Integumentary System

A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What should the nurse expect to identify when assessing this client? 1.Weight loss 2.Hypoglycemia 3.Decreased blood pressure 4.Inadequate wound healing

4.Inadequate wound healing

A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiological response to the radiation should the nurse assess the client during the return visit to the radiology department? 1.Ataxia 2.Hypoxia 3.Arthralgia 4.Dysphagia

4.Dysphagia

A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery? 1.Radiation 2.Burr holes 3.Dermabrasion 4.Laser technique

4.Laser technique

A nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client says, "What should I do about my dry skin? It is so itchy." What is the best response by the nurse? 1."Wear warm clothes to keep moisture in the skin." 2."Use a moisturizer on the skin daily to help reduce itching." 3."Take hot tub baths only twice a week to reduce drying of the skin." 4."Expose the skin to the air to help reduce the sensation of itching."

2."Use a moisturizer on the skin daily to help reduce itching."

A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection because it resulted from: 1.Poor personal hygiene 2.A procedure performed at the hospital 3.Inadequate dietary intake 4.The client's developmental level

2.A procedure performed at the hospital

A client arrives at the emergency department after being bitten by a dog. The bite involved tearing of skin and deep soft tissue injury. The first nursing action is to: 1.Inform the owner of the dog about the client's injury 2.Assess the client's injury, vital signs, and past history 3.Notify the appropriate community agency to capture the dog 4.Obtain a prescription for human rabies immune globulin

2.Assess the client's injury, vital signs, and past history

During a first aid class, a student asks what should be done if a person's clothes catch on fire. The nurse explains that after the flames are extinguished it is most important to: 1.Give the person sips of water 2.Assess the person's breathing 3.Cover the person with a warm blanket 4.Calculate the extent of the person's burns

2.Assess the person's breathing

The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue? 1.Red and swollen 2.Blistered and wet 3.Charred and white 4.Leathery and black

2.Blistered and wet

The nurse explains to a patient that the virus that causes chickenpox also can cause: 1.Athlete's foot 2.Herpes zoster 3.German measles 4.Infectious hepatitis

2.Herpes zoster

A client was admitted with full-thickness burns two weeks ago. Since admission, the client has lost an average of a pound of weight each day. The nurse expects the client's diet to be adjusted to include: 1.Low-sodium milk 2.High protein drinks 3.Foods that are low in potassium 4.Ten percent more calories in the form of fats

2.High protein drinks

When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating: 1.Eggs." 2.Shellfish." 3.Fried poultry." 4.Cottage cheese."

2.Shellfish."

A nurse is caring for a client with the diagnosis of pemphigus vulgaris. Which expected response does the nurse need to address in the client's plan of care? 1.Paralysis 2.Infertility 3.Skin lesions 4.Impaired digestion

3.Skin lesions

A client is admitted with extensive bone and soft-tissue injuries to the leg. Sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. To loosen the dressings, the nurse should: 1.Apply diluted hydrogen peroxide 2.Pull with gentle but steady traction 3.Soak the area in a solution of Betadine 4.Moisten the dressing with sterile saline

4.Moisten the dressing with sterile saline

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching? 1.Placing the old dressing in a plastic bag 2.Changing the dressing without wearing a mask 3.Donning nonsterile gloves for removing the old dressing 4.Using a back-and-forth motion while cleaning the wound

4.Using a back-and-forth motion while cleaning the wound

A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. What is the best response by the nurse? 1."May I take a look at it?" 2."It's time for another graft." 3."Is there any sign of redness?" 4."Let me see whether it is infected."

1."May I take a look at it?"

A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force? 1.30 degrees 2.45 degrees 3.60 degrees 4.90 degrees

1.30 degrees

A client with systemic lupus erythematosus is taking prednisone. The nurse anticipates that the steroid may cause hypokalemia. Taking into consideration food preferences, the nurse encourages the client to eat: 1.Broccoli 2.Oatmeal 3.Fried rice 4.Cooked carrots

1.Broccoli

A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the: 1.Client is able to self-administer pain-relieving drugs as necessary 2.Amount of medication received is determined entirely by the client 3.Amount of drug used for analgesia fluctuates greatly over a given period 4.Self-administration relieves the nurse of monitoring the client for pain relief

1.Client is able to self-administer pain-relieving drugs as necessary

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care? 1.Cool, moist towels 2.Dry, sterile dressings 3.Analgesic sunburn spray 4.Vitamin A and D ointment

1.Cool, moist towels

A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist: 1.Helps health care providers to control infections 2.Decides what antibiotics should be prescribed for infections 3.Works in the laboratory identifying bacteria that cause infection 4.Is responsible for collecting specimens of potentially infectious drainage

1.Helps health care providers to control infections

A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client? 1.Highly contagious 2.Caused by a fungus 3.Chronic with exacerbations 4.Associated with other allergies

1.Highly contagious

A health care provider prescribes bed rest, loperamide (Maalox), and esomeprazole (Nexium) for a client who just had major surgery. After several days of this regimen, the client complains of diarrhea. The nurse concludes that the most likely cause of the diarrhea is: 1.Loperadine 2.Esomeprazole 3.Bed rest 4.Diet alteration

1.Loperadine

A client with a stage IV pressure ulcer is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets

2 tabs

A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. The best initial response by the nurse is: 1."Why did you sign the consent?" 2."Can you tell me why you decided to refuse the procedure?" 3."You are obviously afraid about something concerning the procedure." 4."Although the procedure is very important, I understand why you changed your mind."

2."Can you tell me why you decided to refuse the procedure?"

A client is diagnosed as having cancer of the breast and is admitted to the hospital for a lumpectomy to be followed by radiation. While being admitted to ambulatory surgery by the nurse, the client has tears in her eyes and her chin is quivering. In a shaky voice the client says, "I can't believe this is happening." The nurse's best response is: 1."You can't believe this is happening?" 2."This must be a very scary time for you." 3."Do you have any questions at this time?" 4."Cancer of the breast has a high cure rate."

2."This must be a very scary time for you."

In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. The nurse identifies that the client understands the instructions when the client states, "I will: 1.Sit in a chair for several hours every day." 2.Inspect the incision for healing when I change the dressing." 3.Check to see whether the staples have dissolved within a few days." 4.Call the health care clinic if I see any clear drainage coming from the incision."

2.Inspect the incision for healing when I change the dressing."

The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches that the most effective method for putting out the flames is to: 1.Slap at the flames 2.Log-roll the victim in the grass 3.Pour cold liquid over the flames 4.Remove the victim's burning clothes

2.Log-roll the victim in the grass

After surgery for cancer, a client is to receive chemotherapy. When teaching the client about the side effects of chemotherapy, the nurse emphasizes that the occurrence of alopecia is: 1.Usually rare 2.Not permanent 3.Frequently prolonged 4.Sometimes preventable

2.Not permanent

A nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the primary concern of the nurse when caring for this client? 1.Fluid volume 2.Skin integrity 3.Physical mobility 4.Urinary elimination

2.Skin integrity

A client with pulmonary tuberculosis discusses the dietary plan with the nurse. The nurse expects that the type of diet that will be prescribed for the client is: 1.Liquid protein supplements 2.Small, frequent, high-calorie meals 3.Foods high in calories and low in protein 4.Meals low in calories but high in carbohydrates

2.Small, frequent, high-calorie meals

A nurse is assessing a newly admitted client with a pressure ulcer indicated in the image. What stage pressure ulcer should the nurse document on the admission history and physical? 1.Stage I 2.Stage II 3.Stage III 4.Stage IV

2.Stage II

A client develops a maculopapular rash on the upper extremities and audible wheezing during the administration of intravenous vancomycin (Vancocin). To ensure the client's safety, which action would the nurse carry out first? 1.Notify health care provider 2.Stop infusion 3.Decrease flow rate 4.Reassess in 15 minutes

2.Stop infusion

A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? 1.Bananas 2.Strawberries 3.Green beans 4.Sweet potatoes

2.Strawberries

A client with burns develops a wound infection. The nurse plans to teach the client that local wound infections primarily are treated with what type of antibiotics? 1.Oral 2.Topical 3.Intravenous 4.Intramuscular

2.Topical

A client is diagnosed with psoriasis and the nurse is providing health teaching concerning skin care at home. What recommendation does the nurse include in the teaching? 1.Shower twice a day 2.Soak the affected areas in hot water 3.Apply moisturizing lotion several times a day 4.Cover affected areas when in contact with others

3.Apply moisturizing lotion several times a day

A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should: 1.Cover the cast with plastic wrap until dry 2.Assist with weight bearing when the client ambulates 3.Elevate the affected leg above the level of the heart 4.Insert a finger inside the edges of the cast to check for skin abrasions

3.Elevate the affected leg above the level of the heart

A nurse provides discharge teaching to a client that had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond? 1.Encourage participation in this activity as there is an excellent range-of-motion 2.Instruct the client to take a friend along for safety 3.Explain that the incision should not be immersed in water until it has healed 4.Tell the client that swimming can substitute for the prescribed physical therapy

3.Explain that the incision should not be immersed in water until it has healed

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? 1.Readiness to discuss the client's deformities 2.Indication of a change in family relations 3.Need for more time to think about the future 4.Beginning realization of implications for the future

4.Beginning realization of implications for the future

A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. The nurse's teaching plan should include instructions to: 1.Rinse the mouth three times a day with lemon juice and water 2.Brush the teeth once daily and use dental floss after each meal 3.Vigorously clean the mouth with toothpaste and a firm toothbrush 4.Clean the mouth with a soft toothbrush or a gentle spray

4.Clean the mouth with a soft toothbrush or a gentle spray

A burn victim has waxy white areas interspersed with pink and red areas on the chest and all of both arms. The nurse calculates that the percentage of total body surface area (TBSA) on which the client has sustained burns is: 1. 20 2. 25 3. 30 4. 36

4. 36

A client with a spinal cord injury tends to assume the low-Fowler position excessively. Mark the area of the body that is most vulnerable to the development of a pressure ulcer in this client.

sacrum