Exam 3: Tissue Integrity

Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. 1. Burns 2. Skin cancer 3. Osteomyelitis 4. Diabetic ulcers 5. Myocardial infarction

1. Burns 3. Osteomyelitis 4. Diabetic ulcers

A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. What is the best way for the nurse to assess for jaundice in this patient? 1. Inspect the color of the sclera. 2. Inspect genitalia for color. 3. Blanch the fingernails. 4. Jaundice cannot be assessed in patients with darkly pigmented skin.

1. Inspect the color of the sclera.

A 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. What significant adverse outcome during the first 48 hours should the nurse attempt to prevent? 1. Shock 2. Pneumonia 3. Contractures 4. Hypertension

1. Shock

A patient has multiple solid, red, raised lesions on her legs and groin that she describes as "itchy insect bites." How does the nurse document these lesions? 1. Wheals 2. Bullae 3. Tumors 4. Plaques

1. Wheals

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? 1. "My blood type is A positive." 2. "I smoke one pack of cigarettes a day." 3. "I have been overweight most of my life." 4. "My blood pressure has been high lately."

2. "I smoke one pack of cigarettes a day."

In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. Which statement from the client indicates a correct understanding of the nurse's instructions? 1. "I will sit in a chair for several hours every day." 2. "I will inspect the incision for healing when I change the dressing." 3. "I will check to see whether the staples have dissolved within a few days." 4. "I will call the health care clinic if I see any clear drainage coming from the incision."

2. "I will inspect the incision for healing when I change the dressing."

The nurse observes multiple red circular lesions with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions? 1. Gyrate and linear 2. Annular and generalized 3. Iris and discrete 4. Oval and clustered

2. Annular and generalized

Which change in the epidermis causes increased risk of sunburn? 1. Decreased cell division 2. Decreased melanocyte activity 3. Decreased vitamin D production 4. Decreased immune system cells

2. Decreased melanocyte activity

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. 1. Axilla 2. Fingers 3. Ear lobes 4. Forehead 5. Upper thorax

2. Fingers 3. Ear lobes

A 48-year-old woman asks the nurse how to best protect herself from excessive sun exposure while at the beach. Which response would be most appropriate? 1. "Limit your time in the sun to 5 minutes every hour." 2. "Wear a wet suit that covers your arms and legs." 3. "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours." 4. "Apply sunscreen with a minimum SPF 50 to all skin surfaces before leaving for the beach; this will provide all-day coverage."

3. "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours."

A patient has edema and redness of the skin surrounding the nail on his right index finger. Which data elicited from his history best explains this condition? 1. He has a family history of liver disease. 2. There has been a scabies outbreak among his family members. 3. He has a new full-time position as a dishwasher at a local restaurant. 4. He had several warts removed from his hands 2 years ago.

3. He has a new full-time position as a dishwasher at a local restaurant.

Which diagnostic study is used to investigate the cause of an inflamed joint and determines a client's response to antiinflammatory drug therapy? 1. Duplex venous Doppler 2. Plethysmography 3. Thermography 4. Somatosensory evoked potential

3. Thermography

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up? 1. "I will leave the skin markings intact." 2. "I will protect the skin from sources of heat." 3. "I will wear soft clothing over the upper body." 4. "I will use an oatmeal-based lotion after each treatment."

4. "I will use an oatmeal-based lotion after each treatment."

Which client has a primary lesion? 1. One with scales 2. One with ulcers 3. One with fissures 4. One with erosions

4. One with erosions

Which disorder is an example of a vascular lesion? 1. Dermatofibroma 2. Vitiligo 3. Sebaceous cyst 4. Port wine stain

4. Port wine stain

When examining a 16-year-old male patient, the nurse notes multiple pustules and comedones on the face. The nurse recognizes that increased activity of which cells or glands produce these manifestations? 1. Epidermal cells 2. Eccrine glands 3. Apocrine glands 4. Sebaceous glands

4. Sebaceous glands

A 60-year-old male patient states that he has a sore above his lip that has not healed and is getting bigger. The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are commonly associated with which malignancy? 1. Kaposi's sarcoma 2. Malignant melanoma 3. Basal cell carcinoma 4. Squamous cell carcinoma

4. Squamous cell carcinoma