Custom: VN 500 Integ Pharm 0919

A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

-"How do you handle stress?" Unmanaged stress can affect the client physiologically, and it is important for the nurse to address stress management with the client. However, this question does not obtain specific information in relation to the skin problem and is not necessary for the nurse to include at this time.

A nurse is reviewing discharge instructions with a client who has pruritus following treatment for scabies. Which of the following instructions should the nurse inlclude?

-"Wear loose fitting clothing while you are experiencing itching." The nurse should advise the client that to help relieve the itching of pruritus, the home environmental temperature should be slightly cool and the client should wear loose clothing.

A nurse is reinforcing teaching with a client who has a skin lesion ad is scheduled for an excisional skin biopsy. Which of the following information should the nurse include in the teaching?

-"You will need to change the dressing daily." The nurse should instruct the client that a dressing will be applied after the biopsy which will need a daily dressing change.

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

-A client who has swelling and tenderness around the wound Manifestations of infection include purulent drainage, swelling, warmth, tenderness around the wound, and a failure to heal.

An older adult client in a long-term care facility has a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

-A reddened area over the sacrum A reddened area over a bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

A nurse is assisting with the care of a client who is brought to the emergency department and has burn injuries. Which of the following findings should the nurse identify the client has a deep partial-thickness burn?

-Burned area red in color with eschar present This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain.

A nurse is providing nail care for a client. Which of the following actions should the nurse take?

-Clean under the nail with an orange stick. The nurse should use an orange stick to push back the cuticle and clean under the nail.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

-Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

A nurse in a provider's office is collecting data from a client who reports pruritus and reddened, fluid-filled vesicles on her lower leg. The nurse should suspect which of the following disorders?

-Contact dermatitis Contact dermatitis is an acute or chronic skin inflammation that results from direct skin contact with chemicals or allergens. Typical findings include erythema (redness), pruritus (itching), vesicles, and scales.

A nurse is caring for client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

-Cover the area with saline-soaked sterile dressings. The nurse should cover the wound with a sterile, saline-soaked dressing to keep the exposed organs and tissues moist.

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

-Hardened skin Hardened, tight skin is an expected finding with scleroderma. In addition to rigid skin and subcutaneous tissues, the distal extremities stiffen and lose mobility. It can also cause disorders of the heart, lungs and kidneys.

A nurse is in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?

-History of poor wound healing The presence of hyperglycemia leads to poor wound healing due to decreased blood supply to the tissue.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

-IV insertion site It is essential that the nurse monitor the IV insertion site, generally for a central venous access device for TPN, for signs of infection regardless of the fluid delivery system.

A nurse is reinforcing teaching with a client who has a superficial lesion. A biopsy indicates malignant melanoma. Which of the following treatment choices should the nurse include in the teaching?

-Surgical excision The client who has malignant melanoma should have surgical excision of the malignant melanoma and excision of adjacent tissues to assure surrounding tissue is free of cancer.

A nurse is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficency?

-Swollen, bleeding gums The client who is malnourished can have swollen, bleeding gums from a vitamin C deficiency.

A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the client's room, he states that, following a bout of coughing, "something popped in my belly." The nurse lifts the sheets and sees that the client's gown is bloody. After sending a coworker to get the charge nurse and call the surgeon, which of the following actions should the nurse take next?

-Cover the wound with moist sterile gauze. The greatest risk to the client is injury to the internal organs due to a wound dehiscence; therefore, the next action the nurse should take is to cover the wound with a moist sterile dressing.

A nurse is caring for a client with severe burns to both lower extremities. The clients is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

-"Large incisions will be made in the burned tissue to improve circulation." An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has had a deep burn and is experiencing significant swelling. The swelling that occurs secondary to burn injuries that completely encircle a body part, such as an arm or the chest, can cause tightness and constriction of underlying tissue and can shut off circulation in the affected area. Making surgical incisions into the burned tissue allows the skin to expand and re-establish circulation.

A nurse is reinforcing teaching with a client about the risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching?

-"I need to use sunscreen even in winter." The client should use sunscreen daily to minimize the negative effects of ultraviolet rays. The vast majority of cases of skin cancer diagnosed each year are considered to be sun related.

A nurse is reinforcing teaching with a client who has questions concerning the various treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following treatments should she include in the teaching? (Select all that apply.)

-Cryosurgery Cryosurgery freezes the cancerous tissue and is used in the treatment of BCC. -Electrodessication Electrodessication uses electrical energy to destroy and remove cancerous tissue and is used in the treatment of BCC. -Radiation therapy Radiation therapy can be used in the treatment of BCC depending on client age and the location of the tumor. -Mohs surgery Mohs micrographic surgery is used in the treatment of BCC as the most accurate method of removing the tumor while preserving healthy tissue.

A nurse is caring for a client who was admitted to the emergency department immediately following a snake bite to her forearm. The client suspects that the snake was venomous. Which of the following nursing interventions is appropriate?

-Determine the need for a tetanus immunization. Clients who have a puncture wound to the skin due to a snakebite are at risk for tetanus because the fangs of the snake can be contaminated with bacteria from soil or feces. Therefore, the nurse should ask the client when she had her last tetanus immunization.

A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take?

-Don clean gloves to remove the dressing. Standard precautions require the nurse to don clean gloves whenever there is a possibility of coming into contact with secretions. Sterile gloves are not necessary until applying the new sterile dressing.

A nurse is caring for a client who has psoriasis. The client has a prescription for a coal tar preparation to be used with a therapeutic bath. Which of the following actions should the nurse take when assisting the client with the bath?

-Dry the client by blotting or patting the skin with a towel. The nurse should dry the client after bathing by blotting or patting the skin dry with a towel rather than rubbing the skin.

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

-Edema Manifestations of infection include purulent drainage, swelling, warmth, tenderness around the wound, and a failure to heal.

A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take?

-Empty the suction device every 4 hr. The nurse should empty the client's wound drain every 4 hr to monitor for bleeding.

A nurse is contributing to the plan of care for a client who has herpes zoster. Which of the following actions should the nurse recommend including in the plan of care?

-Empty the suction device every 4 hr. The nurse should empty the client's wound drain every 4 hr to monitor for bleeding.

A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?

-Erythema Erythema (redness), pain, warmth, and swelling indicate phlebitis.

A nurse is caring for a client following the application of an aquathermia pad. Which of the following manifestations should the nurse identify as an indication that the client has a superficial burn?

-Erythema Erythema is a manifestation of a superficial burn.

A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

-Fever Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.

A nurse is collecting data from a client who has severe burn injuries. The nurse shades in the diagram indicating the burned surface areas. What percentage of body surface area should the nurse estimate the client has burned? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

-First, determine the burned areas: Entire left arm Half of right arm Entire front torso -Next, use the Rule of Nines for estimating the percentage of body surface area burned: Head 9% Torso 36% total (front 18%, back 18%) Arm 9% each Leg 18% each Perineum 1% -Apply the Rule of Nines to the client's burns: Left arm = 9%½ of right arm = 4.5% Front torso = 18% -Then, total the burned areas: 9 + 4.5 + 18 = 31.5%

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

-Fully recollapse the reservoir after emptying it. To reestablish the vacuum, the reservoir must be compressed fully after it is emptied.

A nurse is collecting data from a newborn who is 48-hr old. Which of the following findings should the nurse report to the provider?

-Generalized petechiae Generalized petechiae can indicate a clotting factor deficiency or infection; therefore, the nurse should report these findings to the provider for further evaluation.

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?

-Granulation tissue Granulation tissue forms in healing wounds during the proliferative phase. Granulation tissue is soft, red tissue with a granular appearance that bleeds easily.

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

-Granulation tissue on the surface of the wound As the wound heals, the nurse should expect the wound base to become redder as granulation tissue lines the surface of the wound. Therefore, this is an expected finding. The vacuum-assisted closure device assists in wound closure by applying a localized negative pressure to draw the edges of the wound together. The device consists of a suction tube embedded in a foam dressing. The foam dressing is applied to the wound bed and sealed in place with an occlusive dressing. The suction is then attached to the vacuum unit, causing the foam to collapse and resulting in drainage of excess fluids, and increasing circulation to the wound bed.

A charge nurse in a long-term care facility will be implementing a new protocol to meet the joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?

-Identify the clients at greatest risk for development of pressure ulcers. A pressure ulcer is a breakdown in the skin that occurs due to constant pressure against the skin, reducing blood flow during immobility. The most common locations are over bony prominences such as the heels, hips, and ankles. The first action the nurse should take using the nursing process is to collect data from the clients about their risk for developing pressure ulcers.

A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

-Identify when the client first noticed the lesion. The first action the nurse should take using the nursing process is to collect data from the client. Therefore, the priority is to determine when the lesion was first discovered.

A nurse is caring for a client who has recurrent herpes simplex type 1 lesions. The nurse should perform a focused assessment of which of the following areas of the client's body?

-Mouth Herpes simplex type 1 most commonly occurs on the client's mouth.

A nurse is assisting in planning an educational session regarding risk factors for skin cancer to a group of clients. Which of the following information should the nurse plan to include in the session? (Select all that apply.)

-Overexposure to ultraviolet light. Overexposure to ultraviolet light is a risk factor for developing skin cancer. Rays from the sun are known to be carcinogenic and can result in malignant changes. -Chronic skin lesions Chronic skin lesions are a risk factor for developing skin cancer. Clients are taught to monitor for a change in these chronic lesions as a precursor to a malignancy. -Genetic predisposition Genetic predisposition is a risk factor for developing skin cancer, particularly malignant melanoma.

A nurse is reinforcing teaching with a client who has herpes zoster about the order of occurrence of findings associated with this disorder. In what order should the nurse identify the typical occurrence of findings? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

-Parethesia -Redness and swelling -Appearance of vesicles -Weeping blisters -Crusted lesions The client who has the usual presentation of herpes zoster will present with paresthesias followed by redness and swelling, before the vesicles appear along the affected nerve. These vesicles usually open and begin to drain for a few days before they crust over and healing begins.

A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?

-Pinch up a fold of skin to check for turgor. The nurse should pinch an area of skin on the back of the forearm or on the sternum to check skin turgor. If tenting results, it indicates dehydration.

A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take?

-Prepare to administer acyclovir. Acyclovir is effective in the treatment of herpes zoster, especially if administered within the first 2 to 3 days of the eruption.

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan?

-Provide the client a diet high in vitamin C. Vitamin C is essential for wound healing to promote formation of new capillaries, synthesis of new tissue and development of collagen.

A nurse is caring for a client who has suspected superficial spreading melanoma. When collecting data about the client's lesion, which of the following is an expected finding?

-Purplish in color Dark pigmentation of the lesion is an expected finding of malignant melanoma.

A nurse is reinforcing teaching with a client who has herpes zoster. The nurse should include which of the following statements in the teaching?

-Recurrence of infection can be triggered by stress or trauma. The virus remains in the body in a dormant state in the nerve ganglia and the client is asymptomatic. Recurrence of herpes zoster is triggered by physical or psychological stressors such as trauma, fever, or malignancy.

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?

-Reports of exposure to a skin irritant A common cause of contact dermatitis is exposure to a topical irritant; therefore, identifying this irritant is an important component of data collection.

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

-Reposition the client at least every 2 hr. The nurse should change the client's position at least every 2 hr to stimulate circulation and prevent pressure ulcers.

A nurse in the outpatient clinic is collecting data from a client who has psoriasis. Which of the following findings should the nurse expect?

-Silvery, white scales The characteristic lesions of psoriasis are thick, erythematous plaques covered by silvery scales.

A nurse is collecting data from a client who has basal cell carcinoma on her nose. Which of the following findings should the nurse expect?

-Small, translucent nodule These findings are consistent with basal cell carcinoma.

A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause of non-melanoma skin cancer?

-Sun exposure According to evidenced-based practice, the nurse should identify exposure to the sun as the leading cause of non-melanoma skin cancer. Ultraviolet light radiation from the sun can cause cancerous changes in the skin. Decreased ozone protection has increased the amount of radiation exposure and increased the risk of cancer for clients regardless of skin color.

A nurse in a health clinic is assisting in the planning of an educational program on skin cancer. Which of the following statements should be included in the presentation?

-Sun exposure as a child is a significant risk factor for skin cancer. Sunburn as a child is a significant risk factor for the development of skin cancer, with blue-eyed blondes and redheads as the most susceptible.

A nurse is reinforcing teaching about possible treatments with a client who has psoriasis. Which of the following treatment options should the nurse including in the teaching? (Select all that apply.)

-Tar preparations Tar preparations help to impede the proliferation of skin cells and are effective to remove scales as well as increase remission. -Corticosteroids Corticosteroids help reduce the inflammation and pruritus associated with psoriasis. -Ultraviolet light therapy Ultraviolet light therapy is effective in the treatment of psoriasis by decreasing the growth rate of epidermal cells.

A nurse is collecting data on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?

-The client produces black colored sputum. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority finding is black colored sputum which is a manifestation of smoke inhalation and can lead to pulmonary failure and respiratory distress.

A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse?

-The wound has a halo of erythema on the surrounding skin. A ring of redness on the surrounding skin can indicate underlying infection, and the nurse should report any indication of infection such as purulent drainage, swelling, warmth, or strong odor.

A nurse is assisting with the development of a teaching plan for a client who has psoriasis. Which of the following statements should the nurse include in the plan?

-Treatment will include coal tar preparations. Coal tar preparations are used in the treatment of psoriasis; therefore, the nurse should include this treatment in the teaching plan.

A nurse is assisting with the admission of a client who has an open wound that is infected from community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA). The client's wound has not responded to treatment with surgical drainage. The nurse should anticipate that the client will require which of the following interventions?

-Trimethoprim/sulfamethoxazole CA-MRSA is typically caused by strains of staphylococcus. Trimethoprim/sulfamethoxazole is a combination antimicrobial medication that is used frequently to treat CA-MRSA.

A nurse is collecting data from a client following a bee sting. Which of the following findings can indicate an anaphylactic reaction to the venom?

-Urticaria Urticaria or the appearance of hives can signal the onset of an anaphylactic reaction.

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?

-Vitamin C Diets high in protein and vitamin C are an essential recommendation because these nutrients are essential for promoting wound healing.

A nurse is reinforcing medication teaching with a client who has psoriasis and a new prescription for triamcinolone cream. Which of the following statements should the nurse include in the teaching?

-Wrapping plastic around the site can increase the medication's effectiveness. The provider may prescribe occlusive dressings to be applied over the site after the topical corticosteroid is applied in order to increase the medication's effectiveness.

A nurse is caring for a client who has widespread psoriasis. The nurse should prepare the client for which of the following treatments?

-​Exposure to photochemotherapy Photochemotherapy combined with mediation treatment, through the use of ultraviolet light, has been shown to be effective in the treatment of widespread psoriasis.

A nurse is collecting data from a client who has multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy?

-​Irregular borders Findings associated with malignant changes in a nevus include asymmetry, irregular borders, non-uniform pigmentation, and increased diameter. Therefore, the nurse should report irregular borders on any of the nevi to the findings to the provider.

A nurse is caring for a client who states he has nevus that has increased in size and changed in color. On examination, the nurse notes an elevated two centimeter lesion that is dark brownish-black in color with irregular borders. The nurse should recognize that these findings are consistent with which of the following medical diagnoses?

-​Malignant melanoma These findings are consistent with malignant melanoma which is associated with changes in preexisting nevi.