoscopic retrograde cholangiopancreatography for visualization of the pancreatic duct and biliary system and collection of tissue and secretions may be done. B) Data collection 1. Nausea and vomiting 2. Jaundice 3. Unexplained weight loss 4. Clay-colored stools 5. Glucose intolerance 6. Abdominal pain

胰腺癌 说明 1.大多数胰腺肿瘤是高度恶性的，快速增长的腺癌，起源于导管系统的上皮。 2.胰腺癌与年龄增长，糖尿病史，饮酒史，先前胰腺炎史，吸烟，摄入高脂饮食以及接触环境化学物质有关。 3.症状通常要到肿瘤大时才会出现； 因此，预后较差。 4.可以进行内镜逆行胰胆管造影术以显示胰管和胆道系统，并收集组织和分泌物。 B）数据收集 1.恶心和呕吐 2.黄疸 3.无法解释的体重减轻 4.粘土色凳子 5.葡萄糖不耐症 6.腹痛

Bladder Cancer: A) Description 1. Bladder cancer is a papillomatous growth in the bladder urothelium that undergoes malignant changes and that may infiltrate the bladder wall. 2. Predisposing factors include cigarette smoking, exposure to industrial chemicals, and exposure to radiation. 3. Common sites of metastasis include the liver, bones, and lungs. 4. As the tumor progresses, it can extend into the rectum, vagina, other pelvic soft tissues, and retroperitoneal structures. B) Data collection 1. Gross or microscopic, painless hematuria (most common sign) 2. Frequency, urgency, and dysuria 3. Clot-induced obstruction 4. Bladder wash specimens and biopsy confirm the diagnosis.

膀胱癌： 说明 1.膀胱癌是膀胱尿路上皮的乳头状生长，会发生恶性变化并可能渗入膀胱壁。 2.诱发因素包括吸烟，接触工业化学品和接触辐射。 3.转移的常见部位包括肝，骨骼和肺。 4.随着肿瘤的进展，它可以延伸到直肠，阴道，其他骨盆软组织和腹膜后结构。 B）数据收集 1.肉眼或镜下无痛性血尿（最常见的体征） 2.频率，尿急和排尿困难 3.凝块引起的阻塞 4.膀胱冲洗标本和活检确认诊断。

Autografting: a) Autografting provides permanent wound coverage. b) Autografting is the surgical removal of a thin layer of the client's own unburned skin, which is then applied to the excised burn wound. c) Autografting is performed in the operating room with the client under anesthesia. d) Monitor for bleeding after the graft because bleeding beneath an autograft can prevent adherence. e) If prescribed, small amounts of blood or serum can be removed by gently rolling the fluid from the center of the graft to the periphery with a sterile gauze pad, where it can be absorbed. f) For large accumulations of blood, the PHCP will aspirate the blood with the use of a small-gauge needle and syringe. g) Autografts are immobilized after surgery for 3 to 7 days to allow time for the graft to adhere and attach to the wound bed. h) Position the client for the immobilization and elevation of the graft site to prevent the movement and shearing of the graft.

自移植： a）自体移植提供永久性伤口覆盖。 b）自体移植是通过手术去除客户自己未烧伤的皮肤的薄层，然后将其应用于切除的烧伤伤口。 c）在病人麻醉下在手术室进行自体移植。 d）监测移植后的出血，因为自体移植物下方的出血会阻止粘连。 e）如果有规定，可通过用无菌纱布垫将液体从移植物的中心轻轻滚动到移植物的周围，以除去少量的血液或血清，以吸收血液或血清。 f）对于大量积累的血液，PHCP将使用小号针头和注射器吸出血液。 g）自体移植物在手术后固定3至7天，以留出时间使移植物粘附并附着在伤口床上。 h）放置客户以固定和抬高移植部位，以防止移植物移动和剪切。

The camp nurse asks the children to prepare to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? 1. Immediately before swimming 2. 5 minutes before exposure to the sun 3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun 4 Rationale: Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

营地护士请孩子们如果涂了防晒霜，准备在湖里游泳。 护士提醒孩子，什么时候使用化学防晒霜最有效？ 1.游泳前 2.暴露在阳光下前5分钟 3.即将暴露在阳光下 4.暴露在阳光下至少30分钟 4 基本原理：防晒霜在暴露于阳光下至少30分钟之前最有效，这样它们才能渗透皮肤。 游泳或出汗后应重新涂抹所有防晒霜。

A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication? 1. Digoxin 2. Phenytoin 3. Vitamin A 4. Furosemide 3 Rationale: Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide.

诊所中有一名患有严重痤疮的病人，初级保健人员（PHCP）开了异维A酸的处方。护士会检查客户的用药记录，如果客户也正在服用哪种药物，护士会与PHCP联系吗？ 1.地高辛 2.苯妥英 3.维生素A 4.速尿 3 理由：异维A酸是维生素A的代谢产物，可引起异维A酸的普遍毒性。由于可能增加毒性，因此在异维A酸治疗前应停止补充维生素A。没有与地高辛，苯妥英钠或速尿有关的禁忌症。

The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease? Select all that apply. 1. Fatigue 2. Weakness 3. Joint pain 4. Weight gain 5. Night sweats 6. Enlarged lymph nodes 1, 2, 5, 6 Rationale: Hodgkin's disease (lymphoma) is a chronic, progressive neoplastic disorder of the lymphoid tissue that is characterized by the painless enlargement of lymph nodes with progression to extra-lymphatic sites, such as the spleen and liver. Other signs and symptoms include fatigue, weakness, weight loss, and night sweats. Weight gain and joint pain are not associated with Hodgkin's disease.

该客户被诊断患有霍奇金氏病的医院住院。服务对象的哪些症状和体征与霍奇金氏病有关？选择所有符合条件的。 1.疲劳 2.弱点 3.关节痛 4.体重增加 5.盗汗 6.淋巴结肿大 1 2 5 6 原理：霍奇金氏病（淋巴瘤）是一种慢性进行性淋巴组织肿瘤性疾病，其特征是淋巴结无痛性增大，并发展为脾和肝等淋巴外部位。其他体征和症状包括疲劳，虚弱，体重减轻和盗汗。体重增加和关节痛与霍奇金病无关

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? 1. The return of distal pulses 2. Decreasing edema formation 3. Brisk bleeding from the injury site 4. The formation of granulation tissue 1 Rationale: Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under non-distensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema.

进行环臂烧伤的烟气切开手术的预期治疗结果应该是什么？ 1.远端脉搏的返回 2.减少水肿形成 3.受伤部位的出血迅速 4.肉芽组织的形成 1个 基本原理：进行子宫切除术可缓解隔室综合征，这种综合征在圆周性烧伤中不可扩张的焦char下形成水肿时会发生。子宫切除术是通过无血管焦char进行皮下脂肪手术。尽管出血可能从该部位发生，但它被认为是并发症，而不是预期的治疗结果。肉芽组织的形成不是进行切开术的目的，并且切开术不会影响水肿的形成。

Continuous Bladder Irrigation: A) Description 1. A three-way (lumen) irrigation is used to decrease bleeding and to keep the bladder free from clots. One lumen is for inflating the balloon (30 mL), one is for instillation (inflow), and one lumen is for outflow. B) Interventions 1▪ Maintain traction on the catheter, if applied, to prevent bleeding by pulling the catheter taut and taping it to the abdomen or thigh. 2▪ Instruct the client to keep the leg straight if traction is applied to the catheter and it is taped to the thigh. 3▪ Catheter traction is not released without a primary health care provider's (PHCP's) prescription; it is usually released after any bright red drainage has diminished. 4▪ Use only sterile bladder irrigation solution or prescribed solution to prevent water intoxication. 5▪ Run the solution at a rate, as prescribed, to keep the urine pink. Run the solution rapidly if bright red drainage or clots are present; monitor output closely. Run the solution at about 40 drops (gtt)/minute when the bright red drainage clears. 6▪ If the urinary catheter becomes obstructed, notify the registered nurse (RN); turn off the continuous bladder irrigation, and assist to irrigate the catheter with 30 mL to 50 mL of normal saline, if prescribed; notify the PHCP if the obstruction does not resolve.

连续膀胱灌溉： 说明 1.采用三通（腔）冲洗以减少出血并保持膀胱无凝块。一个内腔用于充气球囊（30 mL），一个内腔用于滴注（流入），一个内腔用于流出。 B）干预 1▪保持牵引力（如果已应用），以通过拉紧导管并将其贴在腹部或大腿上以防止出血。 2▪如果对导管施加牵引力并将其绑在大腿上，请指示服务对象使腿保持笔直。 3■没有初级保健提供者（PHCP）的处方，就不会释放导管牵引力；通常在鲜红色的排水减少后释放。 4▪仅使用无菌膀胱冲洗液或规定的溶液以防止水中毒。 5■按照规定的速度运行溶液，以保持尿液呈粉红色。如果存在鲜红色的排水或凝块，请迅速运行溶液。密切监视输出。当鲜红色的排水清除后，以约40滴（gtt）/分钟的速度运行溶液。 6■如果导尿管阻塞，请通知注册护士（RN）；关闭连续膀胱冲洗，并根据需要协助用30 mL至50 mL生理盐水冲洗导管；如果阻塞没有解决，请通知PHCP。

Sunscreens: 1. Ultraviolet (UV) light can damage the skin and cause premalignant actinic keratoses and some types of skin cancer. 2. Sunscreens prevent the penetration of UV light and protect the skin. 3. Organic (chemical) sunscreens absorb UV light; inorganic (physical) sunscreens reflect and scatter UV light. 4. A sunscreen that protects against both UVB and UVA rays and one that has a sun protection factor (SPF) of at least 15 should be used. 5. Sunscreens are most effective when applied at least 30 minutes before exposure to the sun (sunscreens containing para-aminobenzoic acid or padimate O require application 2 hours before sun exposure). 6. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced. 7. Products containing para-aminobenzoic acid need to be avoided by individuals allergic to benzocaine, sulfonamides, or thiazides. 8. Sunscreens can cause contact dermatitis and photosensitivity reactions. 9. The client should be informed that UV light is greatest between the hours of 10:00 AM and 4:00 PM, and that sunglasses, protective clothing, and a hat should be worn to reduce the risk of skin damage from the sun.

防晒霜： 1.紫外线（UV）会损害皮肤并引起恶性光化性角化病和某些类型的皮肤癌。 2.防晒霜可防止紫外线穿透并保护皮肤。 3.有机（化学）防晒霜吸收紫外线；无机（物理）防晒霜可反射和散射紫外线。 4.应使用既能抵御UVB射线又能抵御UVA射线的防晒霜，并且防晒系数（SPF）至少应为15。 5.防晒霜在暴露于阳光下至少30分钟之前最有效（含有对氨基苯甲酸或己二酸O的防晒霜需要在阳光照射前2小时应用）。 6.游泳或出汗后，每2至3小时应重新涂一次防晒霜；否则，保护时间会缩短。 7.对苯佐卡因，磺酰胺或噻嗪类过敏的个人应避免使用含对氨基苯甲酸的产品。 8.防晒霜可引起接触性皮炎和光敏反应。 9.应告知客户在10:00 AM到4:00 PM之间最大的紫外线照射时间，应戴上墨镜，防护服和帽子以减少日光伤害皮肤的风险。

Hodgkin's Disease: A) Description 1. Lymphomas, classified as Hodgkin's and non- Hodgkin's, depending on the cell type, are characterized by abnormal proliferation of lymphocytes. 2. Hodgkin's disease is a malignancy of the lymph nodes that originates in a single lymph node or a chain of nodes. 3. Metastasis occurs to other, adjacent lymph structures and eventually invades nonlymphoid tissue. 4. The disease usually involves the lymph nodes, tonsils, spleen, and bone marrow; it is characterized by the presence of Reed- Sternberg cells in the nodes. 5. Possible causes include viral infections; clients treated with combination chemotherapy for Hodgkin's disease have a greater risk of developing acute leukemia and non- Hodgkin's lymphoma, among other secondary malignancies. 6. Prognosis depends on the stage of the disease. B) Data collection 1. Fever 2. Malaise, fatigue, weakness 3. Night sweats 4. Loss of appetite, significant weight loss 5. Anemia, thrombocytopenia 6. Enlarged lymph nodes, spleen, and liver 7. Positive biopsy of lymph nodes, with cervical nodes most often affected first 8. Presence of Reed-Sternberg cells in nodes 9. Positive computed tomography (CT) scan of the liver and spleen

霍奇金病： 说明 1.淋巴瘤根据细胞类型分为淋巴瘤和非淋巴瘤，其特征是淋巴细胞异常增殖。 2.霍奇金氏病是起源于单个淋巴结或一连串淋巴结的淋巴结恶性肿瘤。 3.转移发生在其他相邻的淋巴结构上，并最终侵入非淋巴组织。 4.该病通常累及淋巴结，扁桃体，脾脏和骨髓。它的特征是节点中存在Reed-Sternberg细胞。 5.可能的原因包括病毒感染；除其他继发性恶性肿瘤外，接受联合化疗治疗霍奇金病的客户发生急性白血病和非霍奇金淋巴瘤的风险更大。 6.预后取决于疾病的阶段。 B）数据收集 1.发烧 2.不适，疲劳，虚弱 3.盗汗 4.食欲不振，体重明显减轻 5.贫血，血小板减少 6.淋巴结，脾脏和肝脏肿大 7.淋巴结阳性活检，宫颈淋巴结最常见 8.节点中存在Reed-Sternberg细胞 9.肝和脾的计算机断层扫描（CT）阳性扫描

Esophageal Cancer A. Description: 1. Esophageal cancer is a malignancy found in the esophageal mucosa, formed by squamous cell carcinoma (SCC) or adenocarcinoma. 2. The cause is unknown but major risk factors include cigarette smoking, alcohol consumption, and chronic reflux, Barrett's esophagus, and vitamin deficiencies. 3. Complications include dysphagia, painful swallowing, loss of appetite, and malaise. 4. The goal of treatment is to inhibit tumor growth and maintain nutrition. B) Data Collection 1. Dysphagia 2. Odynophagia (painful swallowing) 3. Epigastric pain or sternal pain C) Interventions 1. Monitor nutritional status, including daily weight, intake and output, and calories consumed. 2. Inform the client about diet changes that make eating easier. 3. Prepare the client for chemotherapy and radiation as prescribed. 4. Prepare the client for surgical resection of the tumor as prescribed.

食道癌 说明： 1.食道癌是在食道粘膜中发现的一种恶性肿瘤，由鳞状细胞癌（SCC）或腺癌形成。 2.原因未知，但主要危险因素包括吸烟，饮酒和慢性反流，巴雷特食管和维生素缺乏症。 3.并发症包括吞咽困难，吞咽疼痛，食欲不振和不适。 4.治疗的目的是抑制肿瘤生长并保持营养。 B）数据收集 1.吞咽困难 2.吞咽痛（吞咽疼痛） 3.上腹痛或胸骨痛 C）干预 1.监测营养状况，包括每日体重，摄入量和输出量以及消耗的卡路里。 2.告知服务对象有关饮食变化的信息，使饮食更容易食用。 3.按规定为服务对象做好化疗和放疗的准备。 4.按照规定为服务对象准备手术切除肿瘤。

Mouth Care for the Client with Mucositis: 1▪ Inspect the mouth daily. 2▪ Offer complete mouth care before and after every meal and at bedtime. 3▪ Brush the teeth and tongue with a soft-bristled toothbrush or sponge. 4▪ Provide mouth rinses every 12 hours with the prescribed solution. 5▪ Administer topical anesthetic agents to mouth sores, as prescribed. 6▪ Avoid the use of alcohol- or glycerin-based mouthwashes or swabs because they are irritating to the mucosa. 7▪ Offer soft foods that are cool to warm in temperature rather than foods that are hard or spicy.

黏膜炎患者的口腔护理： 1■每天检查口腔。 2■每餐前后以及就寝时间提供全面的口腔护理。 3■用软毛牙刷或海绵刷洗牙齿和舌头。 4▪每隔12小时用规定的溶液漱口水一次。 5▪按规定对口腔溃疡使用局部麻醉剂。 6▪避免使用基于酒精或甘油的漱口水或棉签，因为它们会刺激粘膜。 7■提供温度凉爽至温暖的软性食品，而不是硬质或辛辣的食品。