Tissue Integrity and Nutrition guide

A nurse assesses a client who has psoriasis. Which action would the nurse take first? Don gloves and an isolation gown. Shake the client's hand and introduce self. Assess for signs and symptoms of infections. Ask the client if she might be pregnant.

Shake the client's hand and introduce self.

Parents ask the nurse how their infant developed a Meckels diverticulum. What condition, will the nurse explain, is present causing this diagnosis? a. The yolk sac remains connected to the intestine. b. There is inflammation of the ileocecal valve. c. A pouch forms when the vitelline duct fails to disappear. d. There is a weakness in the abdominal wall.

A pouch forms when the vitelline duct fails to disappear.

After teaching a client who has a stage 2 pressure injury, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? Green salad, a banana, whole wheat dinner roll, coffee Chicken breast, broccoli, baked potato, ice water Vegetable lasagna and green salad, iced tea Hamburger, fruit cup, cookie, diet pop

Chicken breast, broccoli, baked potato, ice water

1. Which finding in a newborn is suggestive of tracheoesophageal fistula? a. Failure to pass meconium in 24 hours b. Choking on the first feeding c. Palpable mass in the sternal area d. Visible peristalsis across abdomen

Choking on the first feeding

A nurse participates in a community screening event for oral cancer. What client is the highest priority for referral to a primary health care provider? Client who has poor oral hygiene practices. Client who smokes and drinks daily. Client who tans for an upcoming vacation. Client who occasionally uses illicit drugs.

Client who smokes and drinks daily.

A nurse knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) Coal miner Electrician Metal worker Plumber Textile worker

Coal miner Metal worker Plumber Textile worker

5. The home health nurse discovers a family infected with pediculosis. What information can the nurse provide to the mother to start eradication of the lice? a. Cover the hair with Vaseline. b. Apply a soda-vinegar solution to the hair. c. Comb through the hair with a vinegar-water solution. d. Shampoo the hair with dish detergent.

Comb through the hair with a vinegar-water solution.

During skin inspection, the nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors will the nurse use to document these observations? Clustered and annular Linear and circinate Diffuse and serpiginous Coalesced and circumscribed

Diffuse and serpiginous Rationale: "Diffuse" is used to describe lesions that are widespread. "Serpiginous" describes lesions with wavy borders. "Clustered" describes lesions grouped together. "Linear" describes lesions occurring in a straight line. Annular lesions are ring like with raised borders, circinate lesions are circular, and circumscribed lesions have well-defined sharp borders. "Coalesced" describes lesions that merge with one another and appear confluent.

A client who had a partial gastrectomy 3 days ago begins to experience vertigo, sweating, and tachycardia about 30 minutes after eating breakfast. What postoperative complication would the nurse suspect? Pyloric obstruction Dumping syndrome Delayed gastric emptying Pernicious anemia

Dumping syndrome Rationale:Dumping syndrome causes autonomic symptoms as food quickly leaves the stomach due to its decreased size after surgery.

4. The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.) Dyspepsia Regurgitation Belching Coughing Chest discomfort Dysphagia

Dyspepsia Regurgitation Belching Coughing Chest discomfort Dysphagia All of these signs and symptoms are commonly seen in clients who have GERD.

8. Which of these client assessment findings is typically associated with oral cancer? Dry sticky oral membranes Increased appetite Itchy rash in oral cavity Painless red or raised lesion

Painless red or raised lesion Rationale: A painless red or raised lesion often indicates a diagnosis of oral cancer. The client usually has a decreased appetite and thick secretions. Itchiness is not a common finding associated with oral cancer.

A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage. What comfort measure would the nurse remind assistive personnel (AP) to provide? Lavaging the tube with ice water Performing frequent oral care Re-positioning the tube every 4 hours Taking and recording vital signs

Performing frequent oral care Rationale: Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Repositioning the tube, if needed, is also done by the nurse. The can take vital signs, but this is not a comfort measure.

A nurse assesses an older adult client with the skin disorder shown below: How will the nurse document this finding? Petechiae Ecchymoses Actinic lentigo Senile angiomas

Petechiae Rationale: Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure, are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising. Actinic lentigo presents as paper-thin, transparent skin. Senile angiomas, also known as cherry angiomas, are red raised lesions.

On the first day following a severe burn, the bodys fluid reserves have left the circulating volume and entered the interstitial space, causing massive edema. What should the nurse monitor for very closely in the burn victim? a. Increasing intracranial pressure b. Reduced urine output c. Eschar formation d. Fluid overload

Reduced urine output

A client with peptic ulcer disease is in the emergency department and reports gastric pain that has gotten much worse over the last 24 hours. The client's blood pressure when lying down is 112/68 mm Hg and when standing is 98/52 mm Hg. What action by the nurse is most appropriate? Administer a proton pump inhibitor (PPI). Call the Rapid Response Team. Start a large-bore IV with normal saline. Tell the patient to remain lying down.

Start a large-bore IV with normal saline. Rationale: This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse would start a large-bore IV with isotonic solution. PPIs are not a treatment for an ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the most appropriate action at this time.

Which allergy would contraindicate the use of silver sulfadiazine (Silvadene) as a topical agent for burns? a. Penicillin b. Iodine c. Tetanus immunizations d. Sulfa

Sulfa

s A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? Suspected deep tissue injury: nonblanchable deep purple or maroon. Stage 2: may have visible adipose tissue and slough. Stage 3: may have a pink or red wound bed. Stage 4: wound bed is obscured with eschar or slough.

Suspected deep tissue injury: nonblanchable deep purple or maroon.

A mother reports that her 2-year-old child experiences constipation frequently. Which food would the nurse recommend to include in the childs diet? a. Cooked vegetables b. Pretzels c. Whole-grain cereal d. Yogurt

Whole-grain cereal

The nurse is caring for a client who had an open traditional esophagectomy. Which assessment findings would the nurse report immediately to the primary health care provider? (Select all that apply.) Nausea Wound dehiscence Fever Tachycardia Moderate pain Fatigue

Wound dehiscence Fever Tachycardia

5. The nursing is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.) "You will need to be on a liquid diet for the first week after the procedure." "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." "Contact the primary health care provider after the procedure if you have increased pain." "You will need a nasogastric tube for a few days after the procedure." "You will have a small incision in your stomach area that will have a wound closure.

"Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." "Contact the primary health care provider after the procedure if you have increased pain."

The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health teaching would the nurse include? "Use the drug before every meal to prevent aspiration." "Increase your intake of citrus foods to help with healing." "Use the drug only at bedtime because you won't be eating." "Be sure to check food temperatures before eating."

"Be sure to check food temperatures before eating." Rationale: Viscous lidocaine has an anesthetic effect in the oral cavity. Therefore, to promote client safety, the nurse would want to teach the client to check food temperature before eating.

A client who has peptic ulcer disease is prescribed quadruple drug therapy for Helicobacter pylori infection. What health teaching related to bismuth would the nurse include? "Report stool changes to your primary health care provider immediately." "Do not take aspirin or aspirin products of any kind while on bismuth." "Take bismuth about 30 minutes before each meal and at bedtime." "Be aware that bismuth can cause frequent vomiting and diarrhea."

"Do not take aspirin or aspirin products of any kind while on bismuth." Rationale: Bismuth is a salicylate drug and causes stool discoloration but not vomiting and diarrhea. It does not have to be taken at a specific time relative to meals. Clients taking bismuth should not take other salicylates, such as aspirin or aspirin-containing products.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) "Have you eaten a large amount of chocolate lately?" "Have you been under a lot of stress lately?" "Have you recently used a public shower?" "Have you been out of the country recently?" "Have you recently had any other health problems?" "Have you changed any medications recently?"

"Have you been under a lot of stress lately?" "Have you recently had any other health problems?" "Have you changed any medications recently?"

1. The nurse is teaching a client who has been treated for acute gastritis. What statement by the client indicates a need for further teaching? "I need to cut down on drinking martinis every might." "I should decrease my intake of caffeinated drinks, especially coffee." "I will only take ibuprofen once in a while when I really need it." "I can continue smoking cigarettes which is better than chewing tobacco."

"I can continue smoking cigarettes which is better than chewing tobacco."

After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client's understanding. Which statement indicates the client has a good understanding of this condition? "This rash is probably due to fluid overload." "I need to wash this daily with antibacterial soap." "I can use powder to keep this area dry." "I will schedule a mammogram as soon as I can."

"I can use powder to keep this area dry." Rationale: Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds.

A nurse is teaching a client who has itchy, raised red patches covered with a silvery white scale how to care for this disorder. What statement by the client shows a need for further information? "At the next family reunion, I'm going to ask my relatives if they have anything similar." "I have to make sure I keep my lesions covered, so I do not spread this to others." "I must avoid large crowds and sick people while I am taking adalimumab." "I will buy a good quality emollient to put on my skin each day."

"I have to make sure I keep my lesions covered, so I do not spread this to others." Rationale: This client has plaque psoriasis which is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links so it would be correct for the client to inquire about other family members who are affects. Adalimumab is a drug used to treat psoriasis and it has a black box warning about serious infection risk and cancer risk, so the client needs to take precautions to avoid infectious individuals. Emollients help keep the plaques soft and reduce itching. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of treatment choices. What statement by the client indicates good understanding of the information? "Dermabrasion or chemical peels can be done in the office." "I may need lymph node resection during Mohs surgery." "This needs only a small excision with local anesthetic." "After surgery I will need 8 weeks of radiation therapy."

"I may need lymph node resection during Mohs surgery."

A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information? "I will shower daily using a super-fatted soap." "I can try taking a bath with colloidal oatmeal." "I will pat my skin dry instead of rubbing it with a towel." "I will be careful to keep my nails filed smoothly."

"I will be careful to keep my nails filed smoothly." !!!!!!!!!!!!

The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which statement by the client indicates a need for further teaching? "I need to take out my dentures until my mouth heals." "I'll try to eat soft foods that aren't spicy and acidic." "I will use a more firm toothbrush to keep my mouth clean." "I'll be sure to rinse my mouth often with warm salt water."

"I will use a more firm toothbrush to keep my mouth clean." Rationale: The client who has stomatitis has oral inflammation which causes discomfort. Therefore, all of these actions help to avoid irritation except for needing to use a soft toothbrush or gauze rather than a firm one.

A nurse is teaching a client and family about self-care at home for the client's wound infected with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information? "I will keep dry bandages on the wound and change them when drainage appears." "I will shower instead of taking a bath in the bathtub each day." "If the dressing is dry, I can sit or sleep anywhere in the house." "I will clean exposed household surfaces with a bleach and water mixture."

"If the dressing is dry, I can sit or sleep anywhere in the house."

A client has multiple lesions all over the body and a family history of skin cancer. The nurse teaches the client to perform a total skin self-examinations on a monthly basis. Which statements will the nurse include in this patient's teaching? (Select all that apply.) "Look for asymmetry of shape and irregular borders." "Assess for color variation within each lesion." "Examine the distribution of lesions over a section of the body." "Monitor for edema or swelling of tissues." "Focus your assessment on skin areas that itch." "Report any lesions that change over time in any way."

"Look for asymmetry of shape and irregular borders." "Assess for color variation within each lesion." "Report any lesions that change over time in any way." Rationale: Patients will be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

5. A nurse assesses an older client who has two skin lesions on the chest. Each lesion is the size of a nickel, flat, and darker in color than the rest of the client's skin. What does the nurse tell the client regarding these lesions? "Monitor these spots for any changes." "You don't need to worry about these." "I will ask for a dermatology referral for you." "We need to schedule you for a skin biopsy."

"Monitor these spots for any changes." Rationale: Because of melanocyte hyperplasia, the older adult frequently has "age spots," or darker spots on the skin. The nurse would teach the client to monitor the spots and report any changes indicative of cancer. Stating the client does not need to worry is inaccurate and dismissive. The client does not necessarily need a dermatology referral and does not need a skin biopsy at this point.

A client contacts the clinic to report a life-long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate? "Take monthly photographs of it so you can document any changes." "Wash daily with warm water and gentle soap to prevent infection." "Keep the lesion covered with a bandage and triple antibiotic ointment." "Please make an appointment to be seen here as soon as possible."

"Please make an appointment to be seen here as soon as possible."

6. A nurse cares for an older adult client who has a chronic skin disorder. The client states, "I have not been to church in several weeks because of the discoloration of my skin." How will the nurse respond? "I will consult the chaplain to provide you with spiritual support." "You do not need to go to church; God is everywhere." "Tell me more about your concerns related to your skin." "Religious people are nonjudgmental and will accept you."

"Tell me more about your concerns related to your skin." Rationale: Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses will assess how the client's skin changes are affecting his or her body image and encourage the client to express feelings about a change in appearance. The other statements are dismissive of the client's concerns.

A new nurse reads a client has a wound "healing by second intention" and asks what that means. Which description by the charge nurse is most accurate? "The wound edges have been approximated and stitched together." "The wound was stapled together after an infection was cleared up." "The wound is an open cavity that will fill in with granulation tissue." "The wound was contaminated by debris and can't be closed at all."

"The wound is an open cavity that will fill in with granulation tissue."

A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which question will the nurse ask to elicit useful information about the possible condition? "What do you do for a living?" "Are your nails professionally manicured?" "Do you have diabetes mellitus?" "Have you had a recent fungal infection?"

"What do you do for a living?" Rationale: The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.

3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question will the nurse ask first? "Are you using lotion on your skin?" "Do you have a family history of this?" "Do your arms itch?" "What medications are you taking?"

"What medications are you taking?" Rationale: Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.

A nurse assesses a young female client who is prescribed tazarotene. Which question should the nurse ask prior to starting this therapy? "Do you spend a great deal of time in the sun?" "Have you or any family members ever had skin cancer?" "Which method of contraception are you using?" "Do you drink alcoholic beverages?"

"Which method of contraception are you using?"

11. A client has a recurrence of gastric cancer and is crying. What response by the nurse is most appropriate? "Do you have family or friends for support?" "Would you tell me what you are feeling now." "Well, we knew this would probably happen." "Would you like me to refer you to hospice?"

"Would you tell me what you are feeling now."

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure injury development? A 44 year old prescribed IV antibiotics for pneumonia A 26 year old who is bedridden with a fractured leg A 65 year old with hemiparesis and incontinence A 78 year old requiring assistance to ambulate with a walker

A 65 year old with hemiparesis and incontinence !!!!!!!!!!!!!

12. What is the treatment of choice for a child with intussusception? a. A barium enema b. Immediate surgery c. IV fluids until the spasms subside d. Gastric lavage

A barium enema

19. What does the nurse expect the appearance of the stools of a child with celiac disease to be? a. Ribbon like b. Hard, constipated c. Bulky, frothy d. Loose, foul-smelling

Bulky, frothy

What action(s) by the nurse is (are) appropriate to promote nutrition in a client who had a partial gastrectomy? (Select all that apply.) Administer vitamin B12 injections. Ask the primary health care provider about folic acid replacement. Educate the client on enteral feedings. Obtain consent for total parenteral nutrition. Provide iron supplements for the client.

Administer vitamin B12 injections. Ask the primary health care provider about folic acid replacement. Provide iron supplements for the client. Rationale: After a partial or total gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, or iron deficiency. The nurse would provide supplements for all these nutrients. The client does not need enteral feeding or total parenteral nutrition.

A client is admitted with a large oral tumor. What assessment by the nurse takes priority? a. Airway b. Breathing c. Circulation d. Nutrition

Airway

1. The nurse recalls that the risk factors for acute gastritis include which of the following? (Select all that apply.) Alcohol Caffeine Corticosteroids Fruit juice Nonsteroidal anti-inflammatory drugs (NSAIDs)

Alcohol Caffeine Corticosteroids Nonsteroidal anti-inflammatory drugs (NSAIDs)

6. A group of football players is taking oral griseofulvin for tinea pedis. What should the school nurse caution them to avoid? a. Citrus fruit and juice b. Eating shellfish c. Alcohol consumption d. Taking corticosteroids

Alcohol consumption

The nurse is teaching a client about risk factors for esophageal cancer. Which risk factors would the nurse include? (Select all that apply.) Alcohol intake Obesity Smoking Lack of fresh fruits and vegetables Untreated GERD Use of NSAIDs

Alcohol intake Obesity Smoking Lack of fresh fruits and vegetables Untreated GERD

A child is brought to the pediatric clinic because he has been vomiting for the past 2 days. What acid-base imbalance would the nurse expect to occur from this persistent vomiting? a. Hyperkalemia b. Hypernatremia c. Acidosis d. Alkalosis

Alkalosis

29. Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying. What is the most appropriate nursing action? a. Delay feeding the child for 6 hours. b. Offer regular formula thinned with water. c. Give small amounts of regular formula thickened with cereal. d. Allow 1 ounce of glucose water at frequent intervals.

Allow 1 ounce of glucose water at frequent intervals.

22. The nurse is speaking to the parent of a 3-year-old child who has mild diarrhea. What dietary modification would the nurse advise? a. Soft foods with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution, such as Pedialyte d. Chicken soup because it is high in sodium

An oral rehydrating solution, such as Pedialyte

What is the appropriate technique for the application of a topical treatment for a child with eczema? a. Apply skin lotions in a circular motion. b. Apply prescribed ointments with a gloved hand. c. Apply as much and as frequently as relieves the symptoms. d. Choose lanolin-based ointments.

Apply prescribed ointments with a gloved hand.

The nurse is caring for a client with sialadenitis. What comfort measures are appropriate for this client? (Select all that apply.) Applying warm compresses Applying ice to salivary glands Offering fluids every hour Providing lemon-glycerin swabs Reminding the patient to avoid speaking

Applying warm compresses Offering fluids every hour Rationale: Warm compresses and fluids can help promote comfort for this client. Application of ice or lemon-glycerin swabs would not be used. Speaking has no effect on this condition.

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) Apricots Coffee cake Milk shake Potato soup Steamed broccoli

Apricots Potato soup

A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be appropriate? Arrange a dietary consult. Increase fluid intake. Limit the client's foods. Make the client NPO.

Arrange a dietary consult.

A child is brought to the emergency department with burns on the face and chest. What is the nurses first priority? a. Assess respiratory status. b. Administer pain medication. c. Remove clothing. d. Insert a Foley catheter

Assess respiratory status.

A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? Assess the client's airway. Irrigate the client's skin. Brush any visible dust off the skin. Call poison control for guidance

Assess the client's airway!!!!!!!!!!!!!!!

5. A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which action would the nurse take first? Draw blood for albumin, prealbumin, and total protein. Prepare for and assist with obtaining a wound culture. Instruct the client to elevate the foot. Assess the right leg for pulses, skin color, and temperature.

Assess the right leg for pulses, skin color, and temperature.

2. What risk is increased with children who have been diagnosed with infantile eczema? a. Pneumonia b. Acne c. Sun sensitivity d. Asthma

Asthma

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.) Asthma Laryngitis Dental caries Cardiac disease Cancer

Asthma Laryngitis Dental caries Cardiac disease Cancer Any of these complications may occur in clients who have uncontrolled or untreated GERD.

8. A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection? WBC 9200 mm/L3 (9.2 109) Boggy feel to granulation tissue Increased size after debridement Requesting pain medication

Boggy feel to granulation tissue

What interventions will the nurse perform when feeding a child with pyloric stenosis? (Select all that apply.) a. Give a formula thinned with water. b. Burp the infant before and during feeding. c. Give the feeding slowly. d. Refeed if the infant vomits. e. Position infant on left side after feeding.

Burp the infant before and during feeding. Give the feeding slowly. Refeed if the infant vomits.

A nurse cares for a client who reports discomfort related to eczematous dermatitis. Which nonpharmacologic comfort measures would the nurse implement? (Select all that apply.) Cool, moist compresses Topical corticosteroids Heating pad Tepid bath with colloidal oatmeal Back rub with baby oil

Cool, moist compresses Tepid bath with colloidal oatmeal Rationale: For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse would implement cool, moist compresses and tepid baths with additives such as colloidal oatmeal. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

22. The nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2 weeks. Which complication does the nurse document and report? a. Diverticulitis b. Stress diarrhea c. Curlings ulcer d. Perforated bowel

Curlings ulcer Curlings ulcer is a complication of burn victims resulting from the stress of their trauma.

11. What description of a childs stool characteristic leads the nurse to suspect with intussusception? a. Currant jelly b. Black and tarry c. Green liquid d. Greasy and foul-smellings

Currant jelly

2. The nurse is caring for a client with a long history of peptic ulcer disease. What assessment findings would the nurse anticipate if the client experiences upper gastrointestinal (GI) bleeding? (Select all that apply.) Decreased heart rate Decreased blood pressure Bounding radial pulse Dizziness Hematemesis Decreased urinary output

Decreased blood pressure Dizziness Hematemesis Decreased urinary output

The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client? Early sign of oral cancer Fungal mouth infection Inflammation of the gums Obvious oral tumor

Early sign of oral cancer

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect for the client to make an accurate diagnosis? Esophagogastroduodenoscopy (EGD) Abdominal arteriogram Nuclear medicine scan Magnetic resonance imaging (MRI)

Esophagogastroduodenoscopy (EGD)

A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? The client may have memory and cognitive issues postburn. Everything between the entry and exit wounds can be damaged. The respiratory system requires close monitoring for signs of swelling. Electrical burns increase the risk of developing future cancers.

Everything between the entry and exit wounds can be damaged. Rationale: As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk.

What should the nurse suggest before a 17-year-old girl starts a protocol of accuntane? (Isotretinoin) a. Get a prescription for oral contraceptives. b. Increase the dose of the present medication. c. Limit intake of chocolate, cola, and peanuts. d. Increase exposure to sunlight.

Get a prescription for oral contraceptives.

1. The nurse is careful to apply only the prescribed amount of ointment to the skin of a 2-month-old. How is infant skin different from adult skin? a. Less perfusion b. Greater moisture c. More perspiration d. Greater absorption

Greater absorption

A child is brought into the ED with suspected appendicitis. What signs and symptoms does the nurse expect to assess? (Select all that apply.) a. Left lower quandrant pain b. Guarding c. Rebound tenderness d. Decreased C-reactive protein e. Pain on lifting thigh when supine

Guarding Rebound tenderness Pain on lifting thigh when supine

A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next? Partial thromboplastin time Hemoglobin and hematocrit Liver enzymes Basic metabolic panel

Hemoglobin and hematocrit Rationale: Pale conjunctivae signify anemia. The nurse will assess the client's hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this client's potential anemia.

12. Which statement made by a parent indicates an understanding of the topical application of medications for a skin condition? a. I apply the medication after I give my child a bath. b. I rub the ointment in a circular motion over the rash. c. I increased the amount of cream because the rash was not improving. d. I use powder and cornstarch to keep the skin dry.

I apply the medication after I give my child a bath.

9. A child has sustained a second-degree deep thermal burn to the hand. What is the best first action to take? a. Immerse the burned area in cold water. b. Apply ice to the burned area. c. Break any blisters that are present. d. Apply petroleum jelly to the burned skin.

Immerse the burned area in cold water.

11. What would help the child with a serious burn meet nutritional needs during the subacute phase of recovery? a. Decrease calories because the child will be on bed rest and will not need as many. b. Increase calories and protein to compensate for the healing process. c. Increase fat to replace the layer of fat next to the burned skin. d. Decrease carbohydrates and starches because the pancreas is strained by the healing process.

Increase calories and protein to compensate for the healing process.

The nurse reads on a chart that a client has lichenification. What assessment finding confirms this description? Increased skin thickness Excessive facial hair Purple skin patches Tightly stretched skin

Increased skin thickness Rationale: Lichenification is increased skin thickness as the result of scarring. Excessive facial hair (or body hair) is hirsutism. Purple patches on the skin are purpura. Tightly stretched skin is from edema.

A nurse is working with a client who has a painful rash consisting of grouped weeping and crusting lesions in distinct lines. What actions by the nurse are most appropriate? (Select all that apply.) Instruct the client to report lesions near the eyes. Have the client take long, hot baths to soak the lesions. Show the client how to make a baking soda compress. Advise the client to avoid exposure to UV light rays. Demonstrate proper use of antifungal medications. Review appropriate hygiene measures.

Instruct the client to report lesions near the eyes. Show the client how to make a baking soda compress.

14. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? Beige freckles on the backs of both hands. Irregular mole with multiple colors on the leg. Large cluster of pustules in the right axilla. Thick, reddened papules covered by white scales.

Irregular mole with multiple colors on the leg.

9. What instruction will the nurse give to parents about preventing the spread and reinfection of pinworms? a. Keep childrens nails short. b. Dress child in loose-fitting underwear. c. Clean the bathroom with bleach solution. d. Wash bed linens in cold water.

Keep childrens nails short.

A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.) Excessive moisture under axilla Increased hair thinning Presence of toenail fungus Lesion with various colors Spider veins on legs Asymmetric 6-mm dark lesion on forehead

Lesion with various colors Asymmetric 6-mm dark lesion on forehead Rationale: The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the Skin Cancer Foundation's hallmark signs for cancer according to the ABCDE method. Other signs and symptoms, while not normal, are not cause for concern.

The nurse is caring for a client experiencing upper gastrointestinal (GI) bleeding. What is the priority action for the client's care? Maintain airway, breathing, and circulation. Monitor vital signs, including orthostatic blood pressures. Draw blood for hemoglobin and hematocrit immediately. Insert a nasogastric (NG) tube and connect to intermittent suction.

Maintain airway, breathing, and circulation.

During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? Hematemesis Pain when eating Melena Weight loss

Melena

The nurse is teaching a parent about pyrvinium (Povan). What would be included in regard to potential side effects? a. Diarrhea b. Skin rash c. Red stool d. Metallic taste

Red stool ......... kills pinworms

4. A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound? Wet-to-damp saline moistened gauze None, the wound is left open to the air A transparent film Multi-fiber superabsorbent dressing

Multi-fiber superabsorbent dressing Rationale: This pressure injury requires a superabsorbent dressing that will collect the exudate but not stick to the wound itself. A wet-to-damp gauze dressing provides mechanical removal of necrotic tissue. A draining wound would not be left open. A transparent film is a good choice for a noninfected stage 2 pressure injury.

18. A child has been diagnosed with ascariasis (roundworm). Which statement made by her mother that may suggest a cause for her condition? a. Ive been airing out the house on these nice breezy days. b. My child often goes out to the garden and pulls up a carrot to eat. c. She runs barefoot so much I have to wash her feet at least twice a day. d. We just remodeled our bathroom at home.

My child often goes out to the garden and pulls up a carrot to eat.

A mother reports that her child has been scratching the anal area and complaining of itching. What does the nurse suspect based on this information? a. Pinworms b. Giardiasis c. Ringworm d. Roundworm

Pinworms remember cleklers kid

A nurse plans care for a client who is immobile. Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) Place a small pillow between bony surfaces. Elevate the head of the bed to 45 degrees. Limit fluids and proteins in the diet. Use a lift sheet to assist with re-positioning. Re-position the client who is in a chair every 2 hours. Keep the client's heels off the bed surfaces. Use a rubber ring to decrease sacral pressure when up in the chair.

Place a small pillow between bony surfaces. Use a lift sheet to assist with re-positioning. Keep the client's heels off the bed surfaces.

6. The nurse is caring for a client diagnosed with oral cancer. What is the nurse's priority for client care? Encourage fluids to liquefy the client's secretions. Place the client on Aspiration Precautions. Remind the client to use an incentive spirometer. Manage the client's pain and inflammation

Place the client on Aspiration Precautions.

Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal reflux? a. Position the infant in the crib on his or her abdomen, with the head elevated. b. Administer medication as ordered to stimulate the pyloric sphincter. c. Give thin rice cereal with formula before feeding solid foods. d. Place the infant in an infant seat after feedings.

Position the infant in the crib on his or her abdomen, with the head elevated.

21. A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. What will be the nursess priority goal of the infants care? a. Prevent fluid and electrolyte imbalance. b. Prevent nutritional deficiency. c. Prevent skin breakdown. d. Prevent malabsorption.

Prevent fluid and electrolyte imbalance.

A client has an open traditional hiatal hernia repair this morning. What is the nurse's priority for client care at this time? Managing surgical pain Ambulating the client early Preventing respiratory complications Managing the nasogastric tube

Preventing respiratory complications Rationale: The client who has traditional surgery (rather than minimally invasive surgery) is at risk for respiratory complications such as atelectasis and pneumonia because he or she has an incision that may prevent the client from taking deep breaths or using an incentive spirometer. Therefore, the nurse's priority is to prevent these potentially life-threatening respiratory problems.

The nurse is interviewing parents of an infant with pyloric stenosis. What would the nurse expect the parents to report? a. Diarrhea b. Projectile vomiting c. Poor appetite d. Constipation

Projectile vomiting!!!!!!!!!

The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a drug in which classification? Gastric acid inhibitor Histamine receptor blocker Mucosal barrier fortifier Proton pump inhibitor

Proton pump inhibitor Rationale: Omeprazole is a proton pump inhibitor.

A nurse assesses a client who has open skin lesions. Which action by the nurse is most important? Put on gloves. Ask the client about his or her occupation. Assess the client's pain. Obtain vital signs.

Put on gloves. Rationale: Nurses wear gloves as part of Standard Precautions when examining skin that is not intact. The other options are part of the full assessment but adhering to Standard Precautions is important for safety and infection control.

A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge? Requests a referral to a registered dietitian nutritionist. Raises the head of the bed no more than 45 degrees. Performs perineal cleansing every 2 hours. Assesses the client's entire skin surface daily.

Raises the head of the bed no more than 45 degrees. Rationale: A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. The nurse needs to keep the head of the bed elevated to no more than 30 degrees to prevent shearing. An RDN consultation, frequent perineal cleaning, and assessing the client's entire skin surface are all appropriate actions.

A 2-day-old infant is noted to have small pustules on her skin. What is the best nursing action? a. Report it immediately because it may be a staphylococcus infection. b. Keep the affected area dry and clean. c. Teach the parents how to care for seborrheic dermatitis. d. Chart the finding because it may be the beginning of a strawberry nevus.

Report it immediately because it may be a staphylococcus infection.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action would the nurse take? Request a prescription for permethrin. Administer an antihistamine. Assess the client's airway. Apply gloves to minimize friction.

Request a prescription for permethrin !!!!!!!!!!!! Rationale: The client's presentation is most likely to be scabies, a contagious mite infestation. The drugs used to treat this infestation are ivermectin and permethrin.

A nurse assesses a client who presents with early koilonychias. Which assessments will the nurse complete next? (Select all that apply.) Review the client's health history for a diagnosis of iron deficiency anemia. Palpate the client's nail base for potential edemata and sponginess. Ask the client about prolonged contact with chemical irritants. Assess the client for signs of chronic obstructive pulmonary disease. Request a prescription to assess the client's hemoglobin A1C.

Review the client's health history for a diagnosis of iron deficiency anemia. Request a prescription to assess the client's hemoglobin A1C. Rationale: Early koilonychias manifests as flattening of the nail plate with an increased smoothness of the nail. This is caused by iron deficiency with or without anemia, poorly controlled diabetes, and local injury. Nails with visible edema and sponginess when palpated are associated with clubbing. Chronic obstructive pulmonary disease may cause clubbing of the nails and chemical irritants are associated with late koilonychias.

34. What assessment(s) would lead a nurse to suspect Hirschsprungs disease in a 1-month-old infant? (Select all that apply.) a. Ribbon-like stools b. Fever c. Failure to thrive d. Vomiting e. Diminished peristalsis

Ribbon-like stools Fever Failure to thrive Vomiting Diminished peristalsis

The nurse has reviewed dietary restrictions for celiac disease with concerned parents. Which grain will the nurse explain can be eaten with celiac disease? a. Wheat b. Oats c. Barley d. Rice

Rice

16. What is the correct nursing response to a mother who asks, How can I get rid of the babys cradle cap? a. Rub baby oil on the infants head at night and shampoo the hair the next morning. b. Use a brush with firm bristles to loosen the scales on the babys head several times a day. c. Wash the babys head every night with a dandruff-control shampoo. d. Lubricate the babys head every morning with a small amount of olive oil.

Rub baby oil on the infants head at night and shampoo the hair the next morning.

An adolescent is at the pediatricians office because he has been experiencing intense itching, particularly in the axilla and between the fingers. The itching is worse during the night and he has not been sleeping well. With what is this symptom associated? a. Scabies b. Pediculosis capitis c. Tinea corporis d. Eczema

Scabies

8. A child had a burn, evidenced by pink skin and blistering. The child complains of pain and is crying. How does the nurse classify this burn when documenting? a. First-degree b. Second-degree superficial c. Second-degree deep dermal d. Third-degree

Second-degree superficial remember...... second degree is considered blistering

Why are rapid respirations a possible cause of dehydration? a. They prevent the child from drinking. b. They increase circulation, thus increasing urine production. c. They cause evaporation of fluid on the mucous membranes. d. They often lead to vomiting.

They cause evaporation of fluid on the mucous membranes Rationale: Rapid respirations cause increased insensible fluid loss.

3. The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.) Thinner skin Slower healing time Decreased mobility Hyperresponsive immune response Increased risk of unnoticed sepsis Pre-existing conditions

Thinner skin Slower healing time Decreased mobility Increased risk of unnoticed sepsis Pre-existing conditions Rationale: Age-related differences that can increase the risk of burns and complications of burns include thinner skin, slower healing, decreased mobility, increased risk of infection that goes unnoticed, and pre-existing conditions that can complicate recovery. The older adult has decreased inflammatory and immune responses.

The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor? Large bowel obstruction Dyspepsia Upper gastrointestinal (GI) bleeding Gastric cancer

Upper gastrointestinal (GI) bleeding

While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action will the nurse take next? Ask the client about current medications he or she is taking. Use pulse oximetry to assess the patient's oxygen saturation. Auscultate the patient's lung fields for adventitious sounds. Palpate the patient's bilateral radial and pedal pulses.

Use pulse oximetry to assess the patient's oxygen saturation. Rationale:Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse will assess for systemic oxygenation before continuing with other assessments.

An adolescent girl with acne is being treated with an antibiotic in addition to topical applications. What side effect does the nurse caution the girl to expect? a. Lessened effectiveness of oral contraceptives b. Urinary burning and frequency c. Breast engorgement d. Vaginitis

Vaginitis

The nurse is documenting a description of a skin assessment. What term can be used for an elevated, fluid- filled blister? a. Pustule b. Papule c. Wheal d. Vesicle

Vesicle