Med Surg integumentary

What factors are considered when classifying a burn wound? Select all that apply. A) Extent B) Depth C) Timing D) Body area

A) Extent B) Depth

The nurse is assessing a patient with pemphigus. What skin manifestations should the nurse expect to observe? A) Rash B) Bullae C) Wheals D) Vesicles

B) Bullae

A 92-year-old woman is admitted from a nursing home to the hospital for colon resection. Four days postoperatively, she reports that her perineum is sore. It is reddened and has whitish discharge. She has been on three intravenous (IV) antibiotics. Which of the following problems does the nurse suspect? 1. Candidiasis 2. Psoriasis 3. Herpes zoster 4. Contact dermatitis

1. Candidiasis

Which of the following actions is appropriate initial treatment of a chemical burn? 1. Lavage with water. 2. Neutralize the chemical. 3. Apply the prescribed topical agent. 4. Wrap the patient in sterile sheets.

1. Lavage with water.

A patient is brought to the emergency department after a house fire. The patient has extensive trunk and lower extremity burns, and is diagnosed with a deep partial thickness burn. What assessment findings does the nurse expect? 1. Snowy white, painless lesions 2. Blistered, pinkish white, painful lesions 3. Blackened, painful lesions 4. Bright red, moist lesion

2. Blistered, pinkish white, painful lesions

Which instruction should the nurse provide to the patient being treated for scabies? 1. "Dry clean all linens, towels, and clothes." 2. "Wash linens, towels, and clothes." 3. "Discard infested mattresses." 4. "Remove infested pets from the home."

2. "Wash linens, towels, and clothes."

The nurse is providing care for a patient with a non-infected pressure ulcer. Which of the following actions is most appropriate? 1. Flushing the wound with 45-psi pressure. 2. Gentle flushing with a needleless 30-mL syringe. 3. Gentle scrubbing with gauze and normal saline 4. Flushing with a 30 mL syringe with an 18-gauge needle.

2. Gentle flushing with a needleless 30-mL syringe.

Place the wounds in correct order from stage I to stage IV. 1. Skin appears abraded. 2. Skin red, intact, and nonblanchable 3. Full-thickness skin loss, muscle and bone showing 4. Full-thickness skin loss, no muscle or bone involvement.

2. Skin red, intact, and nonblanchable 1. Skin appears abraded. 4. Full-thickness skin loss, no muscle or bone involvement. 3. Full-thickness skin loss, muscle and bone showing

A homebound patient is receiving IV antibiotics for an infected burn site. Instructions are to use gravity to infuse 100 mL over 1 hour. How many drops per minute should the nurse administer if the tubing has a drip factor of 15?

25gtt/min

A patient is admitted to the emergency department with flame burns to the entire chest, abdomen, back, and upper extremities. Using the Rule of Nines, what approximate percentage of burns should the nurse document? 1. 36% 2. 45% 3. 54% 4. 64%

3. 54%

Which nursing interventions are appropriate for a patient with a circumferential burn to an extremity? Select all that apply. 1. Apply compression bandages starting at the distal end of the extremity. 2. Administer analgesics if numbness or tingling occur. 3. Check neurovascular status hourly. 4. Assist with escharotomy if indicated. 5. Elevate the extremity.

3. Check neurovascular status hourly. 4. Assist with escharotomy if indicated. 5. Elevate the extremity.

The nurse recognizes that which of the following individuals should be evaluated for specialty bed that provides a pressure-relieving surface? 1. A 46 year old with scoliosis who has a UTI 2. A 94 year old with a Braden score of 15 and left and left arm weakness from a cardiovascular accidet (CVA) 3. An 88 year old with foot drop who has a Foley catheter. 4. A 15 year old with a Braden score of 9 who experiences pain with turning.

4. A 15 year old with a Braden score of 9 who experiences pain with turning.

How will the nurse know if interventions for impaired gas exchange related to smoke inhalation have been effective? 1. PaCO2 is greater than 45 mm Hg. 2. SpO2 is less than 90%. 3. pH is 7.34. 4. PaO2 is 88 mm Hg

4. PaO2 is 88 mm Hg

The nurse notes a pressure wound on a newly admitted patient's ischial tuberosity, with a thick, tough black center. Which intervention is most appropriate first? 1. Coat the ulcer with antibiotic ointment. 2. Snip away the black tissue with sterile scissors. 3. Flush the wound with sterile saline. 4. Talk to the HCP about débridement.

4. Talk to the HCP about débridement.

A patient diagnosed with impetigo contagiosa wants to know when the disease will no longer be contagious. Which response by the nurse is correct? 1. One week after treatment is started 2. After spread of lesions has stopped 3. After all the lesions crust over 4. When all lesions are healed.

4. When all lesions are healed.

A patient with a carbuncle is prescribed oral antibiotics, daily dressing changes with topical antibiotic ointment, and acetaminophen with codeine for pain. Which patient statement indicates that further teaching about the care of this skin condition is necessary? A) "Once the swelling and redness are gone, I can stop taking the antibiotics." B) "I should wash the area gently with antibacterial soap before applying a new dressing." C) "Covering my pillow with plastic and cleaning it every day will help prevent additional infection." D) "I will need to increase my fluid and fiber intake to prevent constipation while I'm taking the pain medication."

A) "Once the swelling and redness are gone, I can stop taking the antibiotics."

A patient with cancer is experiencing hair loss from chemotherapy treatments. Which term should the nurse use to document this finding? A) Alopecia B) Allopathy C) Ecchymosis D) Keratopenia

A) Alopecia

A nurse is reviewing information about a new prescription for corticosteroid cream with a client who has mild psoriasis. Which of the following instructions should the nurse include? (Select all that apply.) A) Apply an occlusive dressing after application. B) Apply three to four times per day. C) Wear gloves after application to lesions on the hands. D) Avoid applying in skin folds.

A) Apply an occlusive dressing after application. C) Wear gloves after application to lesions on the hands. D) Avoid applying in skin folds.

The nurse notes scratch marks on a patient with psoriasis. What are interventions that will decrease itching and protect the skin that the nurse can teach the patient? Select all that apply. A) Apply pressure to the itchy area with a clean cloth. B) Encourage use of gloves at night. C) Bathe daily in a hot soapy bath. D) Consider taking an antihistamine at bedtime. E) Use a room humidifier.

A) Apply pressure to the itchy area with a clean cloth. B) Encourage use of gloves at night. D) Consider taking an antihistamine at bedtime. E) Use a room humidifier.

The nurse notes scratch marks on a patient with psoriasis. What are interventions that will decrease itching and protect the skin that the nurse can teach the patient? Select all that apply. A) Apply pressure to the itchy area with a clean cloth. B) Encourage use of gloves at night. C) Bathe daily in a hot soapy bath. D) Consider taking an antihistamine at bedtime. E) Use a room humidifier.

A) Apply pressure to the itchy area with a clean cloth. B) Encourage use of gloves at night. D) Consider taking an antihistamine at bedtime. E) Use a room humidifier.

Which method is useful for applying medication to large areas of skin? A)Balneotherapy B)Open wet dressings C)Warm compresses D)Occlusive dressings

A) Balneotherapy

The nurse is caring for a patient 3 days following a split-thickness burn injury from a fire. Which observation indicates that nursing interventions to promote cardiac output have been effective? A) Blood pressure is 128/66 mmHg. B) Radial pulses are thready at 112/min. C) Urine output is 1050 mL in 24 hours. D) Patient weight is 4 pounds less than admission weight.

A) Blood pressure is 128/66 mmHg.

A patient has a burn encircling the left thigh from a motorcycle accident. When the nurse enters the room during rounds, the patient appears very anxious and reports a funny feeling in the left foot. What should the nurse do first? A) Check circulatory status in the foot and report changes B) Explain that some numbness and tingling in the affected extremity are normal following a burn. C) Check the burn dressing for an increase in drainage. D) Determine the cause of the patient's anxiety.

A) Check circulatory status in the foot and report changes

When assessing a patient in hospice who is near death , the nurse notes a bluish discoloration and mottled appearance to the patient's feet and lower legs. Which of the following terms would the nurse use to best document this finding ? A) Cyanosis B) Erythema C) Jaundice D) Pallor

A) Cyanosis

After collecting data the nurse is concerned that a patient is at risk for developing a mental illness. What findings caused the nurse to come to this conclusion? (Select all that apply.) A) Difficulty thinking B) Discussed the use of daily exercise to deal with stress C) Made statements indicating being out of touch with reality D) Expressed remorse in having to leave a pet dog with a neighbor E) Explaining a lack of friends because everyone is jealous of the patient

A) Difficulty thinking C) Made statements indicating being out of touch with reality E) Explaining a lack of friends because everyone is jealous of the patient

A nurse is collecting data from a client who sustained deep partial- thickness and full-thickness burns over 40% of his body 24 hrs ago. Which of the following findings should the nurse expect? ( Select all that apply.) A) Dyspnea B) Bradycardia C) Hyperkalemia D) Hyponatremia E) Decreased hematocrit

A) Dyspnea C) Hyperkalemia D) Hyponatremia

A patient with a partial thickness burn wound is prescribed synthetic dressings. What should the nurse explain to the patient about this type of dressing? (Select all that apply.) A) Easier to store B) Cost less to use C) Readily available D) Come in various shapes E) Contain antimicrobial substances

A) Easier to store B) Cost less to use C) Readily available D) Come In various shapes

The nurse is completing the Braden scale to predict pressure ulcer development risk for a patient on bedrest. Which findings should the nurse score as increasing this patient's risk? (Select all that apply.) A) Eats half of offered foods B) Patient responds only to painful stimuli C) Linen must be changed at least once per shift D) Makes body position changes with assistance only E) Walks independently outside of the room twice a day

A) Eats half of offered foods B) Patient responds only to painful stimuli C) Linen must be changed at least once per shift D) Makes body position changes with assistance only

A patient with schizophrenia is returning from a CT scan of the brain followed by an electroencephalogram. Which diagnostic test findings should the nurse identify as supporting this patient's diagnosis? (Select all that apply.) A) Enlarged ventricles B) Reduced amount of gray matter C) Areas of nerve de-myelinization D) Aneurysms of the cerebral vessels E) Diminished prefrontal cortex activity

A) Enlarged ventricles B) Reduced amount of gray matter E) Diminished prefrontal cortex activity

The nurse is at the scene of a fire caring for a patient with a thermal burn on the face, chest, and abdomen. What action should the nurse perform first? A) Ensure an open airway. B) Cover the burns with sterile dressings. C) Wash the burn gently with dilute antiseptic. D) Pour cool, clean water over the burned areas.

A) Ensure an open airway.

The nurse is assisting a patient with psoriasis apply coal tar to the skin. What action should the nurse anticipate providing after the tar is applied to the patient? A) Expose the patient UV light. B) Application of occlusive dressings. C) Have the patient sit in a warm environment. D) Provide the patient with 16 ounces of warm fluids.

A) Expose the patient UV light.

The nurse is assisting in the presentation of the skin for a group of senior citizens in the community center. Which normal changes associated with aging should the nurse include? (Select all that apply.) A) Fibroblasts in dermis die. B) Subcutaneous fat increases. C) Epidermal cell division slows. D) Hair follicles become inactive. E) Sweat glands become more active. F) Sebaceous gland becomes more active.

A) Fibroblasts in the dermis die C) Epidermal cell division slows D) Hair follicles becomes inactive

The nurse is caring for a patient with extensive burns. For which systemic responses to the burn should the nurse monitor the patient? (Select all that apply.) A) Hypovolemia B) Peptic ulceration C) Decreased metabolism D) Increased platelet function E) Increased oxygen consumption F) Depression of immunoglobulins

A) Hypovolemia B) Peptic ulceration E) Increased oxygen consumption F) Depression of immunoglobulins

What are risk factors for pressure ulcers? (Select all that apply.) A)Immobility B)Dermatitis C)Impaired Sensory Perception D)Elderly E)Very Thin or Obese F)Eschar

A) Immobility C)Impaired Sensory Perception D)Elderly E)Very Thin or Obese

A nurse is assisting with the plan of care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A) Limit visitors in the client's room. B)Encourage fresh vegetables in the diet. C) Increase protein intake. D) Instruct the client to consume 2,000 calories/day. E) Restrict fresh flowers in the room.

A) Limit visitors in the client's room. C) Increase protein intake. E) Restrict fresh flowers in the room.

The nurse notes that a patient with full thickness burns has an increase in hematocrit level. What should the nurse realize is causing this change in laboratory value? A) Loss of intravascular fluid B) Destruction of blood vessels C) Increased function of platelets D) Migration of white blood cells

A) Loss of intravascular fluid

The nurse is assisting in planning care for a patient with extreme anxiety. Which interventions should the nurse include in this patient's plan of care? (Select all that apply.) A) Maintain a calm environment. B) Encourage verbalization of feelings. C) Model and encourage positive self-talk. D) Encourage participation in competitive activities. E) Permit the patient to have time alone during acute anxiety events.

A) Maintain a calm environment. B) Encourage verbalization of feelings. C) Model and encourage positive self-talk.

A 62-year-old woman is admitted to the hospital with a lesion on her face that is a small, pearly papule. It has a rolled, waxy edge with crusting an ulceration. Which action by the nurse is best? A) Notify the physician B) Clean the lesion C) Place a gauze dressing on the lesion D) Place an occlusive dressing on the lesion.

A) Notify the physician

A nurse is caring for a nursing home resident with a red, pruritic skin rash. The patient is confused and scratches the rash which results in broken skin. Which interventions will help the rash heal? (Select all that apply.) A) Pat the skin dry after bathing. B) Leave topical agent as ordered at the bedside so the patient can apply when itching is severe. C) Place transparent dressing on the rash to prevent scratching. D) Place gloves or mitts on the patient. E) Keep the patient's fingernails short. F) Place wrist restraints on the patient during the night.

A) Pat the skin dry after bathing. D) Place gloves or mitts on the patient. E) Keep the patient's fingernails short.

The nurse is reviewing potential patient teaching needs. For which prescribed medications should the nurse plan to instruct patients to follow a tyramine-free diet? (Select all that apply.) A) Phenelzine (Nardil) B) Buspirone (Buspar) C) Isocarboxazid (Marplan) D) Valproic acid (Depakote) E) Lithium carbonate (Eskalith)

A) Phenelzine (Nardil) C) Isocarboxazid (Marplan)

The nurse is assisting in the preparation of an educational seminar on anxiety disorders. Which anxiety disorders should the nurse make sure are included in this presentation? (Select all that apply.) A) Phobia B) Panic disorder C) Schizophrenia D) Unipolar depression E) Post-traumatic stress disorder F) Obsessive-compulsive disorder

A) Phobia B) Panic disorder E) Post-traumatic stress disorder F) Obsessive-compulsive disorder

A patient with extreme anxiety is arriving for out-patient chemotherapy. What should the nurse do to help reduce the patient's anxiety during this current treatment? A) Play a CD with nature sounds. B) Select a television station with a sporting event. C) Close the door to the room during the treatment. D) Remind the patient that anxiety is not going to make the treatment effective.

A) Play a CD with nature sounds.

What equipment is most important to have readily available when a patient is undergoing skin testing for allergies? A) Resuscitation equipment B) Flashlight C) Measuring device D) Alcohol and cotton swabs

A) Resuscitation equipment

The nurse is participating in planning care for a patient with pemphigus. What nursing diagnosis should the nurse recommend be used to guide this patient's care? A) Risk for Infection B) Fluid Volume Excess C) Self-Care Deficit: Skin Care D) Imbalanced Nutrition: Less Than Body Requirements

A) Risk for Infection

While collecting data on a patient, the nurse observes that the patient's facial skin is yellowish. What other area should the nurse assess to confirm presence of jaundice? A) Sclera B) Nail beds C) Conjunctivae D) Mucous membranes

A) Sclera

The nurse is caring for a patient experiencing depression. Which neurotransmitters should the nurse consider being decreased in this patient? (Select all that apply.) A) Serotonin B) Dopamine C) Substance P D) Acetylcholine E) Norepinephrine

A) Serotonin B) Dopamine D) Acetylcholine

A patient comes into the emergency department experiencing chest pain and feelings of impending doom. Which assessment findings should the nurse use to determine if this patient is experiencing a panic attack? (Select all that apply.) A) Shaking B) Neck pain C) Dissociation D) Vomiting brown emesis E) Occurs at 3 p.m. every day

A) Shaking C) Dissociation E) Occurs at 3 p.m. every day

The nurse is caring for a patient experiencing anxiety. Which techniques should the nurse use when instructing on progressive muscle relaxation therapy? (Select all that apply.) A) Start at the head and neck. B) End with the lower extremities. C) Play soft music to aid with relaxation. D) Systematically tense and relax muscle groups. E) Imaging a pleasurable experience from the past.

A) Start at the head and neck. B) End with the lower extremities. D) Systematically tense and relax muscle groups. E) Imaging a pleasurable experience from the past.

The nurse is visiting the home of a patient with a mental health disorder. What should the nurse ensure during this home visit? (Select all that apply.) A) Status of suicide ideation B) Ability to provide self-care safely C) Patient's risk of falling in the home D) Number of family members who visit E) Compliance with prescribed medications

A) Status of suicide ideation B) Ability to provide self-care safely C) Patient's risk of falling in the home E) Compliance with prescribed medications

Which of the following dressings should a nurse choose for a deep pressure ulcer that has purulent drainage? A) Sterile gauze B) Transparent film (OpSite) C) Hydrocolloid (DuoDERM) D) Occlusive

A) Sterile gauze

Which layer of skin, unbroken, prevents the entry of most pathogens? A) Stratum corneum B) papillary layer C) stratum germinativum D) Dermis

A) Stratum corneum

A nurse in a provider's office is collecting data from a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A) Superficial thickness B) Superficial partial thickness C) Deep partial thickness D) Full thickness

A) Superficial thickness

A nurse is preparing to collect a wound culture. which of the following would be included in the collection process? (Select all that apply.) A) Swab wound and wound edges in a rotating motion B) Swab over areas of eschar C)Use sterile saline to remove excess debris before culture D)Use clean cotton-tipped swab to collect purulent drainage E) Swab wound 10 times in a diagonal pattern F) Obtain sterile calcium alginate swab for culture collection

A) Swab wound and wound edges in a rotating motion C)Use sterile saline to remove excess debris before culture E) Swab wound 10 times in a diagonal pattern F) Obtain sterile calcium alginate swab for culture collection

The nurse assists with admission of a patient to the hospital with pancreatitis and a history of alcohol abuse. Why should the nurse observe the patient for agitation, tremors, and hallucinations? A) These are symptoms of alcohol withdrawal. B) These symptoms indicate possible cirrhosis of the liver. C) The patient may be using alcohol in the hospital setting. D) Patients with a history of alcohol abuse are at risk for mental illness.

A) These are symptoms of alcohol withdrawal.

A nurse is providing care for a patient with burns across 30% of her body. Which of the following observations would cause the nurse to contact the registered nurse (RN) or physician? A) Urinary output of 50 mL in the past 2 hours B) Patient reports pain of 6/10; oral narcotic is due in 10 minutes. C) Respiratory rate is 20 and oxygen saturation is 94% D) Blood sugar is 175 mg/dL.

A) Urinary output of 50 mL in the past 2 hours.

What are effects of aging on the integumentary system? Select all that apply. A)Wrinkles develop B)Skin becomes more moist C)Skin becomes thinner D)Hair follicles become inactive E)Subcutaneous fat decreases

A) Wrinkles develop C) Skin becomes thinner D) Hair follicles become inactive E) Subcutaneous fat decreases

The nurse is reviewing the functions and purpose of the skin with a group of high school students. From what source should the nurse explain that the epidermis receives its nourishment? A) Dermis B) Melanocytes C) Epithelial cells D) Epidermal capillaries

A)Dermis

What are the best interventions to prevent contractures? (Select all that apply.) A)Exercises B)Pressure garments C)Splints D)Dressings

A)Exercises B)Pressure garments C)Splints

A patient is prescribed vitamin A acid (Retin-A) as treatment of acne vulgaris. What should the nurse instruct the patient about the purpose of this medication? (Select all that apply.) A) It decreases scarring. B) It loosens pore plugs. C) It kills bacteria in follicles. D) It stabilizes hormone levels. E) It stimulates the immune system. F) It prevents occurrence of comedomes.

B) It loosens pore plugs F) it prevents occurrence of comedomes

When is the best time for the nurse to apply prescribed ointment to a patient with an inflamed skin rash? A) In the morning before the patient dresses B) When the patient will be resting for at least an hour C) After the patient bathes D) In the evening before bed

C) After the patient bathes

A 55 year old woman is burned with hot water over her anterior trunk and her right anterior thigh. Using the Rule of Nines, what is the approximate percentage of burn? A) 18% B) 23% C) 36% D) 52%

B) 23%

A patient wants to know how long it will take to know if a skin graft used to cover a burn site is successful. How many days should the nurse explain as needed for graft vascularization to occur? A) 1 to 2 B) 3 to 5 C) 7 to 9 D) 11 to 13

B) 3 to 5

A nurse is reinforcing teaching with a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include in the teaching? A) Apply vitamin A cream before treatment. B) Adminster a psoralen medication before the treatment. C) Use the treatment every evening. D) Remove the scales gently following each treatment.

B) Adminster a psoralen medication before the treatment.

The nurse is caring for a patient who is verbalizing concerns related to a difficult relationship. Which responses by the nurse will block communication and should be avoided? (Select all that apply.) A) Using silence B) Asking "why" C) Changing the subject D) Agreeing or disagreeing E) Verbalizing the implied

B) Asking "why" C) Changing the subject D) Agreeing or disagreeing

The nurse is documenting findings from collecting data with a patient. What term should the nurse use to document transverse depressions in the nails? A) Paronychia B) Beau's lines C) Koilonychias D) Splinter hemorrhages

B) Beau's lines

while caring for a 28-year-old patient newly admitted for burns received in a household fire , the nurse would be most concerned by which of the following? A) Hematocrit = 48% B) Blood pressure = 92/40 mm Hg C) Pulse = 96 beats per minute D) Respiratory rate = 22 per minute

B) Blood pressure = 92/40 mm Hg

A victim of a fire in a manufacturing plant is brought to the emergency department. The HCP suspects this victim has sustained an inhalation injury. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.) A) Chest x-ray B) Bronchoscopy C) Arterial blood gases D) CT scan of the thorax E) Carboxyhemoglobin level

B) Bronchoscopy C) Arterial blood gases E) Carboxyhemoglobin level

A patient with depression is prescribed duloxetine (Cymbalta). What should the nurse instruct the patient about this medication? A) Take with fruit juice. B) Do not take with St. John's wort. C) Stop the medication if experiencing adverse effects. D) Expect blood pressure to drop with this medication.

B) Do not take with St. John's wort.

A patient is experiencing a fever. What structure should the nurse expect to provide an effective cooling mechanism for the body? A) Capillaries B) Eccrine glands C) Adipose tissue D) Ceruminous glands

B) Eccrine glands

The nurse is preparing to apply dressings to a patient's partial-thickness burn wounds. What should the nurse keep in mind when applying these dressings? (Select all that apply.) A) Wrap digits as one dressing. B) Elevate affected extremities. C) Limit the amount of dressing bulk. D) Wrap extremities from distal to proximal. E) Double the estimated size of dressing material.

B) Elevate affected extremities. C) Limit the amount of dressing bulk. D) Wrap extremities from distal to proximal.

Debridement is essential when which of the following is present? A)Open wound B)Eschar C)Scab D)Granulation tissue

B) Eschar

A nurse is reinforcing teaching with a female client on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following information should the nurse include? Select all that apply. A) Recommended for facial lesions. B) Expect a stinging sensation upon application. C) Apply to the scalp. D) Obtain a pregnancy test. E) Limit application to skin folds.

B) Expect a stinging sensation upon application. C) Apply to the scalp. D) Obtain a pregnancy test. E) Limit application to skin folds.

Which cause of or type of burn is commonly associated with an inhalation injury? A) Electrical B) Flame C) Scald D) Contact

B) Flame

The nurse is caring for a patient in a wound clinic who is treated with plastic wrap dressings. Which findings indicate complications related to prolonged application of the dressings? (Select all that apply.) A) Cyanosis B) Folliculitis C) Maceration D) Skin atrophy E) Lichenification F) Hyperpigmentation

B) Folliculitis C) Maceration D) Skin atrophy

The nurse is caring for a patient with impetigo contagiosa. For which complication should the nurse monitor when caring for this patient? A) Psoriasis B) Glomerulonephritis C) Respiratory infection D) Basal cell carcinoma

B) Glomerulonephritis

A patient diagnosed with a mental illness is being considered for psychotherapy. What should the nurse realize are the goals for this treatment? (Select all that apply.) A) Relaxing the body B) Improve social interactions C) Clarify the meaning of events D) Reduce emotional discomfort E) Enhance performance in situations

B) Improve social interactions D) Reduce emotional discomfort E) Enhance performance in situations

The nurse is reviewing the causes of anxiety with a patient diagnosed with an anxiety disorder. Which neurotransmitter abnormalities should the nurse include as causing symptoms of anxiety? (Select all that apply.) A) Increased substance P B) Increased epinephrine C) Increased somatostatin D) Decreased norepinephrine E) Decreased gamma-aminobutyric acid (GABA)

B) Increased epinephrine E) Decreased gamma-aminobutyric acid (GABA)

Which nursing interventions are essential to achieve maximum benefit for the patient receiving balneotherapy for widespread dermatitis? Select all that apply. A) Maintain the bath water at the hottest temperature tolerated by the patient. B) Keep the patient in the water for 15 to 30 minutes. C) Keep the tub room warm. D) Dry the skin vigorously following the bath. E) Use gentle or emollient soaps.

B) Keep the patient in the water for 15 to 30 minutes. C) Keep the tub room warm. E) Use gentle or emollient soaps

A patient with a wound is prescribed wet-to-dry dressings. What should the nurse do prior to performing a dressing change for this patient? A) Assist the patient to void B) Medicate the patient for pain C) Wash hands and apply sterile gloves D) Moisten the dressing before removing

B) Medicate the patient for pain

which substances are formed when the UV rays of the sun strike the skin? A) Vitamin A and Keratin B) Melanin and Vitamin D C) Sebum and Vitamin A D) Keratin and Melanin

B) Melanin and Vitamin D

The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patient's temperature is newly elevated at 100.2°F (37.9°C), and the patient exhibits new-onset agitation and confusion. What should the nurse do first? A) Increase oral fluids to 3000 mL/day. B) Notify the registered nurse (RN) or primary care provider. C) Monitor the patient for further changes in mental status. D) Administer a prn dose of acetaminophen (Tylenol) for the fever.

B) Notify the registered nurse (RN) or primary care provider

A patient has lost all hair over the head, face, and neck from a house fire. What should the nurse do to help the patient since the protective function of the hair has been lost? (Select all that apply.) A) Increase fluids B) Protect the eyes C) Filter the room air D) Ensure for warmth E) Provide pain medication

B) Protect the eyes C) Filter the room air D) Ensure for warmth

A patient with second-degree burns is concerned about skin repair. What should the nurse include when explaining the functions of the epidermal layers of the skin? (Select all that apply.) A) Contain sensory receptors B) Provide a barrier against pathogens C) Prevent loss of water and dehydration D) Present foreign antigens to helper T cells E) Prevent entry of excess water into the body

B) Provide a barrier against pathogens C) Prevent loss of water and dehydration D) Present foreign antigens to helper T cells E) Prevent entry of excess water into the body

A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take? (Select all that apply.) A) Scrape the site with a wooden tongue depressor. B) Puncture the crusted area with a sterile needle. C) Swab the crusted area with a sterile cotton-tipped applicator. D) Place cotton-tipped applicator in culturette tube. E) Place culturette tube in ice.

B) Puncture the crusted area with a sterile needle. D) Place cotton-tipped applicator in culturette tube. E) Place culturette tube in ice.

The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which actions should be included in the plan of care? (Select all that apply.) A) Apply ice packs to burn sites. B) Remove all contaminated clothing. C) Cover the patient with a clean sheet. D) Apply neutralizing agent to burn area. E) Obtain a history of the event and burning agent. F) Provide copious tepid water lavage for 20 minutes.

B) Remove all contaminated clothing C) Cover the patient with a clean sheet. E) Obtain a history of the event and burning agent. F) Provide copious tepid water lavage for 20 minutes.

A home care nurse visits an 82 yr old patient. On entering the home, the nurse finds that the patient has just dropped a pot of boiling water on both legs. What action should the nurse take first? A) Call 911 B) Remove the clothing from the affected area C) Place ice on the affected area D) Assess the extent of the burn

B) Remove the clothing from the affected area

The nurse is preparing to establish a relationship with a newly admitted patient. On which qualities should the nurse focus when creating this nurse-patient relationship? (Select all that apply.) A) Humor B) Respect C) Honesty D) Empathy E) Sympathy F) Friendship

B) Respect C) Honesty D) Empathy

The nurse is noting the texture of a patient's skin and hair. Which secretion should the nurse identify that prevents drying of skin and hair? A) Sweat B) Sebum C) Melanin D) Cerumen

B) Sebum

A patient has a wound draining moderate blood-tinged clear fluid. Which of the following would be an appropriate description of this drainage for the nurse to document? A) Purulent drainage B) Serosanguineous drainage C) Copious drainage D) Serous drainage

B) Serosanguineous drainage

The nurse is caring for a patient with lesions on the skin. Which assessment finding should cause the nurse to suspect scabies? A) Large, fluid-filled blisters B) Short, wavy, brownish black lines C) Reddish brown dots at the base of hairs D) Gray blue macules on the thighs and axillae

B) Short, Wavy, brownish black lines

A patient develops wounds on the sacrum and buttocks despite being turned and repositioned regularly. Which factors may have contributed to the patient's skin breakdown? (Select all that apply.) A) The patient is 20 pounds overweight. B) The patient commonly slides down in the chair. C) Staff use a lift sheet to move the patient in bed. D) The patient sits in a chair most of the day. E) The patient is often diaphoretic. F) The patient is incontinent of urine and stool.

B) The patient commonly slides down in the chair. D) The patient sits in a chair most of the day. E) The patient is often diaphoretic. F) The patient is incontinent of urine and stool.

A nurse caring for a client who has contact dermatitis and a new prescription for diphenhyramine. For which of the following adverse effects should the nurse monitor? A) Elevated blood glucose levels. B) Urinary retention C) Hyperpigmentation of the skin D) Insomnia

B) Urinary retention

A patient is diagnosed with a benign skin lesion caused by a virus. For which skin condition should the nurse plan care for this patient? A) Cyst B) Wart C) Keloid D) Pigmented nevi

B) Wart

The nurses are reviewing actions to reduce the incidence of infectious skin disorders in patients admitted to the care area. What action should the nurses identify as being the most important to prevent infectious skin disorders? A) Use antibacterial soap. B) Wash hands frequently. C) Use isolation precautions. D) Sterilize all contaminated objects.

B) Wash hands frequently.

The nurse is assisting with teaching a patient who is to begin taking a monoamine oxidase inhibitor (MAOI). Which foods should the nurse teach the patient to avoid? (Select all that apply.) A) Fish B) Wine C) Bread D) Pastas E) Aged cheese

B) Wine E) Aged cheese

A patient has a pressure ulcer that has purulent drainage, areas if black material, foul smelling, and painful. What should the nurse do first for healing to occur? A) Wound culture B) Wound débridement C) Topical antibiotic administration D) Intravenous antibiotic administration

B) Wound débridement

The nurse notes that an older patient is malnourished and has minimal subcutaneous tissue. Which functions of the subcutaneous tissue of the skin should the nurse consider as being potentially altered in this patient? (Select all that apply.) A) Store energy B) Cushion bones C) Support hair growth D) Provide nourishment to tissues E) Provide insulation from the cold F) Destroy pathogens that passed through broken skin

B)Cushion bones E) Provide insulation from the cold F) Destroy pathogens that passed through broken skin

The nurse is caring for a dark-skinned African American patient. Which sites should the nurse use evaluate for the presence or absence of cyanosis? (Select all that apply.) A) Sclera B) Nail beds C) Hard palate D) Soles of the feet E) Inner aspect of the arm

B)Nail beds D) Soles of the feet

What are nursing interventions for itching due to dermatitis? (Select all that apply.) A)Tepid vinegar baths B)Pressure with a clean cloth C)Antihistamines D)Humidification E)Antibiotics

B)Pressure with a clean cloth C)Antihistamines D)Humidification

A patient has been prescribed fluoxetine (Prozac) to treat depression. What should be included in the nurse's teaching about the drug? (Select all that apply.) A) "You need to take this drug only once a week." B) "Take the prescribed dose in the early evening." C) "A decreased interest in sexual activity may occur with this medication." D) "You should not consume red wine, aged cheese, or other tyramine-rich foods." E) "Do not expect immediate results; it usually takes 6 to 8 weeks for therapeutic effects to be felt." F) "You may experience some nausea, vomiting, and anorexia, but these side effects will subside in time."

C) "A decreased interest in sexual activity may occur with this medication." F) "You may experience some nausea, vomiting, and anorexia, but these side effects will subside in time."

A nurse is reinforcing discharge instructions with a client who had a skin biopsy with sutures. Which of the following client statements indicates that the teaching has been effective? A) "I can expect redness around the site for 5 to 7 days." B) "I will most likely have a fever for the first few days." C) "I should apply an antibiotic ointment to the area." D) "I will make a return appointment in 3 days for removal of my sutures."

C) "I should apply an antibiotic ointment to the area."

A nurse is reinforcing teaching with a client about a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include in the teaching? A) "It reduces the discomfort of a herpetic infection but dose not cure the infection." B) "This is a cream to treat a bacterial infection." C) "I will apply the topical medication for up to 2 weeks after the lesions are gone." D) "I will apply the cream to lesions while they are moist."

C) "I will apply the topical medication for up to 2 weeks after the lesions are gone."

The nurse is teaching a patient skin care to prevent cancer. Which time of day should the patient instruct to avoid the sun? A) 7 to 9 a.m. B) 9 to 10 a.m. C) 10 a.m. to 4 p.m. D) 2 to 4 p.m.

C) 10 a.m to 4 p.m

The nurse is caring for a patient with burns covering the entire surface of both arms and the anterior trunk. Approximately what percentage of the patient's body surface area has been affected? A) 18% B) 27% C) 36% D) 45%

C) 36%

A patient has burns on both legs and in the genital/perineum area. What is this patient's percentage of burned area? A) 18% B) 19% C) 37% D) 54%

C) 37%

The nurse is caring for a patient who has a stage 4 pressure ulcer that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which patient assessment finding should be communicated to the registered nurse (RN) immediately? A) Patient report of pain B) Yellow wound drainage C) A reddened area adjacent to the ulcer D) Pink grainy appearance at wound edges

C) A reddened area adjacent to the ulcer

Which of the following tissues stores fat in subcutaneous tissue? A) Fibrous connective tissue B) Stratified squamous epithelium C) Adipose tissue D) Areolar connective tissue

C) Adipose tissue

A nurse is reinforcing teaching with a client on home care after a culture for a bacterial infections and cellulitis. Which of the following information should the nurse include? A) Bathe daily with moisturizing soap. B) Apply antibacterial topical medication to the crusted exudate. C) Apply warm compresses to the affected area. D) Cover affected area with snug

C) Apply warm compresses to the affected area

A nurse is reinforcing teaching with a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include? A) Bathe daily with moisturizing soap. B) Apply antibacterial topical medication to the crusted exudate. C) Apply warm compresses to the affected area. D) Cover affected area with snug-fitting clothing.

C) Apply warm compresses to the affected area.

What information is most important for the nurse to teach patients about avoiding malignant skin lesions? A) Shower or bathe daily. B) Avoid contact with allergens and irritants C) Avoid overexposure to ultraviolet rays D) Avoid others with malignant lesions

C) Avoid overexposure to ultraviolet rays

The nurse is assisting with data collection on a patient newly diagnosed with schizophrenia. Which observations should the nurse consider as being positive symptoms of schizophrenia? (Select all that apply.) A) Alogia B) Apathy C) Delusions D) Hallucinations E) Social isolation F) Disorganized behavior

C) Delusions D) Hallucinations F) Disorganized behavior

For which type of burn should you overestimate the percentage of injury on initial evaluation? A) Flame B) Chemical C) Electrical D) Contact

C) Electrical

While changing the dressing on a burned arm the patient complains of feeling cold and having extreme pain. However, the patient asks the nurse to not apply so much pressure when wrapping gauze around the limb. What should these findings indicate to the nurse? A) All nerves in the limb are damaged B) Free nerve endings in the arm are injured C) Encapsulated nerve endings in the arm are intact D) Encapsulated nerve endings in the arm are injured

C) Encapsulated nerve endings in the arm are intact

Which type of burn involves the muscle and bone? A) Superficial partial thickness B) Deep partial thickness C) Full thickness

C) Full thickness

While inspecting the skin of a patient's arm the nurse notes lesions that are clustered together. How should the nurse document this finding? A) Linear B) Discrete C) Grouped

C) Grouped

The nurse is caring for a patient who is receiving fluid replacement after being burned on 37% of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, heart rate of 120 beats/min, and urine output of 10 mL over the past hour. After reporting these findings, which order should the nurse expect to be prescribed for this patient? A) Discontinue the IV fluid infusion. B) Change the IV fluid to dextrose and water. C) Increase the amount of IV fluid administered per hour. D) Decrease the amount of IV fluid administered per hour.

C) Increase the amount of IV fluid administered per hour.

Which of the following actions should the nurse take when new petechiae are observed on a patient's skin? A) Cleanse the skin B) Apply cool compresses C) Inform the registered nurse or physician D) Apply heat to the area

C) Inform the registered nurse or physician

A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Most of the burns are full-thickness burns on the arms, face, neck and shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. These findings are indications of which of the following? A) Pulmonary edema B) Bacterial pneumonia C) Inhalation injury D) Carbon monoxide poisoning

C) Inhalation injury

A nurse is assisting with the care of a client who sustained deep partial-thickness and full-thickness burns over 60% of his body 24hr ago and is requesting pain medication. The nurse should ensure the medication is administered using which of the following routes to administer the medication? A) Subcutaneous B) Oral C) Intravenous D) Transdermal

C) Intravenous

A patient with a deep partial thickness burn is prescribed wet to dry gauze dressings. Which type of debridement is the nurse performing with this dressing? A) Surgical B) Chemical C) Mechanical D) Escharotomy

C) Mechanical

A nurse is reinforcing teaching with the parent of a child who has contact dermatitis. Which of the following information should the nurse include? A) Use fabric softener dryer sheets when drying the child's clothing. B) Apply a warm, dry compress to the rash area. C) Place the child in a bath with colloidal oatmeal. D) Leave the child's hands uncovered during the night.

C) Place the child in a bath with colloidal oatmeal.

Which of the following activities creates a mechanical force that can lead to the formation of a pressure ulcer? A) Massaging nonreddened areas. B) Whirlpool baths C) Pulling a patient up in bed D) Range-of-motion exercises

C) Pulling a patient up in bed

The nurse is applying a medicated plastic wrap dressing to a patient's leg. What intervention should the nurse include in the plan of care to prevent development of complications? A) Apply the dressing twice a day. B) Apply the dressing four times daily. C) Remove the dressing for 12 hours a day. D) Remove the dressing for 24 hours every other day.

C) Remove the dressing for 12 hours a day.

A patient is admitted to the emergency department with chemical burns to the chest and abdomen. The RN immediately begins a sterile saline lavage. What should the licensed practical nurse (LPN) do to assist during this procedure? A) Apply a neutralizing agent. B) Apply ice to the burned area. C) Remove the patient's clothing. D) Prepare intravenous morphine for administration by the RN.

C) Remove the patient's clothing.

A patient is brought to the emergency department with burns over 40% of the body from an apartment fire. Which assessment should take priority? A) Burn depth B) Percent of body surface burned C) Respiratory status D) Circulatory status

C) Respiratory status

Which type of burn is caused by a hot liquid? A) Radiation B) Contact C) Scald D) Chemical

C) Scald

White blood cells, which destroy pathogens that enter breaks in the skin, are found in which of the following structures? A) Stratum Corneum B) Keratinized layer C) Subcutaneous tissue D) Adipose cells

C) Subcutaneous tissue

The nurse is caring for a patient who is 2 days post-inhalation burn injury from a house fire. Which outcome best indicates that nursing interventions for impaired gas exchange have been effective? A) PaCO2 is 56 mm Hg. B) The patient is afebrile. C) The patient is alert and oriented. D) Peripheral pulses are present and strong.

C) The patient is alert and oriented.

A nurse is providing care for an older adult patient who reports being sensitive to cold temperatures. The nurse would base teaching on which of the following principles? A) There is slower cells division in the epidermis with aging B) Older adults experience deterioration of collagen and elastin fibers C) There is less fat in the subcutaneous layer with age D) Death of melanocytes in the skin occurs with age

C) There is less fat in the subcutaneous layer with age

A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratory findings should the nurse anticipate the provider reviewing to confirm this diagnosis? A) Potassium hydroxide (KOH) B) Diasopy C) Tzanck smear report D) Biopsy

C) Tzanck smear report

Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 cm? A) Macule B) Papule C) Vesicle D) Wheal

C) Vesicle

During report, the nurse is told that a patient "has moderate jaundice." Which assessment finding should the nurse expect to see? A) Flushing in the face B) Pale mucous membranes C) Yellow discoloration of the skin D) Bluish tinge to the fingers and toes

C) Yellow discoloration of the skin

What term would the nurse use to document a large (> 1cm) fluid-filled lesion? A)Nodule B)Wheal C)Bulla D)Vesicle

C)Bulla

The nurse notices small purplish dots on the abdomen of a patient. Which statement should the nurse use to document the finding? A) "Diffuse erythema of the abdomen." B) "Purpura scattered across abdomen." C) "Scattered ecchymoses noted on abdomen." D) "Multiple petechiae noted across the abdomen."

D) "Multiple petechiae noted across the abdomen."

The nurse is preparing wet dressings for a patient who has a weeping skin lesion. What is the maximum length of time the wet dressings should be used? A) 24 hours B) 36 hours C) 48 hours D) 72 hours

D) 72 hours

The nurse is cleansing a patient's infected pressure ulcer. What type of equipment should the nurse use? A) A needleless 30-mL syringe B) A needleless 60-mL syringe C) A 10-mL syringe with a 24-gauge needle D) A 30-mL syringe with an 18-gauge needle

D) A 30-mL syringe with an 18-gauge needle

A patient is newly diagnosed with a trauma related disorder. Which medication should the nurse expect to be prescribed for this patient? A) Paroxetine (Paxil) B) Sertraline (Zoloft) C) Buspirone (Buspar) D) Alprazolam (Xanax)

D) Alprazolam (Xanax)

The nurse is caring a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4°F (36.3°C). Which new assessment finding should be immediately communicated to the health care provider (HCP)? A) Report of increasing pain B) Temperature 99°F (37.2°C) C) Serum-filled blister formation D) Blood pressure 122/74 mm Hg

D) Blood pressure 122/74 mm Hg

How do arterioles in the dermis respond to a cold environment ? A) Dilate to release heat B) Constrict to release heat C) Dilate to conserve heat D) Constrict to conserve heat

D) Constrict to conserve heat

During morning report, a nurse is assigned a patient who is in Stage III burn care. What care can the nurse anticipate providing during the shift? A) Dressing changes B) Debridement C) Pain management D) Exercises

D) Exercises

What term would the nurse use to document a slit or crack-like sore? A)Scale B)Excoriation C)Ulcer D)Fissure

D) Fissure

The nurse notes a thickening and hardening of the skin from continued irritation on an individual who is wheelchair-bound. What term should the nurse use to describe this finding? A) Crust B) Papule C) Excoriation D) Lichenification

D) Lichenification

Which of the following dressing types is most appropriate for the nurse to apply to skin tear in an older adult patient? A) Moist sterile gauze B) OpSite transparent dressing C) Paste D) Nonadherent dressing

D) Nonadherent dressing

The nurse is reviewing a patient chart and notes the following: "Poor elasticity and dry thin skin noted" The nurse recognizes this is a normal finding for which of the following patient groups ? A) Adolescents B) young adults C) Middle- aged adults D) Older adults

D) Older Adults

The nurse is providing wound care to a patient's skin graft donor sites used for burn treatment. For which type of wound is this nurse providing care? A) Skin tear B) Full thickness C) Split thickness D) Partial thickness

D) Partial thickness

The nurse is monitoring a patient's stage 3 pressure ulcer for healing during treatment. Which finding indicates that the nursing interventions have been effective? A) There is a hard crust over the wound. B) The patient states that pain is minimal. C) The wound drainage is serosanguinous. D) The wound has a grainy, spongy texture.

D) The wound has a grainy, spongy texture.

The nurse is assisting a patient who has a suspected diagnosis of tinea capitis (ringworm). For which diagnostic test should the nurse prepare the patient? A) Patch test B) Scratch test C) Skin biopsy D) Wood's light examination

D) Wood's light examination

The nurse notes that a patient has a honey-colored crust over a thin-walled vesicle. For which infectious skin disorder should the nurse plan care? A) Scabies B) Carbuncle C) Pediculosis D) Impetigo contagiosa

D) impetigo contagiosa

Which protein gives skin its characteristic color? Albumin Melanin Collagen Myosin

Melanin