Exam 1 MEDSURG
A nurse's hands are visibly soiled. What is the minimum amount of time the nurse should spend rubbing a lather during hand hygiene? Fill in the blank with a number.
20 seconds Rationale: When using lathered soap for hand hygiene, the nurse should rub vigorously for 20 seconds or longer if the hands are visibly soiled.
While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is: "All family members need to be treated." "If someone develops symptoms, tell him to see a physician right away." "Just be careful not to share linens and towels with family members." "After you're treated, family members won't be at risk for contracting scabies."
A. All families members need to be treated Rationale: When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
A client diagnosed with influenza is admitted to the hospital. Which precautions should the nurse initiate? A.Droplet B.Airborne C.Contact D.Neutropenic
A.Droplet Rationale: Influenza is transmitted via droplets; therefore, the nurse should initiate droplet precautions. Tuberculosis and varicella would qualify for airborne precautions. Contact precautions are used for organisms that are transmitted by skin-to-skin contact. Neutropenic (or reverse) precautions are used for immunosuppressed clients.
The nurse should assess all possible causes of pruritus for a patient complaining of generalized pruritus. What does the nurse understand can be another cause for this condition? A.End-stage kidney disease B.Hyperthyroidism C.Pneumonia D.Myasthenia gravis
A.End-stage kidney disease Rationale: Systemic disorders associated with generalized pruritus include chronic kidney disease.
A nurse is caring for a client with ringworm. Which of the following microorganisms causes ringworm in a client? A.Fungi B.Rickettsiae C.Protozoans D.Helminths
A.Fungi Rationale: Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes.
When writing a plan of care for a client with psoriasis, the nurse would know that an appropriate nursing diagnosis for this client would be what? A.Impaired Skin Integrity Related to Scaly Lesions B.Acute Pain Related to Blistering and Erosions of the Oral Cavity C.Impaired Tissue Integrity Related to Epidermal Shedding D.Anxiety Related to Risk for Melanoma
A.Impaired Skin Integrity Related to Scaly Lesions Rationale: An appropriate diagnosis for a client with psoriasis would include Impaired Skin Integrity as it relates to scaly lesions. Psoriasis causes pain but does not normally affect the oral cavity. Similarly, tissue integrity is impaired, but not through the process of epidermal shedding. Psoriasis is not related to an increased risk for melanoma.
A patient is being evaluated for nodular cystic acne. What systemic pharmacologic agent may be prescribed for the treatment of this disorder? A.Isotretinoin (Accutane) B.Benzoyl peroxide C.Retin-A D.Salicylic acid
A.Isotretinoin (Accutane) Rationale: Isotretinoin vitamin A compounds (i.e., retinoids) are used with dramatic results in patients with nodular cystic acne unresponsive to conventional therapy. One compound is isotretinoin, which is used for active inflammatory popular pustular acne that has a tendency to scar. Isotretinoin reduces sebaceous gland size and inhibits sebum production. It also causes the epidermis to shed (epidermal desquamation), thereby unseating and expelling existing comedones.
A client has a squamous cell carcinoma removed from the right lower leg. After the surgery, the nurse reviews instructions for care of the pressure dressing and provides health information about the cancer. Which statements are correct regarding squamous cell carcinoma? Select all that apply. It is the third most common of all three types of skin cancer. It is an invasive carcinoma. It can develop from a keratosis. It is responsible for approximately 4,000 deaths per year. It requires follow-up examinations every 3 months for 1 year.
A.It is the third most common of all three types of skin cancer. B.It is an invasive carcinoma. C.It can develop from a keratosis. D.It is responsible for approximately 4,000 deaths per year. E.It requires follow-up examinations every 3 months for 1 year. Rationale: Squamous cell carcinoma is the second most common type of skin cancer in the United States. It is an invasive carcinoma that can develop from a keratosis. The U.S. Department of Health and Human Services believes that squamous cell carcinoma is responsible for approximately 4,000 deaths per year.
Which term describes the time interval after primary infection when a microorganism lives within the host without producing clinical evidence? A.Latency B.Virulence C.incubation period D.Susceptibility
A.Latency Rationale: During a period of latency, the person who is infected has no signs or symptoms.. Virulence is the degree of pathogenicity of an organism. The incubation period is the time between contact and onset of sign and symptoms. Susceptibility is not possessing immunity to a particular pathogen.
A client's blistering disorder has resulted in the formation of multiple lesions in the client's mouth. What intervention should be included in the client's plan of care? A.Provide chlorhexidine solution for rinsing the client's mouth. B. Avoid providing regular mouth care until the client's lesions heal. C.Liaise with the primary provider to arrange for parenteral nutrition. D.Encourage the client to gargle with a hypertonic solution after each meal.
A.Provide chlorhexidine solution for rinsing the client's mouth. Rationale: Frequent rinsing of the mouth with chlorhexidine solution is prescribed to rid the mouth of debris and to soothe ulcerated areas. A hypertonic solution would be likely to cause pain and further skin disruption. Meticulous mouth care should be provided and there is no reason to provide nutrition parenterally.
A nurse assesses a client with dry, rough, scaly skin without lesions on the legs. The client reports itching in the affected area. What skin assessment would the nurse document? A.Pruritus B.Shingles C.Candidiasis D.Seborrhea
A.Pruritus Rationale: Pruritus (itching) is one of the most common symptoms of patients with dermatologic disorders. Itch receptors are unmyelinated, penicillate (brush-like) nerve endings that are found exclusively in the skin, mucous membranes, and cornea. Shingles presents with lesions. Candidiasis presents with reddened skin and is often found in the folds of skin. Seborrhea refers to dry, scaly patches usually located on the scalp.
A nurse is caring for a client with Lyme disease. Which of the following causes Lyme disease? A.Rickettsiae B.Fungi C.Protozoans D.Mycoplasmas
A.Rickettsiae Rationale: Rickettsiae that resemble bacteria cause Lyme disease. Intermediate life forms such as fleas, ticks, lice, or mites transmit rickettsial diseases to humans. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails. Examples of fungal infections include ringworm, athlete's foot, and vaginal yeast infection. Protozoans are single-celled animals classified according to their ability to move. Mycoplasmas infect the surface linings of the respiratory, genitourinary, and gastrointestinal tracts. Fungi, protozoans, and mycoplasmas do not cause Lyme disease
What should the nurse assess for to determine if a patient using corticosteroids for a dermatologic condition is having local side effects? Select all that apply. A.Skin atrophy B.Striae C.Telangiectasia D.Comedones E.Ecchymosis
A.Skin atrophy B.Striae C.Telangiectasia D.Comedones E.Ecchymosis Rationale: Local side effects of topical corticosteroids may include skin atrophy and thinning, striae (bandlike streaks), and telangiectasias (small, red lesions caused by dilation of blood vessels).
The nurse is triaging a client over the phone who states having a contact dermatitis rash. Which treatment option of over-the-counter preparations does the nurse suggest for the client? Select all that apply. A.Topical antihistamines C.Cosmetic lotions C.1820 cream D.Moisturizing cream E.Lanolin based ointment
A.Topical antihistamines C.1820 cream D.Moisturizing cream E.Lanolin based ointment
When performing a skin assessment, the nurse notes a localized skin infection of a single hair follicle. The nurse documents the presence of A.a furuncle. B.a carbuncle. C.cheilitis. D.a comedone.
A.a furuncle Rationale: Furuncles are localized skin infections of a single hair follicle. They can occur anywhere on the body but are most prevalent in areas subjected to irritation, pressure, friction, and excessive perspiration, such as the back of the neck, the axillae, or the buttocks. A carbuncle is a localized skin infection involving several hair follicles. Cheilitis refers to dry cracking at the corners of the mouth. Comedones are the primary lesions of acne, caused by sebum blockage in the hair follicle.
A day care worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears: A.erythematous with raised papules. B. dry and scaly with flaking skin. C.inflamed with weeping and crusting lesions. D.excoriated with multiple fissures
A.erythematous with raised papules. Rationale: Contact dermatitis is caused by exposure to a physical or chemical allergen, such as skin care products, cleaning products, and latex gloves. Initial symptoms of itching, erythema, and raised papules occur at the site of exposure and can begin within 1 hour of exposure. Allergic reactions tend to be red, not scaly or flaky. Weeping, crusting lesions are also uncommon unless the reaction is severe or has been present for a long time. Excoriation is more common in skin disorders associated with a moist environment.
A client is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have? A.psoriasis B.plantar warts C.undesired tattoo D.dandruff
A.psoriasis Rationale: Photochemotherapy is used to treat psoriasis.
Which primary lesions are associated with acne caused by sebum blockage in hair follicles? A.Furuncles B.Comedones C.Carbuncles D.Striae
B.Comedones Rationale: A comedone is the primary lesion of acne caused by sebum blockage in the hair follicle. A furuncle is a localized skin infection of a single hair follicle. A carbuncle is a localized skin infection involving several hair follicles. Striae are bandlike streaks on the skin, distinguished by color, texture, depression, or elevation from the tissue in which they are found
To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? A.Minoxidil (Rogaine) B.Tretinoin (retinoic acid [Retin-A]) C.Zinc oxide gelatin D.Fluorouracil (5-fluorouracil, 5-FU [Efudex])
B.Tretinoin (retinoic acid [Retin-A] Rationale: Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.
A nurse is caring for a child who was admitted to the ped iatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration? A.Labile BP B.Weak pulse C.Fever D.Diaphoresis
B.Weak pulse Rationale: Assessment of dehydration includes evaluation of thirst, oral mucous membrane dryness, sunken eyes, a weakened pulse, and loss of skin turgor. Diaphoresis, labile BP, and fever are not characteristic signs and symptoms of dehydration.
During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply. A.virulence B.infectious agent C..portal of entry D.susceptible host E.fomites
B.infectious agent C..portal of entry D.susceptible host Rationale: The six components involved in the transmission of microorganisms are described as the chain of infection. All components in the chain of infection must be present to transmit an infectious disease from one human or animal to a susceptible host: an infectious agent, an appropriate reservoir, exit route, means of transmission, portal of entry, and susceptible host.
The process of phagocytosis involves A. Secretion of a nonspecific chemical inhibitor B.Depletion of serotonin in the brain cells C. Digestion of microbes by WBCs D.Breakdown of proteins into amino acids
C. Digestion of microbes by WBCs Rationale: Many leukocytes function as phagocytes, digesting and destroying microbial invaders
A nurse providing care for a client diagnosed with psoriasis is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment? A.Assessment of the client's stool for evidence of intestinal sloughing B.Assessment of the client's apical heart rate for dysrhythmias C.Assessment of the client's joints for pain and decreased range of motion DAssessment for cognitive changes resulting from neurologic lesions
C.Assessment of the client's joints for pain and decreased range of motion Rationale: Asymmetric rheumatoid factor-negative arthritis of multiple joints occurs in up to 30% of people with psoriasis, most typically after the skin lesions appear. The most typical joints affected include those in the hands or feet, although sometimes larger joints such as the elbow, knees, or hips may be affected. As such, the nurse should assess for this musculoskeletal complication. Gastrointestinal, cardiovascular, and neurologic functions are not affected by psoriasis.
A client's diagnostic testing revealed that the client is colonized with vancomycin-resistant enterococcus (VRE). What change in the client's health status could precipitate an infection? A.Use of a narrow-spectrum antibiotic B.Treatment of a concurrent infection using vancomycin C.Development of a skin break D.Persistent contact of the bacteria with skin surfaces
C.Development of a skin break Rationale: Colonization can progress to infection if there is a portal of entry by which bacteria can invade body tissues. The use of vancomycin, or any other antibiotic, would not necessarily precipitate a VRE infection. Prolonged skin contact is similarly unlikely to cause infection, provided the skin remains intact.
A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation? A.Mumps B.Impetigo C.Measles D.Cholera
C.Measles Rationale: Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.
A nurse receives a report on a client who has circular lesions on his neck. Which condition is the client most likely to have? A.Candidiasis B.Molluscum contagiosum C.Tinea corporis D.Tinea pedis
C.Tinea corporis Rationale: Tinea corporis, or ringworm, is a flat, scaling, papular lesion with raised borders. Candidiasis is a fungal infection of the skin or mucous membranes commonly found in the oral, vaginal, and intestinal mucosal tissue. Molluscum contagiosum is a viral skin infection with small, red, papular lesions. Tinea pedis is a superficial fungal infection on the feet, commonly called athlete's foot, that causes itching, sweating, and a foul odor.
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: A.squamous cell carcinoma. B.actinic keratoses. C.melanoma. B.basal cell carcinoma.
C.melanoma Rationale: The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma. Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration. Actinic keratosis is a premalignant skin lesion. Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated.
A client has had a surgical procedure to correct an ingrown toenail. What would the nurse advise the client to do in order to prevent recurrences? A.Use nail clippers to trim toenails. B.Wear tight, form-fitting socks and shoes. C.Keep the feet moistened to avoid drying and cracking. D.Round off corners when trimming toenails
D.Round off corners when trimming toenails Rationale: The client should be advised to do the following. Use nail clippers rather than scissors to trim toenails; toenails should be trimmed so that they are slightly longer than the end of the toes, without rounding off of the corners. Wear wide shoes and loose socks with sufficient room for the toes. Keep the feet clean and dry. Avoid physical activities that involve sudden stops which jam the toes into the front of the shoe.
The nurse is caring for a client with secondary syphilis. What intervention should the nurse institute when caring for this client? A. Ensure that the client is housed in a private room. B. Administer hydrocortisone ointment to the lesions as prescribed. C. Administer combination therapy with antiretrovirals as prescribed. D.Wear gloves if contact with lesions is possible.
D.Wear gloves if contact with lesions is possible Rationale: Lesions of primary and secondary syphilis may be highly infective. Gloves are worn when direct contact with lesions is likely, and hand hygiene is performed after gloves are removed. Isolation in a private room is not required. Corticosteroids antiviral medications are not indicated.
