Final Exam ( Disregard the first 30-40 Questions, as I started creating this set before the final, and added the remaining questions after the final.)

Which of the following are nursing interventions and patient teaching for the treatment of head lice and scabies?

1.) Clothing, linens, and bath articles thoroughly cleaned in hot water 2.) Stress nature and transmission of the disease

Prioritize the intervention of the first responder to the victim during the emergent phase of burn management. 1.) Stop, drop, and roll. 2.) Provide an open airway. 3.) Control any bleeding. 4.) Remove all nonadherent clothing and jewelry. 5.) Cover victim with clean cloth or sheet. 6.) Transport victim to hospital.

1.) Stop, drop, and roll, is the answer.

A nurse is inspecting a lesion on the client who has basal cell carcinoma. Which of the following findings should the nurse expect?

A pearly, shiny nodule

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following pieces of information should the nurse include in the teaching? A.) Use pursed-liped breathing during periods of dyspnea B.) Limit fluid intake to 1,500mL per day C.) Practice chest breathing each day D.) Wear home oxygen to maintain an SaO2 of at least 94%

A) Use pursed-liped breathing during periods of dyspnea

The main components of the skin are the: A) epidermis and dermis. B) dermis and hypodermis. C) epidermis, dermis, and hypodermis. D) epidermis, dermis, hypodermis, and the subcutaneous layer.

A) epidermis and dermis.

The nurse is obtaining the history from the parents of an infant who suffered an episode of apnea. If the apnea was an acute life threatening event, what would the nurse expect the parents to report? Select all that apply? A.)Coughing B.) Change in color C.) Altered muscle tone D.) Tachycardia E.) Bradycardia

A, B, C, E

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35ml of purulent drainage. Which of the following findings indicate a tension pneumothorax? ( select all that apply.) A.) Tracheal deviation to the left B.) Temperature of 38.8 C.) Absent breath sounds of the right side D.) Neck vein distention E.) Bradypnea

A, C, D

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A.) Stabbing chest pain B.) Calf tenderness C.) Elevated temperature D.) Bradycardia

A.) Stabbing chest pain

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement. The client reports feeling apprehensive and restless. The nurse collects additional data from the client. Which of the following findings is an indication of pulmonary embolism? A.) Sudden onset of dyspnea B.) Tracheal deviation C.) Bradycardia D.) Difficulty swallowing

A.) Sudden onset of dyspnea

What should the nurse examine in assessing a patient for tinea corporis?

Abdomen

A 73-year-old patient with diabetes was admitted for below-the-knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?

Ablative

A frail, older adult home heath patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

Access frequently for herpes zoster.

In reviewing the medical records, the nurse notes the client's medications include isotretinoin (Accutane). The nurse recognized the client is being treated for what?

Acne

A pt is admitted with herpes zoster. The nurse should plan to administer which medication in a frequent basis?

Acyclovir (Zovirax)

The HCP has scheduled a debridement for a pt who has partial thickness burns on his chest and right upper leg. Which nursing intervention is important?

Administer an opioid analgesic intravenously before debridement

Burn wound is periodically debrided using hydrotherapy. Which nursing intervention is essential either before or after the therapeutic modality?

Administering a prescribed analgesic.

A nurse is caring for a client who has partial thickness to full thickness burns to his head, neck, and chest. The nurse should recognize which of the following is a priority risk to the client?

Airway obstruction

Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery?

Anticoagulant agent

When transferring a client to a chair, a nurse notices the pressure relieving mattress overlay has deep imprints of the client's buttocks, heels and scapulae. Which action should the nurse implement?

Apply a different pressure relieving device.

In performing the preoperative assessment, the nurse discovers that the patient is allergic to latex. What should the nurse do initially?

Apply a medical alert band to patient's wrist

A nurse is contributing to a plan of care with a client who has herpes zoster. Which of the following actions should the nurse recommend in the plan of care?

Apply cold compresses to the effected area

A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

Assess respiratory status

What should the nurse do to minimize the potential for venous stasis?

Assist with early ambulation

nurse is caring for a child who has tinea pedis. The child's parent asks the nurse what this infection is commonly called. The nurse should respond with which of the following common names?

Athletes foot

A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide?

Avoid caffeine while taking this medication

A patient with severe eczema is starting a coal tar derivative treatment. What should the nurse include in the teaching plan for the patient relative to this treatment?

Avoid exposure to sunlight for 72 hours after use

A pt complains that he has basal cell carcinoma and is going to die. When planning the best response to make the nurse should include what knowledge?

Basal cell carcinoma us rarely terminal

A nurse is caring for a client who has active TB and is to be started on IV rifampin therapy. The nurse should instruct that this medication can cause which of the following adverse effects?

Body secretions turning a red-orange color

It is important to teach a pt the warning signs of skin cancer. Which is a warning sign of skin cancer?

Border irregularity and delayed or prolonged lesional healing

What should be included in the assessment of a pt with an electrical burn?

Cardiac irregularities

A pt is admitted with partial and full thickness burns on his right lower extremity. What is likely to be included in the plan of care?

Closed dressing change every 3 hours

Which of the following early postoperative observations should be reported immediately?

Coffee ground" emesis

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?

Comb though hair with a vinegar-water solution

The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an oral temperature of 94° F?

Cover with a warm blanket

Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?

Curling Ulcer.

The nurse understands that a patient with human immunodeficiency virus (HIV) starts to develop immune problems when their CD4 count:

Drops below 200

A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? Select all that apply?

Dyspnea Barrel chest Clubbing of the fingers shallow respirations

which of the following are early signs and symptoms of an hiv infection? select all that apply

Dyspnea Sore Throat Weight loss

patient is admitted for pain and tenderness in his lower right leg. The nurse's assessment reveals the extremity is warm, swollen, and has a slightly pitted appearance. Which measure would the nurse use to relieve the discomfort?

Elevate the leg with pillows to reduce edema.

A nurse is checking a school age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?

Firmly attached white particles on the hair

A client complains of burning pain in his lower thoracic area. Upon inspection, there is an area that is found to be erythematous and edematous with a cluster of vesicles on one side of the body. What do you suspect?

Herpes Zoster

A pt complains of a burning pain on his lower thoracic area. On inspection, the area is found to be erythematous and edematous with a cluster of vesicles. What condition is most likely to be diagnosed?

Herpes zoster

A nurse is caring for a patient with partial and full thickness burns to 65% of the body. When planning nutritional intervention for the patient, what dietary choices should the nurse implement?

High calorie and high protein foods

What would help the child with a serious burn meet nutritional needs during the subacute phase of recovery?

Increase calories and protein to compensate for the healing process.

Which may indicate a malignant melanoma in a nevus on a patient's arm?

Irregular border of the mole

What is Pityriasis Rosea?

Is a rash that usually begins as a large circular or oval spot on your chest, abdomen or back. Called herald patch, this spot can be up to 4 inches across.

Which patient instruction should the nurse include in the teaching plan relative to the management of systemic lupus erythematosus?

Maintain a balance between rest and activity

A nurse is reviewing the urinalysis results of a client who reports urinary frequency and burning. Which of the following finding should the nurse report to the provider?

Microscopic hematuria

A nurse is caring for a client who comes to a provider's office for treatment of acne vulgaris on her cheeks. Which of the following instructions should the nurse

Minimize sun exposure

nurse is caring for a client who has recurring herpes simplex type 1 lesions. A nurse should perform focused assessment on which of the following areas of the client's body

Mouth

A nurse is collecting data from a client who has herpes zoster or shingles. Which of the following is an expected finding?

Painful vesicles following a nerve pathway

A pt has a rash in her back that began about 10 days ago with a raised, scaly border and a pink center. Now she has similar eruptions on both sides of her back. What condition are these manifestations most consistent with?

Pityriasis rosea

A nurse is collecting data from a client with SLE. Which of the following is the highest priority to report to the provider?

Presence of peripheral edema

A nurse is caring for a child who has atopic dermatitis. Which of the following finding should the nurse expect?

Rashes with thick skin

When examining the client's skin who has psoriasis, which finding would the nurse expect to observe?

Red skin patches covered with silvery scales

In a patient admitted with cellulitis of the left foot, which clinical manifestation or symptoms would the nurse expect to find on assessment of the left foot?

Redness and swelling

On the first day following a severe burn, the body's 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?

Reduced urine output

A nurse in the PACU is collecting data from a newly admitted client and ovserves intervostal retractions and a high-pitched inspiratory sound. The nurse should identify that these findings are mainfestations of which of the following complications? A.) Pulmonary edema B.) Tension pneumothorax C.) Flail chest D.) Respiratory obstruction

Respiratory Obstruction

7: A pt is admitted with partial thickness burns on his upper chest and face. What is the most important thing for the nurse to initially monitor in the pt?

Respiratory problems

Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms of hemorrhage?

Restlessness

A client phones the clinic and tells the nurse that a family member has been diagnosed with ringworm (tinea corporis). The client asks the nurse if ringworm is contagious. Which of the following would be an appropriate response by the nurse?

Ringworm is a fungal skin infection that is contagious with direct, skin-to-skin contact

A nurse in a provider's office is caring for a client who has tinea pedis. Which of the following findings should the nurse expect?

Scaling and redness between the toes

The home health nurse is assessing skin lesions using the PQRST mnemonic as a guide. What does the "S" in this guide indicate?

Severity of the symptoms

A pt with thermal burns over 30 percent of his body has maintained a urinary output of 250 ml for the past 8 hours. what can the nurse infer for this information?

Stage of hypovolemic shock is resolving

The most appropriate intervention by the nurse to decrease the pain of an abdominal incision while coughing would be to:

Support the surgical site with a pillow

A nurse is reinforcing discharge instructions for a client who has asthma and is about to start taking theophylline. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of the medication?

Tachycardia

A nurse is caring for a client who has bacterial pneumonia. The nurse should expect what assessment finding?

Temp 101.8 degrees F Rat.: an elevated temp is an expected finding for a client who has bacterial pneumonia

A nurse arrives at an accident scene where the victim has just received an electrical burn. What is the nurse's primary concern?

The likelihood of cardiac arrest.

In which situation might surgery be delayed?

The patient is still taking anticoagulants

A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complaints of pain and pruritus. Why would the nurse use a Woods lamp?

To cause fluorescence of the infected hairs.

A nurse working in the emergency department is caring for a client following a chest trauma. What findings indicates a tension pneumothorax?

Tracheal deviation to the unaffected side. Rat.: a tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is caring for a client with second and third degree burns who is prescribed a high calorie, high protein diet. Which of the following is the appropriate meal for the practical/vocational nurse to assist the client in selecting?

Turkey and cheese sandwich, scalloped potatoes

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Turn your patient every two hours

A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with refampin. The nurse should plan to include what in the client's discharging teaching plan?

Urine and other secretions will be orange.

What should the nurse do when administering a therapeutic bath to a patient who has severe pruritis?

Use Barrow's solution to help promote healing

A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What should the nurse do when administering this drug?

Use gloves.

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?

Vaginitis

A nurse is instructing a mother about caring for a child who has impetigo contagiosa. Which of the following should the nurse care plan include?

Wash the child's clothes in tepid water.

In report, the nurse finds the assigned client is suspected of having scabies. Which precaution will the nurse institute during the care of the client?

Wearing gown and gloves

A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?

Within 12 hours after burn trauma

Which of the following are considerations for the older adult surgical patient? (Select all that apply.)

a.) The need for specific clear preoperative and postoperative teaching b.) Presence of coexisting conditions c.) Increased risk of respiratory complications

A nurse in urgent care is caring for a patient who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

administering a nebulizer beta-adrenergic

an african american patient is seen with impending shock after an accident. how would the nurse expect the skin to appear during the assessment of the patient?

ashen, gray, or dull

A nurse in a provider's office is collecting data from a client who has systemic lupus erythematosus (SLE) and takes hydroxychloroquine (Plaquenil) to reduce skin inflammation. The nurse should identify the adverse effects of taking hydroxychloroquine.

blurred vision

which of the following is composed of loose connective tissue? a. Epidermis b. Reticular layer of dermis c. Hypodermis d. Both a and b e. Both b and c

c. Hypodermis

When caring for a client who has emphysema, which of the following findings should the nurse expect to assess in the patient? Dyspnea, bradycardia, barrel chest, clubbing of fingers, shallow respirations (select all that apply)

dyspnea, barrel chest, clubbing, shallow respiration

A nurse is reinforcing teaching with a 20 year old patient who has atopic dermatitis. Which of the following information should the nurse include?

he doctor might recommend an antihistamine to control your symptoms.

Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from

hypovolemic shock and renal failure.

A nurse treatment plan includes using open method of burn wound management. It is most appropriate to use this method for which of the following complications?

infection

A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is:

infection.

a parent tells the dermatologist that her doughter seems to be losing interest in school. which medication could have caused the patient's change in behavior?

isotretinoin (accutane)

which conditions would predipose the patient to cellulitis

malnutrition treatment with steroids or chemotherapy alcoholism

What is the most common symptom of scabies?

nocturnal pruritus

The nurse debriding a burn wound explains that the purpose of debridement is to:

prevent infection and promote healing.

hen the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of:

pulmonary embolus

the nurse planning to care for a patient who has impetigo expects to administer which topical drug to the patient?

retapamulin

when teaching home care to a patient with recurrent genital herpes infection, it is important to include that:

the patient will need to use protection even when no lesions are evident

What would the nurse stress to the 17 year old girl who has been prescribed isotretinoin (Accautane) for her acne?

use dependable birth control to avoid pregnancy.

The school nurse recognizes the signs of scabies when a child presents with:

wavy threadlike lines on the body and pruritus.