Med/Surg Final

A patient diagnosed with bedbug bites says to the nurse, "I am so embarrassed. I shower daily and do not live in an unclean environ- ment." Which response by the nurse is most appropriate? a. "No need to be embarrassed. These things happen." b. "Showering will not kill bedbugs." c. "Have you been traveling or staying in a hotel?" d. "Have you seen bedbugs or their eggs on your clothing?"

c. "Have you been traveling or staying in a hotel?"

Which class of medication would exclude a patient from participating in negative pressure wound therapy (NPWT)? a. Antihypertensives b. Anticoagulants c. Nonsteroidal anti-inflammatory drugs d. Antidepressants

b. Anticoagulants

The nurse is assessing a patient's wound every day for signs of healing or infection. Which finding is a positive indication that healing is progressing as expected? a. Eschar starts to lift and separate from the tissue beneath, which appears dry and pale. b. Area appears pale pink, progressing to a spongy texture with a beefy red color. c. Tissue is softer and more yellow, and wound exudate increases substantially. d. Ulcer surface is excessively moist with a deep reddish-purple color.

b. Area appears pale pink, progressing to a spongy texture with a beefy red color.

Which finding indicating infection does the nurse report to the health care provider immediately? a. Presence of granulation and re-epithelialization b. Changes in the quantity, color, or odor of exudate c. Progressive decrease in ulcer size or depth d. Beefy red color as it grows and fills the wound

b. Changes in the quantity, color, or odor of exudate

The nurse is caring for a patient who is several days postoperative. The unlicensed assistive personnel (UAP) reports that the patient's linens were changed but are wet again. The nurse notes that the patient's skin is excessively warm and moist. What is the nurse's priority action? a. Monitor intake and output. b. Check the patient's temperature. c. Direct the UAP to change the linens. d. Help the patient with hygiene

b. Check the patient's temperature.

The patient reports a red, raised, itchy rash over most of his body. What terms would the nurse use to document the patient's skin problem? a. Red, macular, lichenified b. Erythematous, diffuse, pruritic c. Cyanotic, annular, papular d. Red, universal, circinate

b. Erythematous, diffuse, pruritic

he health care provider informs the nurse that the patient is having severe pruritus. Based on this information, the nurse is most likely to observe which assessment finding? a. Fluid-filled, weeping blisters b. Excoriations from scratching c. Dry, flaking skin with peeling d. Signs or symptoms of infection

b. Excoriations from scratching

The nurse is assessing the nutritional status of a patient at risk for skin breakdown who has been refusing to eat the hospital food. Which indicator is the most sensitive in identifying inadequate nutrition for this patient? a. Serum albumin level of 3.5 mg/dL b. Prealbumin level of 17.5 mg/dL c. Lymphocyte count of 1900/mm3 d. Weight loss of 10% of total body weight

b. Prealbumin level of 17.5 mg/dL

he school nurse discovers a child has tinea capitis. What does the nurse instruct the parents to do? a. Treat the family pet and temporarily isolate the pet. b. Refrain from sharing items like combs or hats. c. Scrub the shower area and keep the feet dry. d. Ensure all family members carefully wash their hands.

b. Refrain from sharing items like combs or hats.

The school nurse is examining a child and observes linear ridges on the inner aspect of the wrists. The child reports intense itching, especially at night. The nurse scrapes the lesion and examines it under a microscope. Which condition does the nurse suspect? a. Head lice b. Scabies c. Body lice d. Dermatitis

b. Scabies

A fair-skinned patient has a history of chronic liver problems; liver enzyme tests and biliru- bin results are pending. In order to assess for jaundice, where is the best place for the nurse to look for a yellowish discoloration? a. Hard palate b. Sclera c. Palms d. Conjunctivae

b. Sclera

A home health nurse is visiting an older patient in January who lives alone in a small mobile home in the southwestern United States. The patient is recovering from a hip fracture. What is an expected finding for this patient? a. Wound healing is delayed. b. Skin is generally very dry. c. Affected leg has edema. d. Surgical site has petechiae

b. Skin is generally very dry.

An obese elderly patient who has been living alone presents with overall poor hygiene. Her clothes are dirty, and she has a strong body odor. The nurse systematically assesses the patient's skin surface and will give special attention to which area? a. Scalp b. Skinfolds c. Nails d. Mucous membranes

b. Skinfolds

In order to assist the health care provider in determining if avoidance therapy is appropriate for a patient, which question would the nurse ask? a. Do you have a history of surgery for removal of skin growths? b. Have you noticed a change in appearance of a mole? c. Does anyone residing in your household have a similar skin problem? d. Have you used any new soaps, detergents, or personal care products?

d. Have you used any new soaps, detergents, or personal care products?

The nurse is interviewing a patient with a red rash that itches and burns. Which question would the nurse ask to help identify a trans- mittable disorder? a. "When did you first notice the redness and itching?" b. "Is there a family history of chronic skin problems?" c. "Have you recently traveled outside of the United States?" d. "Have any of your family members had recent skin problems?"

d. "Have any of your family members had recent skin problems?"

Using the Braden Scale to evaluate a patient for pressure ulcer risk, which factors are documented? Select all that apply. a. Incontinence b. Mental status c. Gas exchange d. Nutrition status e. Mobility f. Immunity

a. Incontinence b. Mental status d. Nutrition status e. Mobility

A mother reports that her child has dry skin with itching that seems to worsen at night. What nonpharmacologic interventions does the nurse teach to the mother? Select all that apply. a. Keep the child's fingernails trimmed short and filed to reduce skin damage. b. Place mittens or splints on the child's hands at night if the scratching is causing skin tears. c. Ensure a warm and moderately humid sleeping environment. d. Read the child a relaxing and familiar story to reduce stress. e. Use antibacterial soap during bathing to decrease the risk of infection. f. Provide adequate fluid intake to keep the child well hydrated.

a. Keep the child's fingernails trimmed short and filed to reduce skin damage. b. Place mittens or splints on the child's hands at night if the scratching is causing skin tears. d. Read the child a relaxing and familiar story to reduce stress. f. Provide adequate fluid intake to keep the child well hydrated.

The emergency department (ED) nurse is giving discharge instructions to the parents of a child who has been diagnosed with bedbug bites. What instructions does the nurse give to the parents? a. Washing linens in hot soapy water will eliminate the problem. b. Using a topical insecticide kills bedbugs on the body surface. c. Repeatedly vacuuming surfaces of furniture or mattresses will help. d. Hiring a pest control company with bedbug experience is an option.

d. Hiring a pest control company with bedbug experience is an option

In which chronic health condition is the nurse most likely to observe increased moisture of the patient's skin? a. Kidney disease b. Diabetes mellitus c. Polycythemia vera d. Hyperthyroidism

d. Hyperthyroidism

The nurse is assessing the skin of an older patient. Which assessment finding needs follow-up? a. Multiple liver spots on the arms b. Dry, flaking skin on the lower extremities c. Presence of cherry hemangiomas d. Irregular light-brown macule (6.5 cm) on the right scapula

d. Irregular light-brown macule (6.5 cm) on the right scapula

The health care provider has ordered diagnostic testing to determine if a patient has a fungal infection of the skin. Which test does the nurse prepare the patient for? a. Shave biopsy b. Punch biopsy c. Wood's light examination d. KOH test

d. KOH test

he nurse reads in the chart that the patient has palmoplantar pustulosis (PPP). Which area of the patient's body will the nurse assess for this condition? a. Skinfold areas, such as axillae or beneath breasts b. Mouth area and oral mucous membranes c. Bony prominences such as heels, sacrum, or trochanters d. Palms of the hands and soles of the feet

d. Palms of the hands and soles of the feet

The nurse is caring for an obese patient who has been on bedrest for several days. The nurse observes that the patient is beginning to develop redness on the sacral area. What intervention is used to decrease the shearing force? a. Place the patient in a high Fowler's position. b. Instruct the patient to use arms and legs to push when moving self in bed. c. Obtain an order for the patient to be up 3-4 times per day in a recliner chair. d. Place the patient in a side-lying position.

d. Place the patient in a side-lying position.

In regulating body temperature, how much evaporative water loss can occur during hot weather or exercise? a.500-600 mL/day b.700-900 mL/day c.2-4 L/day d.10-12 L/day

d.10-12 L/day

A nurse is performing a musculoskeletal assessment on an older adult living independently. What normal physiologic changes of aging does the nurse expect? Select all that apply. A. Muscle atrophy B. Slowed movement C. Scoliosis D. Arthritis E. Widened gait

A, B, D, E

Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? A. Decreased skin turgor B. Decreased pulse pressure C. Decreased core body temperature D. Decreased urine specific gravity

D. Decreased urine specific gravity

A patient receiving negative pressure wound therapy (NPWT) should be monitored closely for which potential complication? a. Bleeding b. Infection c. Pain d. Nausea

a. Bleeding

In an older adult, decreased vitamin D production increases the patient's susceptibility to which condition? a.Osteomalacia b. Osteodystrophy c.Hypothermia d.Dry skin

a. Osteomalacia

The patient has a superficial raised lesion. Which type of biopsy does the nurse prepare the patient for? a. Excisional biopsy b. Shave biopsy c. Punch biopsy d. Tzanck smear

b. Shave biopsy

In caring for an older adult patient, the room may need to be kept warmer because of a decrease in which integumentary factor? a. Sebum production b. Subcutaneous fat layer c. Thickness of epidermis d. Number of active melanocytes

b. Subcutaneous fat layer

While performing skin assessment on an elderly client, the nurse observes an isolated brownish-purple lesion with irregular borders on the anterior chest wall. The lesion feels slightly raised on palpation, and crusted blood is visible at the lower edge. Which is the appropriate nursing intervention? A. Wash the lesion gently with warm water to remove the crusts and teach not to pick it. B. Document lesion's location, size, and characteristics and request a dermatology consult. C. Reassure that the lesion is a common occurrence with aging, especially in sun-exposed areas. D. Ask the patient about exposure to new lotions or perfumes that could cause an allergic reaction.

B. Document lesion's location, size, and characteristics and request a dermatology consult.

A client recently diagnosed with primary bone cancer states, "My life is over. I'll never get married now!" What is the nurse's best action at this time? A. Refer the client to a clergy member or spiritual leader. B. Ask the client what is meant by that statement. C. Listen while the client expresses feelings. D. Provide hope that marriage will happen.

C. Listen while the client expresses feelings.

Which statement, made by the student nurse, requires further teaching by the nurse preceptor? A. "I will always remove crusts from bacterial lesions before applying topical antimicrobials." B. "I will avoid using adult briefs for my bedridden incontinent client who has a perineal yeast infection." C. "If signs and symptoms of a systemic infection are present, I will contact the health care provider to discuss ordering blood cultures." D. "I will tell my client that transmission-based precautions are not necessary after the first dose of oral antiviral therapy for herpes zoster is taken."

D. "I will tell my client that transmission-based precautions are not necessary after the first dose of oral antiviral therapy for herpes zoster is taken."

Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for further teaching by the nurse? A. "I'm going to continue having my DXA scans as my doctor orders." B. "I'll drink only a half glass of wine occasionally to help me sleep." C. "I plan to increase calcium and vitamin D foods in my diet." D. "I'm going to jog every day for at least 30 minutes."

D. "I'm going to jog every day for at least 30 minutes."

The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? A. "You can see black smoke when carbon monoxide is in the air." B. "If you are experiencing carbon monoxide poisoning, your skin will begin to turn blue." C. "The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire." D. "It is important to have carbon monoxide detectors in your home because this is an odorless gas."

D. "It is important to have carbon monoxide detectors in your home because this is an odorless gas."

A client returns to the postanesthesia care unit (PACU) after an arthroscopy to repair a knee injury. What is the nurse's priority when caring for this client? A. Perform passive range-of-motion exercises. B. Keep the affected leg immobilized. C. Ensure that the patient uses the patient-controlled analgesia (PCA) pump. D. Check the neurovascular status of the affected leg and foot.

D. Check the neurovascular status of the affected leg and foot.

The nurse is instructing the unlicensed assistive personnel (UAP) about how to perform skin care for a patient who is at risk for pressure ulcers because of immobility and incontinence. What instructions would the nurse give? a. After cleaning, apply a commercial skin barrier to areas exposed to urine or feces. b. After cleaning, apply a light layer of powder or talc directly on the perineum. c. Scrub and vigorously rub the skin to completely remove soil or dried feces. d. Use an antibiotic soap and rinse with hot water to remove soap residue.

a. After cleaning, apply a commercial skin barrier to areas exposed to urine or feces.

Which condition is most likely to result in clubbing of the fingernails? a. Chronic hypoxia b. Prolonged vitamin D deficiency c. Uncontrolled blood glucose d. Prolonged febrile state

a. Chronic hypoxia

he nurse sees in the patient's record that the patient has a Braden score of 20. Which nursing action is the nurse most likely to perform in the care of this patient? a. Continue routine assessments. b. Turn patient every 2 hours. c. Consult with the nutritionist. d. Assist to keep skin clean and dry.

a. Continue routine assessments.

A patient is prescribed a topical steroid for treatment of contact dermatitis. Which instruction does the nurse provide to the patient about this drug? a. Moisten dressings with warm tap water; place over topical steroids for short periods. b. Apply topical steroids and then cover with an occlusive dressing. c. Apply a topical corticosteroid sparingly on the face. d. Discontinue the use of topical steroids when symptoms subside.

a. Moisten dressings with warm tap water; place over topical steroids for short periods.

The nurse is caring for an older adult patient with very dark skin. The patient has a low hemoglobin and hematocrit. How does the nurse assess for pallor in this patient? a. Observe the mucous membranes for an ash-gray color. b. Use indirect, low fluorescent lighting. c. Gently push on the skin and watch for blanching. d. Inspect the conjunctivae for a yellowish color.

a. Observe the mucous membranes for an ash-gray color.

A patient with a history of heart failure goes to the outpatient clinic for a follow-up appointment. How does the nurse assess for dependent edema in this patient? a. Palpate the dorsum of the foot or the medial ankle. b. Weigh the patient and compare to the baseline weight. c. Check the patient's buttocks or lower back. d. Ask the patient about intake and output.

a. Palpate the dorsum of the foot or the medial ankle.

The nurse is caring for a patient with myxedema. Which area of the body is the nurse most likely to assess for evidence of nonpitting edema? a. Tibia b.Forehead c.Ankle d.Sacrum

a. Tibia

What does the treatment for psoriasis include? Select all that apply. a. Ultraviolet light therapy b. Calcipotriene topical cream c. Topical methotrexate d. Oral ciprofloxacin e. Corticosteroids f. Light therapy with lasers

a. Ultraviolet light therapy b. Calcipotriene topical cream c. Topical methotrexate e. Corticosteroids f. Light therapy with lasers

The nurse is caring for a patient admitted with a rash of white or red edematous papules or plaques of various sizes. The patient states that the rash developed after he ate seafood, and he thinks he is allergic to it. What does the nurse suspect? a. Urticaria b. Pruritus c. Eczema d. Psoriasis

a. Urticaria

he nurse is teaching an older adult about how to deal with and prevent dry skin. What information does the nurse include? Select all that apply. a. Use a room humidifier during the winter months or whenever the furnace is in use. b. Take a complete bath or shower every day. c. Maintain a daily fluid intake of 1000 mL unless contraindicated. d. Avoid clothing that continuously rubs the skin, such as tight belts or pantyhose. e. Thoroughly rinse soap from the skin. f. Vigorously rub the skin until it is free of moisture.

a. Use a room humidifier during the winter months or whenever the furnace is in use. d. Avoid clothing that continuously rubs the skin, such as tight belts or pantyhose. e. Thoroughly rinse soap from the skin.

The nurse is caring for a patient in a prolonged coma after a serious head injury. The nurse uses which interventions to prevent the development of pressure ulcers for this patient? Select all that apply. a. Use pillows or padding devices to keep heels pressure free. b. Assess heel positioning every 8 hours. c. Delegate turning and positioning every 2 hours. d. Obtain an order for pressure-relief devices. e. Give special attention to fleshy or muscular areas. f. Provide adequate nutrition for positive nitrogen balance

a. Use pillows or padding devices to keep heels pressure free. c. Delegate turning and positioning every 2 hours. d. Obtain an order for pressure-relief devices. f. Provide adequate nutrition for positive nitrogen balance

Which factors are included in the ABCDE features associated with skin cancer? Select all that apply. a.Asymmetry of shape b. Border regularity c. Color variation within a lesion d.Crusting, bleeding, or itching e.Diameter greater than 5 mm f.Evolving or changing of any feature

a.Asymmetry of shape c. Color variation within a lesion f.Evolving or changing of any feature

Which individual has the highest risk for chronic paronychia? a.Construction worker b. Nurse c.Homeless veteran d.Immigrant from Southeast Asia

b. Nurse

It is important for the nurse to avoid taping the skin of an older adult patient because of a decrease in which integumentary factor? a. Vitamin D production b. Thickness of epidermis c. Dermal blood flow d. Epidermal permeability

b. Thickness of epidermis

The nurse is caring for a very dark-skinned patient who has high risk for thrombocytopenia. Which area of the patient's body is the best place to check for petechiae? a.Anterior chest b.Oral mucosa c.Palmar surface d.Periorbital area

b.Oral mucosa

A patient has a partial-thickness wound. How long does the nurse anticipate the healing by epithelialization will take? a. 24 hours b. 2-3 days c. 5-7 days d. 12-14 days

c. 5-7 days

For which action must the nurse intervene when a nursing student is providing care for a patient with increased risk for pressure ulcer development? a. Student assists patient to consume most of lunch tray. b. Student provides assistance with bathing of back, lower legs, and feet. c. Student massages reddened area over the coccyx region. d. Student reminds patient to change positions every 2 hour

c. Student massages reddened area over the coccyx region.

During change of shift report, the nurse is informed that the patient has lichenified areas on both lower extremities. Based on this information, the nurse expects to observe which clinical finding on the lower extremities? a. Loss of hair b. Liver spots c. Thickened skin d. Yellow discoloration

c. Thickened skin

The nurse is caring for a patient with a liver disorder. In addition to observing for a yellow- orange discoloration of the skin, which laboratory test is the nurse most likely to monitor? a. Hemoglobin level b. Vitamin D level c. Total serum bilirubin d. Serum calcium level

c. Total serum bilirubin

A patient is diagnosed with Stevens-Johnson syndrome. What is the priority action for the health care team? a. Treat the subjective symptoms of pain and itching. b. Closely observe for signs of renal failure. c. Protect against localized skin infection. d. Identify the offending drug and discontinue it

d. Identify the offending drug and discontinue it

A decreased number of active melanocytes in an older adult lead to which result? a. Decreased wound healing b. Decreased skin tone and elasticity c. Increased skin transparency d. Increased sensitivity to sun exposure

d. Increased sensitivity to sun exposure

What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry. B. Check the surgical dressing to ensure that it is intact. C. Assess neurovascular assessment in the affected arm. D. Monitor intake and output.

A. Monitor vital signs, including pulse oximetry.

The nurse is teaching a patient about treatment of pediculosis pubis. What information does the nurse include? Select all that apply. A. Proper use of topical sprays or creams, such as permethrin B.Abstinence from sexual intercourse with the infected person C. Treatment of the patient's social contacts D. Side effects of ciprofloxacin or doxycycline E. Washing clothing and bedding in hot water with detergent F. Pubic lice are found only in the genital regions

A. Proper use of topical sprays or creams, such as permethrin B.Abstinence from sexual intercourse with the infected person C. Treatment of the patient's social contacts E. Washing clothing and bedding in hot water with detergent

The nurse is preparing patient education material about healthy skin. What is the single most important preventive health behavior the nurse promotes? A. Limit continuous sun exposure. B. Drink plenty of water. C. Practice good skin hygiene. D. Eat a well-balanced diet. Brush the skin surface and observe for flaking. Push on the skin and observe for Gently pinch the skin on the chest and observe for tenting. Push on the skin over the tibia and observe for depth of indentation.

A. Limit continuous sun exposure.

Which are appropriate nursing interventions for a client who has poor personal hygiene? Select all that apply. A. Obtain a social history. B. Assist the client with bathing. C. Tell the client that he or she smells bad. D. Consult social services to assess the client's living conditions. E. Teach client and family members how to help with personal hygiene. F. Notify the health care provider of any suspected drug or alcohol addiction. G. Assess for poor cognitive function or physical limitations that might interfere with grooming. H. Instruct the client and family to use rubbing alcohol to cleanse skin areas with most visible amount of dirt.

A. Obtain a social history. B. Assist the client with bathing. D. Consult social services to assess the client's living conditions. E. Teach client and family members how to help with personal hygiene. F. Notify the health care provider of any suspected drug or alcohol addiction. G. Assess for poor cognitive function or physical limitations that might interfere with grooming.

Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? Select all that apply. A. Place client in isolation. B. Encourage multiple visitors to support client. C. Ensure that no plants or flowers are in the client's room. D. Teach family members not to bring fresh fruit and vegetables to the client. E. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.

A. Place client in isolation. C. Ensure that no plants or flowers are in the client's room. D. Teach family members not to bring fresh fruit and vegetables to the client.

Which additional assessment data will the nurse collect from an older Euro-American (white) woman to determine the client's risk for osteoporosis? Select all that apply. A. Tobacco use, especially smoking B. Alcohol use each day C. Exercise and activity level D. Dietary intake of vitamin D E. Use of calcium supplements F. Medication history

A. Tobacco use, especially smoking B. Alcohol use each day C. Exercise and activity level D. Dietary intake of vitamin D E. Use of calcium supplements F. Medication history

The nurse is teaching a client how to treat pediculosis (lice). Which teaching will the nurse include? Select all that apply. A. Use a fine-tooth comb to remove nits. B. Chemical killing of these parasites is required. C. Wash bed linens in cold water to remove lice and eggs. D. Lice do not affect clothing items because they jump off of fabric. E. Eggs of lice must be killed to reduce the risk for development of skin cancer. F. Lice can infest hair on the head, in the genital region, in the axillae, on eyelashes, and on other body hair (e.g., arms, chest, legs).

A. Use a fine-tooth comb to remove nits. B. Chemical killing of these parasites is required. F. Lice can infest hair on the head, in the genital region, in the axillae, on eyelashes, and on other body hair (e.g., arms, chest, legs).

What is the appropriate nursing response when a client asks, "What is a punch biopsy?" A. "The health care provider will use a scalpel to remove a portion of the skin." B. "A circular cutting instrument will be used to remove a small plug of tissue." C. "A deep specimen of skin will be taken, and then the health care provider will suture this area closed." D. "A local anesthetic will be injected before a razor blade is moved parallel to the skin's surface to obtain a sample."

B. "A circular cutting instrument will be used to remove a small plug of tissue."

The nurse is encouraging range-of-motion exercises for the client, who states, "This hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). Select all that apply. A. "You have to do the exercises to get well." B. "Range of motion helps promote mobility." C. "Just visualize a beach to get your mind off of the pain." D. "Let me check when you were last given pain medication." E. "Which techniques for pain management have you used in the past that were helpful?" F. "The health care provider has ordered these exercises, and it is important that you do them as instructed."

B. "Range of motion helps promote mobility." D. "Let me check when you were last given pain medication." E. "Which techniques for pain management have you used in the past that were helpful?"

A client has a synthetic cast placed for a right wrist fracture in the emergency department. Which priority health teaching is important for the nurse to provide for this client before returning home? Select all that apply. A. "Keep your right arm below the level of your heart as often as possible." B. "Use an ice pack for the first 24 hours to decrease tissue swelling." C. "Move the fingers of the right hand frequently to promote blood flow." D. "Report coolness or discoloration of your right hand to your doctor." E. "Don't place any device under the cast to scratch the skin if it itches."

B. "Use an ice pack for the first 24 hours to decrease tissue swelling." C. "Move the fingers of the right hand frequently to promote blood flow." D. "Report coolness or discoloration of your right hand to your doctor." E. "Don't place any device under the cast to scratch the skin if it itches."

The nurse is caring for a client immediately after a bunionectomy. What is the nurse's priority action? A. Relieve or reduce the patient's pain. B. Assess neurovascular status in the affected foot. C. Apply a hot compress to the surgical area. D. Check the surgical dressing for intactness.

B. Assess neurovascular status in the affected foot.

A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse's best initial action? A. Remove the splint to reduce skin pressure. B. Perform a neurovascular assessment. C. Report the client's concern to the primary health care provider. D. Inspect the skin under the elastic bandage.

B. Perform a neurovascular assessment.

A 45-year-old client is receiving subcutaneous injections of a biologic therapy for plaque psoriasis. Which condition will the nurse immediately report to the health care provider? A. Missed injection B. Increased pruritus C. Cough with fever D. New plaques on leg

C. Cough with fever

The nurse is performing an assessment on a female client and notices a large, irregularly shaped mole on her upper back. The client expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a dermatological health care provider. B. Ask if there are any other lesions that bother her. C. Perform a head-to-toe skin assessment and document the findings. D. Teach about the importance of avoiding excessive sun exposure and tanning beds.

C. Perform a head-to-toe skin assessment and document the findings.

A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A. "The pain will go away after the swelling decreases." B. "That's phantom limb pain, and every amputee has that." C. "Your foot has been amputated, so it's in your head." D. "On a scale of 0 to 10, how would you rate your pain?"

D. "On a scale of 0 to 10, how would you rate your pain?"

When developing a plan of care for a patient who is at high risk for skin breakdown, what interventions does the nurse include in the plan of care? Select all that apply. a. Applying a pressure reduction overlay to the mattress b. Frequent repositioning of the patient c. Instructing UAP to assess the patient's skin daily d. Instructing UAP to massage reddened areas e. Using positioning devices to keep heels pressure free f. Applying a skin barrier to areas exposed to urine or stool

a. Applying a pressure reduction overlay to the mattress b. Frequent repositioning of the patient e. Using positioning devices to keep heels pressure free f. Applying a skin barrier to areas exposed to urine or stool

The nurse is directing the home health unlicensed assistive personnel (UAP) in the care of an older adult patient. The patient wants to prevent dry skin. What does the nurse direct the UAP to do? a. Assist with a complete bath or shower only every other day (wash face, axillae, perineum, and any soiled areas with soap daily). b. Generously apply oil and leave it on for 20 minutes; then bathe the patient, especially the genital and axillary areas. c. Use an antimicrobial skin soap and wash the patient carefully; then apply alcohol- based astringent, especially to the legs and arms. d. Use hot water with a deodorant soap; then gently pat the patient dry and apply oil and cream to the skin.

a. Assist with a complete bath or shower only every other day (wash face, axillae, perineum, and any soiled areas with soap daily).

The health care provider recommended over- the-counter diphenhydramine to treat the patient's hives. What does the nurse suggest to the patient for self-care? a. Avoid alcohol consumption, which can potentiate the sedative effect of diphenhydramine. b. Warm environments and warm showers will accelerate metabolism and recovery. c. Use an emollient cream or lotion after bathing to reduce the itching. d. Apply a topical antibiotic cream after bathing in the evening.

a. Avoid alcohol consumption, which can potentiate the sedative effect of diphenhydramine.

The nurse and the unlicensed assistive personnel (UAP) are helping patients to move in bed. For which patient are they most likely to use a lift sheet? a. Elderly patient on steroids with thin, fragile skin b. Obese patient at risk for sacral pressure ulcers c. Child with a total body rash with vesicular oozing d. Patient with diabetes and delayed wound healing

a. Elderly patient on steroids with thin, fragile skin

The nurse is performing a physical exam on a patient and observes a dark asymmetrical lesion on the patient's back. The patient states, "I can't see back there and I don't know how long it has been there." What is the most important intervention for this patient? a. Encourage the patient to make an appointment with a dermatologist. b. Teach the patient how to do a total skin self-evaluation. c. Instruct the patient on self-care measures, such as use of sunscreen. d. Obtain an order for a fungal culture and take a fungal specimen.

a. Encourage the patient to make an appointment with a dermatologist.

A patient has a history of heart failure and demonstrates some mild shortness of breath, with crackles on auscultation. The skin is tight and shiny over the patient's lower extremities. How does the nurse interpret these findings? a. Fluid retention and edema b. Early signs of poor circulation c. Early stage of infection d. Normal for this patient

a. Fluid retention and edema

Which skin disorder is most associated with a familial disposition? a. Psoriasis b. Ringworm c. Cellulitis d. Paronychia

a. Psoriasis

The nurse is interviewing a patient who has come to the walk-in clinic and observes the patient has matted hair, body odor, and soiled clothes. For which conditions will the nurse assess that could contribute to the patient's overall hygiene? Select all that apply. a. Range of motion and strength to perform self-care b. Access to shower facilities and a laundry c. Patient's knowledge (or memory) of how to perform hygiene care d. Patient's perception of how he or she appears to others e. Patient's current antihypertensive drug prescription f. Intactness of sensory functions (e.g., sight, smell)

a. Range of motion and strength to perform self-care b. Access to shower facilities and a laundry c. Patient's knowledge (or memory) of how to perform hygiene care d. Patient's perception of how he or she appears to others f. Intactness of sensory functions (e.g., sight, smell)

The nurse is giving discharge instructions to a patient and family who must continue dressing changes and wound care at home. Which point does the nurse emphasize to help the family prevent infection and minimize cost? a. Scrupulous handwashing before and after wound care b. Use of sterile water for flushing and sterile dressing materials c. Use of clean gloves for performing dressing changes d. Careful disposal of contaminated dressings in a biohazard bag

a. Scrupulous handwashing before and after wound care

The nurse is assessing a patient's coccyx region and finds an area that is reddened but intact. When pressure is applied, the area does not blanch. What does this suggest to the nurse? a. Stage 1 pressure ulcer b. Stage 2 pressure ulcer c. Stage 3 pressure ulcer d. Stage 4 pressure ulcer

a. Stage 1 pressure ulcer

he nurse is assessing a patient's skin and notes a 2" 3 2" purplish-colored area on the coccyx with skin intact. These findings suggest which stage of a pressure ulcer? a. Suspected deep tissue injury b. Stage I pressure ulcer c. Stage II pressure ulcer d. Unstageable

a. Suspected deep tissue injury

The nurse is examining a patient's skin and sees large, sore-looking, raised bumps with pustular heads. Which method does the nurse use to obtain a specimen to test for a bacterial infection? a. Take a culture swab of the purulent material. b. Take cells from the base of a lesion for a Tzanck smear. c. Scrape scales from the lesions and prepare a slide with KOH. d. Assist the health care provider with a skin biopsy.

a. Take a culture swab of the purulent material.

The nurse is caring for a postsurgical patient and observes that the patient's skin is red, moist, and hot to the touch. Which vital sign is of primary interest? a. Temperature b. Pulse c. Respirations d. Blood pressure

a. Temperature

The health care provider instructs the nurse to prepare a light-skinned patient for evaluation of skin pigment changes. Which piece of equipment does the nurse obtain to assist the provider with this examination? a. Wood's light b. Glass slide c. Biopsy tray d. Nonfluorescent light

a. Wood's light

The nursing student must perform a skin assessment on an older adult patient and observe for signs of skin breakdown. What does the student do to meet the clinical objective for effective time management? a.Examine the skin while bathing or assisting the patient with hygiene. b.Complete the assessment before the end of the clinical experience. c.Check to see if the primary nurse has already completed the assessment. d.Perform the examination when the patient willingly consents and agrees.

a.Examine the skin while bathing or assisting the patient with hygiene.

The nurse is assessing a patient who is African American with very dark skin. Which technique does the nurse use to assess the health of the nails? a.Gently squeeze the end of the finger, exert downward pressure, and then release the pressure. b.Obtain a color chart to identify the normal color of nails for the dark-skinned patient. c. Observe the nail bed for a pale pink color and a shiny, smooth surface. d.Soak the fingertips in warm water; then gently push back the cuticle

a.Gently squeeze the end of the finger, exert downward pressure, and then release the pressure.

The nurse is performing a skin assessment on a patient and notes an area on the forearm that feels hard or "woody." How does the nurse interpret this physical finding? a.Inflammation b. Subcutaneous fat c.Psoriasis d. Skin cancer

a.Inflammation

Age-related changes in the integumentary system include a decrease in which factors? Select all that apply. a.Vitamin D production b.Thickness of epidermis c.Thickness of dermis d.Epidermal permeability e.Dermal blood flow f.Size of nasal pores

a.Vitamin D production b.Thickness of epidermis d.Epidermal permeability e.Dermal blood flow

The unlicensed assistive personnel (UAP) is helping a patient with morning care. The patient has nonintact skin. What priority instruction does the nurse provide for the UAP when providing care for this patient? a.Wear gloves using universal precautions. b.Save any fingernail clippings or hair samples for testing. c.Have a second UAP assist you when getting this patient out of bed. d.Let the patient soak in the bathtub for15 minutes before rinsing.

a.Wear gloves using universal precautions.

A young female patient reports an unusual increase in facial hair. Which question helps the nurse if an examination of the genitalia is required? a. "Have you noticed any bruising or unusual bleeding?" b. "Have you noticed any deepening of your voice quality?" c. "Are you having any trouble urinating?" d. "Does your skin seem unusually dry and flaky?"

b. "Have you noticed any deepening of your voice quality?"

A patient weighs 110 pounds. The nurse knows that the patient must have an intake of 30 to 35 calories per kilogram of body weight in order to maintain a positive nitrogen balance. How many calories per day does the patient need to take in? a. 1200-1500 b. 1500-1750 c. 1800-2050 d. 2100-2350

b. 1500-1750

Which patients with pressure ulcers are at high risk for developing infection? Select all that apply. a. 39-year-old with rotator cuff injury b. 56-year-old with diabetes mellitus c. 62-year-old with COPD on steroid therapy d. 70-year-old with high cholesterol who walks 2 miles a day e. 76-year-old with low white blood cell count f. 80-year-old with right hip replacement who needs help repositioning

b. 56-year-old with diabetes mellitus c. 62-year-old with COPD on steroid therapy e. 76-year-old with low white blood cell count f. 80-year-old with right hip replacement who needs help repositioning

Which patients are at risk for pressure ulcers? Select all that apply. a. A confused patient who likes to wander through the halls b. A middle-aged quadriplegic patient who is alert and conversant c. A bedridden patient who is in the late stage of Alzheimer's d. A very overweight patient who must be assisted to move in the bed e. An ambulatory patient who has occasional urinary incontinence f. A thin patient who sits for long periods and refuses meals

b. A middle-aged quadriplegic patient who is alert and conversant c. A bedridden patient who is in the late stage of Alzheimer's d. A very overweight patient who must be assisted to move in the bed f. A thin patient who sits for long periods and refuses meals

The home health nurse reads in the documentation that the patient has chronic venous stasis. Which assessment finding does the nurse expect to observe? a. Reddish-blue color to the hands b. Grayish-tan color in the lower legs c. Warmth and redness in the lower legs d. Yellowish tinge to soles of the feet

b. Grayish-tan color in the lower legs

Which assessment finding is the best indicator of a healthy nail? a. Nail bed color is normal for the patient. b. Nail bed blanches with gentle pressure. c. Nails are well groomed and nicely shaped. d. Nail surface is smooth and transparent.

b. Nail bed blanches with gentle pressure.

he wound care specialist nurse is selecting a product to be used in caring for a patient with pressure ulcers. Which factors will the nurse consider? Select all that apply. a. Insurance reimbursement and cost b. Number and severity of pressure ulcers c. Patient's ability to reposition self d. Need to reduce shearing forces e. Risk for developing new pressure ulcers f. Wishes and concerns of family member

b. Number and severity of pressure ulcers c. Patient's ability to reposition self d. Need to reduce shearing forces e. Risk for developing new pressure ulcers

A patient has a stage III pressure ulcer over the left trochanter area that has a thick exudate. The wound bed is visible and beefy red, and the edges are surrounded with swollen pink tissue. The exudate has an odor. How does the nurse determine which dressing is best for this wound? a. Selects a hydrophilic dressing for heavy exudate b. Obtains an order to consult certified wound care specialist c. Obtains an order for the type of dressing from health care provider d. Applies a dry dressing and observes for "strike through"

b. Obtains an order to consult certified wound care specialist

Extensive destruction of the epidermis will result in the loss of the body's ability to perform which function? a. Cellular regeneration for wound healing and skin repair b. Photoconversion of 7-dehydrocholesterol to active vitamin D c. Cutaneous vascular promotion or inhibition of heat loss d. Storage of extra energy reserve for periods of decreased intake

b. Photoconversion of 7-dehydrocholesterol to active vitamin D

The nurse observes that the patient has large areas of ecchymoses. Which laboratory result is the nurse most likely to check? a. Total serum bilirubin b. Platelet count c. Hemoglobin level d. White cell count

b. Platelet count

A patient is referred to a dermatologist for evaluation of a rash of unknown origin. The patient has trouble communicating specific information because of "nervousness." Which questions does the nurse use to help the patient prepare for the dermatologist's appointment? Select all that apply. a."Have you received the flu vaccine?" b."When did you first notice the rash?" c."Where on the body did the rash first start?" d."How do you feel about the skin rash?" e."Are you having an itching or burning sensation?" f."Have you been having fever or sore throat?"

b."When did you first notice the rash?" c."Where on the body did the rash first start?" e."Are you having an itching or burning sensation?" f."Have you been having fever or sore throat?"

A dark-skinned patient is admitted for pneumonia. What is the most accurate method to assess for cyanosis in this patient? a.Observe for shallow and rapid respirations. b.Check the tongue and lips for a gray color. c.Auscultate for decreased breath sounds in lung fields. d.Inspect the palms and soles for a yellow-tinged color.

b.Check the tongue and lips for a gray color.

What should the nurse notice in a patient with adequate tissue integrity and body protection related to skin function? a.Body temperature is normal after dose of b.Oral mucous membranes are moist and pink. c.Areas of uneven pigmentations are covered with clothing. d.Hair is patchy and brittle but clean and well groomed

b.Oral mucous membranes are moist and pink.

A patient on the unit has herpes zoster. Which staff members would be best to assign to the care of this patient? a.Any staff member, as long as personal protective equipment (PPE) is utilized b.Staff members who have had chickenpox c.Staff members who have completed training on herpes zoster d.Staff members with no small children at home

b.Staff members who have had chickenpox

What is a key teaching point for an older patient with a decreased number of active melanocytes? a.Teach the patient to avoid applying tape to skin. b.Teach the patient to wear sunscreen and a large hat when outside. c.Teach the patient to keep track of pigmented lesions. d.Teach the patient to apply moisturizers to skin at least twice every day.

b.Teach the patient to wear sunscreen and a large hat when outside.

Which expected outcome is most appropriate for a patient with a 1" 3 1" stage II sacral pressure ulcer? a. Wound will show healing and no infection. b. Patient will verbalize that wound is smaller. c. Wound will show granulation and decrease in size. d. Patient will rate pain at an acceptable level.

c. Wound will show granulation and decrease in size.

The nurse is interviewing a patient who wants evaluation of a skin problem. When the nurse attempts to collect demographic data, the patient states, "My age, race, occupation, and hobbies should not affect my access to health care." What is the nurse's best response? a. "The information obtained has nothing to do with access to care." b. "I understand your concerns, but we will see you regardless of your answers." c. "Age, race, occupation, and hobbies can be contributing factors to skin problems." d. "We are happy to see you, but you have to answer these questions."

c. "Age, race, occupation, and hobbies can be contributing factors to skin problems."

he nurse is performing daily wound care and dressing changes on a patient with a full-thickness wound. The patient protests when the nurse attempts to debride the wound. What is the nurse's best response? a. "Reepithelialization, granulation, and contraction are natural body processes that will occur if this tissue is removed." b. "I know this is uncomfortable, but don't you want your wound to heal as fast as possible? This treatment allows the body to heal itself." c. "Harmful bacteria can grow in the dead tissue, and it also interferes with the body's attempt to fill in the wound with new cells and collagen." d. "I would never force a patient to do anything, but this really is the best treat- ment for the wound that you have."

c. "Harmful bacteria can grow in the dead tissue, and it also interferes with the body's attempt to fill in the wound with new cells and collagen."

A patient is scheduled to have a punch biopsy for a lesion on the midback. What does the nurse tell the patient about the procedure? a. There will be a small scar similar to any surgical procedure. b. The surgeon uses a scalpel to punch through the lesion. c. A local anesthetic is used, and it causes a temporary burning sensation. d. The health care provider uses a lens that punches the skin to reveal the shape of the lesion.

c. A local anesthetic is used, and it causes a temporary burning sensation.

The nurse is assessing a patient's skin and notes a slightly darkened area over the left ankle. The patient denies pain but reports a recent swelling in the area. Based on the skin appearance and the patient's report, what does the nurse do next? a. Ask the patient if there was a serious and deep burn to the area. b. Observe the area for scar tissue. c. Ask the patient if there was inflammation to the area. d. Take a scraping of the skin for culture.

c. Ask the patient if there was an inflammation to the area.

To differentiate between color changes in the nail bed related to vascular supply and those from pigment disposition, what does the nurse do? a. Examine the nail plate under a Wood's light. b. Assess for thickness. c. Blanch the nail bed. d. Evaluate for lesions.

c. Blanch the nail bed.

The nurse is caring for a patient with liver failure who has been unable to get out of bed for several days. In which area is the nurse most likely to find evidence of dependent edema? a. Dorsum of foot b. Medial ankle c. Buttocks and sacrum d. Lower abdomen

c. Buttocks and sacrum

Which statement is true about the application and use of topical preparations? a. Topical applications are generally much safer than oral medications. b. Using a water-soluble cream in the groin area could cause maceration. c. Using an oil-based ointment in the axillary area could cause folliculitis. d. An oil-based gel should be massaged into hairy areas.

c. Using an oil-based ointment in the axillary area could cause folliculitis.

The nurse is assessing the skin of an older adult patient who is at risk for dehydration as a result of excessive vomiting. The skin appears dry and loose. Where is the best site for the nurse to check skin turgor on this patient? a. Lower abdomen b. Forearm c. Forehead d. Midthigh

c. Forehead

A patient is at risk for hypovolemia. The nurse assesses this patient's skin using which assessment technique? a. Brush the skin surface and observe for flaking. b. Push on the skin and observe for c. Gently pinch the skin on the chest and observe for tenting. d. Push on the skin over the tibia and observe for depth of indentation.

c. Gently pinch the skin on the chest and observe for tenting.

The nurse is collecting a superficial specimen for a suspected fungal infection from a patient's groin area. What is the correct technique to obtain this specimen? a. Obtain a small sample of tissue by using a biopsy needle. b. Express exudate from a lesion and use a sterile swab to collect the fluid. c. Gently scrape scales with a tongue blade into a clean container. d. Aspirate fluid from the lesion using sterile technique

c. Gently scrape scales with a tongue blade into a clean container.

A thin, malnourished patient requires emer- gency abdominal surgery. After the operation, in order to promote wound healing, what does the nurse encourage? a. High-calorie diet b. Low-sodium and low-carbohydrate diet c. High-quality protein diet d. Low-fat diet with vitamin supplements

c. High-quality protein diet

Which common complication should the nurse monitor for in an older patient diagnosed with herpes zoster? a. Nausea and vomiting b. Infections of the arms and legs c. Severe pain after the lesions have resolved d. Severe itching after the lesions have resolved

c. Severe pain after the lesions have resolved

A patient has been prescribed acitretin for psoriasis. What information does the nurse tell the patient about this drug? a. Wear dark glasses after taking a dose. b. It is the first choice for psoriasis. c. Strict birth control measures are necessary. d. Apply it to superficial lesions.

c. Strict birth control measures are necessary.

A patient reports a subjective sensation of pain and tenderness "because my arthritis is flaring up." In order to assess for inflammation, what does the nurse do? a. Place the hand just above the area and feel for radiant warmth. b. Use fingertips to depress tissue area and then release and observe. c. Use the back of the hand to palpate the area for warmth. d. Use the palm and make a circular motion over the area.

c. Use the back of the hand to palpate the area for warmth.

The nurse is assessing a wound on a patient's abdomen. What is the correct technique? a.Stand on the right side of the bed and lay a sterile cotton swab across the width and the length of the wound. b.Read the previous nursing documentation and follow the same pattern that other nurses are using for standardization. c.Assess the wound as a clock face with 12 o'clock toward the patient's head and 6 o'clock toward the patient's feet. d.Observe the wound after the dressing is removed and estimate the shape and record the appearance.

c.Assess the wound as a clock face with 12 o'clock toward the patient's head and 6 o'clock toward the patient's feet.

Seeing a reddened area on a patient's skin, the nurse presses firmly with fingers at the center of the area and sees that the area blanches with pressure. The nurse interprets this finding as changes related to which factor? a. Inflammation b.Infection c.Blood vessel dilation d.Tissue damage

c.Blood vessel dilation

For which nursing action is the nurse most likely to don clean gloves? a. Inspecting for purpura, petechiae or ecchymosis b.Comparing temperature between affected and nonaffected extremity c.Obtaining a bacterial culture from a primary lesion (vesicle) d.Gently pinching up the skin on the forehead to check for "tenting"

c.Obtaining a bacterial culture from a primary lesion (vesicle)

What is the best rationale for encouraging the patient to follow through and seek treatment for dandruff? a.Dandruff flakes are caused by a dry scalp and suggest possible dehydration. b.Dandruff is merely a cosmetic problem but appearance is important to self-esteem. c.Severe dandruff is caused by excessive oiliness and could cause hair loss. d.Brushing the hair every day prevents dandruff, but it weakens the hair follicle.

c.Severe dandruff is caused by excessive oiliness and could cause hair loss.

Which instruction will the nurse emphasize with the older patient to address changes of the subcutaneous layer of the skin related to aging? a. Teach to wear sunscreen and hat and avoid direct sun exposure during midday. b. Urge use of a multivitamin or a calcium supplement with vitamin D. c. Encourage application of moisturizers while skin is still moist. d. Advise the patient to dress warmly in cold weather and change position every 2 hours.

d. Advise the patient to dress warmly in cold weather and change position every 2 hours.

The nurse is assisting the health care provider to obtain specimens for diagnostic testing. For which test should the nurse obtain a vial of sterile nonbacteriostatic saline? a. Culture for a fungal infection b. Vesicle fluid to culture for viral infection c. Punch biopsy of a superficial skin lesion d. Biopsy for suspected deep cellulitis

d. Biopsy for suspected deep cellulitis

A toddler is miserable with itching from chickenpox. Which type of bath is the best to help relieve the toddler's discomfort? a. Sitz bath b. Bath with oil c. Sponge bath d. Colloidal oatmeal

d. Colloidal oatmeal

Which chronic health condition is most likely to contribute to delayed wound healing or recurrence of a pressure ulcer after healing has occurred? a. Osteoporosis b. Hypertension c. Psoriasis d. Diabetes mellitus

d. Diabetes mellitus

While obtaining a health history on a patient with a chronic skin condition, the nurse observes that the patient does not make eye contact and keeps the affected area covered with a scarf. What is the most appropriate nursing action? a. Explain all actions and procedures to the patient. b. Explain to the patient that it is normal to be embarrassed. c. Discuss the patient's behavior with another nurse for validation. d. Explore the patient's feelings about the condition

d. Explore the patient's feelings about the condition

The patient has a diagnosis of acute pressure ulcers on both heels. Which medical-surgical concept has highest priority for this patient? a. Cellular regulation b. Fluid and electrolyte balance c. Immunity d. Tissue integrity

d. Tissue integrity

The patient has reddened scratch marks on the right forearm. Which is the priority medical surgical concept for this patient? a. Cellular regulation b. Perfusion c. Immunity d. Tissue integrity

d. Tissue integrity

he nurse is irrigating a large pressure ulcer on a patient's hip and notes a small opening in the skin with purulent drainage. Which technique does the nurse use to check for tunneling? a. Ask the health care provider to order an ultrasound. b. Palpate the surface of the wound to identify spongy areas. c. Continue to flush the wound and watch the flow of the fluid. d. Use a sterile cotton-tipped applicator to probe gently for a tunnel.

d. Use a sterile cotton-tipped applicator to probe gently for a tunnel.

The nurse has collected several specimens from patients who have skin conditions. Which specimen must be immediately placed on ice? a. Punch biopsy performed with sterile technique for collection of a tissue piece. b. Exudate taken by sterile technique and swabbed on a bacterial culture medium. c. Aspirate taken by sterile technique and placed in a bacterial culture tube. d. Vesicle fluid taken by sterile technique and placed in a viral culture tube.

d. Vesicle fluid taken by sterile technique and placed in a viral culture tube.