PrepU Tissue Integrity

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside? a. Indwelling urinary catheter kit b. Tracheostomy set c. Cardiac monitor d. Humidifier

b; After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client's bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn't indicated for this client.

The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective? a. "I will not need to worry about being incontinent of urine." b. "My urine will be eliminated through a stoma." c. "My urine will be eliminated with my feces." d. "A catheter will drain urine directly from my kidney."

b; An ileal conduit is a non-continent urinary diversion whereby the ureters drain into an isolated section of ileum. A stoma is created at one end of the ileum, exiting through the abdominal wall.

Which factor causes wrinkles among older adults? a. Decrease in melanin b. Loss of subcutaneous tissue c. Decrease in estrogen production d. Decrease in sebum

b; The loss of subcutaneous tissue causes wrinkles in older adults. A decrease in melanin results in a change of hair color to gray. The decrease in the production of estrogen and sebum do not cause wrinkles in older adults.

After teaching a group of students about the signs and symptoms of breast cancer, the instructor determines that additional teaching is needed when the group identifies which of the following? a. Peau d'orange skin b. Breast symmetry c. Nipple retraction d. Painless mass

b; The primary sign of breast cancer is a painless mass in the breast. Other signs of breast cancer include a bloody discharge from the nipple, a dimpling of the skin over the lesion, retraction of the nipple, peau d'orange (orange peel) appearance of the skin, and a difference in size between the breasts.

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion? a. Macule b. Papule c. Vesicle d. Wheal

c; A vesicle is a circumscribed, elevated, palpable mass containing serous fluid less than 0.5 cm. Examples include herpes simplex/zoster, varicella, poison ivy, and 2nd-degree burn (blister).

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? a. Complaints of intense thirst b. Moderate to severe pain c. Urine output of 70 ml the first hour d. Hoarseness of the voice

d; Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

Which of the following is an enzyme secreted by the gastric mucosa? a. Pepsin b. Trypsin c. Ptyalin d. Bile

a; Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.

A term used to describe a partial or complete separation of wound edges is: a. dehiscence. b. evisceration. c. erythema. d. hemorrhage.

a; Dehiscence is the partial or complete separation of wound edges. Evisceration occurs when organs protrude through the surgical incision. Erythema refers to redness of the skin. Hemorrhage is excessive bleeding.

A nurse is caring for a client who underwent a skin biopsy and has Philadelphia, three stitches in place. This wound is healing by: a. First intention b. Second intention c. Third intention d. Fourth intention

a; Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

Which ulcer is associated with extensive burn injury? a. Cushing ulcer b. Curling ulcer c. Peptic ulcer d. Duodenal ulcer

b; Curling ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

A nurse comes to the employee health center for evaluation and is diagnosed with allergic contact dermatitis related to latex. What manifestation would the nurse most likely exhibit? a. Laryngeal edema b. Rhinitis c. Blistering d. Angioedema

c; Manifestations associated with allergic contact dermatitis related to latex include blisters, pruritus, erythema, swelling, and crusting or other skin lesions. Laryngeal edema, rhinitis, and angioedema would be noted with a latex allergy.

A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction? a. Cyanosis b. Gangrene c. Pallor d. Ulceration

c; Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.

The nurse is assessing the skin of a client with tinea pedis and notes a linear crack. The nurse documents this as: a. scale. b. erosion. c. ulcer. d. fissure.

d; Linear cracks in the skin are documented as fissures. Scales are flakes secondary to desquamated, dead epithelium. Erosions are defined as loss of superficial epidermis that does not extend into the dermis. Ulcers show skin loss that extends past the epidermis.

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition? a. Lymphedema b. Trousseau's sign c. IV infusion infiltration d. Muscle atrophy

a; Lymphedema is a common postoperative effect of modified radical mastectomy and lymph node dissection. Elevation of the left arm and hand will allow gravity to assist lymph drainage. Other preventive measures include exercises in which the arms are elevated. Trousseau's sign is a sign of hypocalcemia and isn't an expected finding in this situation. IV infusions shouldn't be given in the left arm nor should venipunctures be done in this arm. Although muscle atrophy is a potential adverse effect if the client doesn't exercise her left arm, it wouldn't be prevented by elevation.

The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about? a. WBC count of 4,200 cells/uL b. Hematocrit of 38% c. Platelet count of 9,000/mm3 d. Creatinine level of 1.0 mg/dL

c; Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency (thrombocytopenia). The low platelet count can cause ecchymoses (bruises) and petechiae. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm3.

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? a. "I will change the vest liner periodically." b. "If a pin becomes detached, i'll notify the surgeon." c. "I can apply powder under the liner to help with sweating." d. "I'll check under the liner for blisters and redness."

c; Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

Photochemotherapy has been used as a treatment for which of the following skin disorders? a. Shingles b. Psoriasis c. Allergic dermatitis d. Rosacea

b; Photochemotherapy is used for severe, disabling psoriasis that does not respond to other methods of treatments.

A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers? a. 2.5 g/mL b. 3.1 g/mL c. 3.5 g/mL d. 4.0 g/mL

a; Serum albumin is a sensitive indicator of protein deficiency. Levels below 3 g/mL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers.

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? a. Dry sterile dressing b. Sterile petroleum gauze c. Moist sterile saline gauze d. Povidone-iodine-soaked gauze

c; Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order? a. Incision and drainage b. Culture c. Debridement d. Irrigation

c; Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture identifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation, usually with an antibiotic solution, to treat the infection and clean the wound.

Which condition is an autoimmune disease involving immunoglobulin G? a. Toxic epidural necrolysis (TEN) b. Stevens-Johnson syndrome (SJS) c. Pemphigus d. Bullous pemphigoid

c; Pemphigus is an autoimmune disease involving immunoglobulin G. TEN, SJS, and bullous pemphigoid do not involve immunoglobulin G.

Assessment of a client reveals signs and symptoms of Paget's disease. Which of the following would be most likely? a. Skull narrowing b. Lordosis c. Long bone bowing d. Upright gait

c; Some clients with Paget's disease are asymptomatic with only some mild skeletal deformity. Other clients have marked skeletal deformities which may include enlargement of the skull, bowing of the long bones, and kyphosis.

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? a. Elevate the affected extremity. b. Contact the nursing supervisor. c. Administer oxygen. d. Contact the health care provider.

c; The client is demonstrating clinical manifestations consistent with a fatty embolus. Administering oxygen is the top priority. Elevating the extremity won't alter the client's condition. Notifying the nursing supervisor may be indicated by facility policy after other immediate actions have been taken. The nurse should contact the health care provider after administering oxygen.

The nurse is providing care for a 90-year-old client whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area? a. The client's elbows b. The soles of the client's feet c. The client's heels d. The client's knees

c; Full inspection of the client's skin is necessary, but the sacrum and the heels are the most susceptible areas for skin breakdown due to shear and friction.

The nurse is performing a musculoskeletal assessment for a client whose right leg muscles exhibit no tone and are limp. Which descriptor should the nurse use to document this condition? a. Flaccid b. Spastic c. Atonic d. Atrophic

a; The term flaccid describes muscles that have no tone or are limp. Spastic describes muscles that have greater-than-normal tone. Atonic describes muscles that are not enervated and become soft and flabby. Atrophic describes muscles deterioration that occurs with lack of use and exercise.

A client is considering breast augmentation. Which of the following would the nurse recommend to the client to ensure that there are no malignancies? a. Mammogram b. Mastopexy c. Ultrasound d. Breast biopsy

a; When caring for a client considering breast augmentation, the nurse should provide her with a general guideline to have a mammogram to verify that there are no malignancies. Mastopexy involves a breast lift for drooping breasts. Ultrasound or breast biopsy would not be necessary unless there was evidence of a problem.

A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose? a. contusion b. sprain c. strain d. subluxation

a; A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A subluxation is a partial dislocation.

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? a. Superficial b. Full-thickness c. Superficial partial-thickness d. Deep partial-thickness

a; A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

A client complains of having tender and painful breasts, often feeling multiple lumps within her breast tissue. The nurse would need to gather additional information about which of the following? a. Alcohol and caffeine consumption b. Client's workplace in relation to the surroundings c. Timing of symptoms in relation to the menstrual cycle d. Bathing frequency and living surroundings

c; Considering that the client has tender and painful breasts and that she often feels lumps within her breast tissue, it is most likely that she suffers from fibrocystic breast disease. To confirm these findings, the nurse should ask relevant questions about the characteristics and timing of symptoms in relation to the menstrual cycle. Symptoms of fibrocystic breast disease are noticeable before menstruation and usually abate during menstruation. The size of the cyst becomes larger before menstruation and often changes with the menstrual cycle. The nurse should further ask the client about her habits of smoking and consuming coffee, chocolate, and caffeinated soft drinks, not alcohol, because they aggravate the condition. Workplace surroundings or cleanliness habits do not matter because fibrocystic breast disease is not infectious.

A client with Stage IV prostate cancer is to receive hormone therapy. The nurse would inform the client about possible adverse effects including which of the following? a. Increased libido b. Deepening of voice c. Breast tenderness d. Enhanced potency

c; Feminizing side effects occur with hormone therapy. The client's voice may become higher, hair and fat distribution may change, and breasts may become tender and enlarged. Libido and potency also are diminished.

A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client? a. Semi-private room with a client diagnosed with pneumonia b. Semi-private room with a client who had chickenpox and was admitted with a GI bleed. c. Private room d. Isolation room with negative airflow

c; Herpes zoster, a highly contagious infection, is transmitted by direct contact with vesicular fluid or airborne droplets from the infected host's respiratory tract. Placing the client with a client diagnosed with pneumonia places that client at risk for contracting herpes zoster. An isolation room with negative airflow isn't necessary for the client with herpes zoster. The nurse should assign the client to a private room. The client could safely room with the client who already had chickenpox; however, visitors might be unnecessarily exposed.

When assessing the skin of a client with allergic contact dermatitis, the nurse would most likely expect to find irritation at which area? a. Dorsal aspect of the hand b. Lower arms c. Ankles d. Plantar aspects of the feet

a; With allergic contact dermatitis, irritation is most common on the dorsal aspects of the hand. Irritant, phototoxic, and photoallergic types of contact dermatitis are commonly seen on the hands and lower arms.

The nurse identifies which of the following as an age-related change in the respiratory system? a. Increased residual lung volume b. Increased vital capacity c. Increased diffusion capacity d. Increased cough efficiency

a; The older adult experiences an increase in residual lung volume, decreased vital capacity, decreased diffusing capacity, and decreased cough efficacy.

The nurse is instructing clients at a prenatal class. Which term does the nurse state as the medical name of what is removed during a circumcision? a. The prepuce b. The glans c. The shaft d. The corpora cavernosa

a; The prepuce or foreskin is removed during circumcision. The prepuce covers the glans. The shaft is tubular and composed of erectile tissue. The corpora cavernosa is a column of erectile tissue.

Which is the primary symptom of achalasia? a. Difficulty swallowing b. Chest pain c. Heartburn d. Pulmonary symptoms

a; The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care? a. Application of an ostomy pouch b. Intermittent catheterizations c. Exercises to promote sphincter control d. Irrigating the urinary diversion

a; An ileal conduit involves care of a urinary stoma, much like that of a fecal stoma, including the application of an ostomy pouch, skin protection, and stoma care. Intermittent catheterizations and irrigations are appropriate for a continent urinary diverse such as a Kock or Indiana pouch. Exercises to promote sphincter control are appropriate for an ureterosigmoidoscopy.

In a client with burns on the legs, which nursing intervention helps prevent contractures? a. Applying knee splints b. Elevating the foot of the bed c. Hyperextending the client's palms d. Performing shoulder range-of-motion exercises

a; Applying knee splints is one method which can help prevent leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs which is the focus for this individual's treatment and care.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? a. Arterial insufficiency b. Venous insufficiency c. Neither venous nor arterial d. Trauma

a; Characteristics of arterial insufficiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterior tibial area.

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? a. escharotomy b. debridement c. allograft d. silvadene application

a; Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? a. Administer analgesic medications as ordered. b. Keep the hand in the circulating bath for 1 hour. c. Rupture any hemorrhagic blebs that are noted. d. Have the client complete active range-of-motion exercises.

a; During rewarming, an analgesic for pain is administered as prescribed because the rewarming process may be very painful. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and unruptured. Nonhemorrhagic blisters are debrided to decrease the inflammatory mediators found in the blister fluid. After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures.

A public health nurse is presenting an educational event to the local disaster response team on radiation injury. The nurse describes a client whose burns and trauma are evident. What type of radiation injury is this? a. External b. Direct c. Internal d. Indirect

a; External radiologic contamination occurs from exposure to fallout on the skin, hair, and clothing Radiologic contamination is not characterized as direct or indirect. This does not describe a client with internal radiologic contamination.

A client has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing their ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? a. Inadequate vitamin D intake b. Bleeding at the injury site c. Inadequate immobilization d. Venous thromboembolism (VTE)

a; Inadequate fracture immobilization can delay or prevent union. A short-term vitamin D deficiency would not likely prevent bone union. VTE is a serious complication but would not be a cause of nonunion. Similarly, bleeding would not likely delay union.

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do? a. Inform the physician immediately. b. Squeeze the nipple to check for drainage. c. Check the area after the next menses. d. Put a heating pad on the area to reduce inflammation.

a; The client should notify the physician immediately because a breast lump may be a sign of breast cancer. The client shouldn't squeeze the nipple to check for drainage until the physician examines the area. The client shouldn't wait until after the next menstrual period to inform the physician of the breast lump because prompt treatment may be necessary. Placing a heating pad on the area would have no effect on a breast lump.

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action? a. Extravasation b. Stomatitis c. Nausea and vomiting d. Bone pain

a; The nurse needs to monitor IV administration of antineoplastics (especially vesicants) to prevent tissue necrosis to blood vessels, skin, muscles, and nerves. Stomatitis, nausea/vomiting, and bone pain can be symptoms of the disease process or treatment mode but does not require immediate action.

The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation? a. Dry skin thoroughly after washing b. Apply barrier powder c. Apply triamcinolone acetonide spray d. Dust with nystatin powder

a; The nurse should teach the client without peristomal skin irritation to dry the skin thoroughly after washing. Barrier powder, triamcinolone acetonide spray, and nystatin powder are used when the client has peristomal skin irritation and/or fungal infection.

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client? a. Reinforce the neck dressing when blood is present on the dressing. b. Assess the graft for color and temperature. c. Administer prescribed intravenous vancomycin at the correct time. d. Cleanse around the drain using aseptic technique.

b; Assessing the graft for color and temperature addresses circulation and is most important for the nurse to complete. Reinforcing the neck dressing is important, but not the priority. Administering medication and cleansing the drain site are not most important interventions with the client after graft reconstruction of the neck.

A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response? a. Removes the entire growth. b. Through the application of extreme cold, the tissue is destroyed. c. Freezes the growth, so the physician can remove it at the next appointment. d. Lasers the growth off.

b; Cryosurgery is the application of extreme cold to destroy tissue. The other statements are false.

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client a. Prevent infection b. Fluid resuscitation c. Endotracheal tube placement d. Strict intake and output

b; Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.

Which intervention has the highest priority when providing skin care to a bedridden client? a. Changing the client's position frequently. b. Keeping the skin clean and dry without using harsh soaps. c. Gently massaging the skin around the pressure areas. d. Rubbing moisturizing lotion over the pressure areas.

b; Keeping the skin clean and dry is always the highest priority. Changing the client's position frequently and gently massaging the skin around the pressure areas are also important but only after the skin is cleaned. The nurse should rub lotion around, not directly over, pressure areas to avoid skin breakdown.

A fracture is considered pathologic when it: a. results in a fragment of bone being pulled away by a ligament or tendon and its attachment. b. occurs through an area of diseased bone. c. involves damage to the skin or mucous membranes. d. presents as one side of the bone being broken and the other side being bent.

b; Pathologic fractures can occur without the trauma of a fall. An avulsion fracture results in a fragment of bone being pulled away by a ligament or tendon and its attachment. A greenstick fracture presents as one side of the bone being broken and the other side being bent. A compound fracture involves damage to the skin or mucous membranes.

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as: a. spider angioma. b. petechiae. c. ecchymosis. d. telangiectasia.

b; Petechiae are associated with bleeding tendencies or emboli to the skin. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and bleeding tendencies. Telangiectasia is associated with venous pressure states.

A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort? a. Apply warm compresses over the areas. b. Instruct to pat and not scratch the areas. c. Elevate the extremities above heart level. d. Provide pain medication as needed.

b; Post-burn pruritus (itching) affects almost all clients with burns and is one of the most distressing symptoms in the post-burn period. The client should be instructed to "pat, don't scratch" in order to prevent further discomfort and infectious complications. Other actions to reduce the itching include oral antipruritic agents, environmental conditions, frequent lubrication of the skin with water or silica-based lotion, and diversion activities. Warm compresses will enhance the itching. Elevating the extremities above the level of the heart helps reduce edema. Pain medication is not used to treat pruritis.

A client asks the nurse what psoriasis is. What is the best answer? a. It is a chronic, infectious inflammatory disease. b. It is characterized by patches of redness covered with silvery scales. c. A cure is possible with prompt treatment. d. The onset typically occurs in young children.

b; Psoriasis is characterized by patches of erythema covered with silvery scales, usually on the extensor surfaces of the elbows, knees, trunk, and scalp. It is a chronic non-infectious inflammatory disease. Psoriasis has no cure. The onset is in young and middle adulthood.

Painless chancres are associated with which systemic disease? a. Kaposi sarcoma b. Syphilis c. Psoriasis d. Urticaria

b; Syphilis is manifested by a painless chancres. Psoriasis is exhibited by plaques with scales. Kaposi sarcomas are cutaneous lesions that are blue-red or dark brown in color. Urticaria is wheals or hives due to infection or allergic reactions.

A client is 4 weeks postoperative from a vaginoplasty. Which client statement indicates an understanding of postoperative teaching focused on activity? a. "I ride my bike to work daily." b. "I still have my membership to the pool placed on hold." c. "I can start going to the gym to lift weights this week.' d. "I plan to start running again next week."

b; The client should avoid swimming for 3 months after a vaginoplasty. The client understands the teaching if the client has placed membership to the pool on hold. The client demonstrates a lack of understanding the teaching regarding activity after the vaginoplasty if the client rides a bike daily (need to wait 3 months after surgery), or if the client is engaging in strenuous activities such as weightlifting or running (this can begin 6 weeks after surgery; the client is only at 4 weeks).

What advice should the nurse give a client with dermatitis until the etiology of the dermatitis is identified? a. Use wool, synthetics, and other dense fibers. b. Wear rubber gloves when in contact with soaps. c. Rub the skin vigorously to dry. d. Use hot water for bathing.

b; The nurse should advise the client to wear rubber gloves when coming in contact with any substance such as soap or solvents. The client should avoid wool, synthetics, and other dense fibers. The client should use tepid bath water and should pat rather than rub the skin dry.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? a. Necrotic and hard b. Pale yet able to blanch with digital pressure c. Pink to red and soft, bleeding easily d. White with long, thin areas of scar tissue

c; In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.