Practice questions for exam 1

Which descriptions characterize dandruff? Select all that apply. A. can cause hair loss if not treated B. It can affect the skin of the face and neck C. Manifestation of hormonal imbalance D. caused by excessive dryness E. It is a collection of diffuse white scales on scalp.

Can cause hair loss Affect skin of face and neck Collection of white scales on scalp.

amount of urine needed to be produced within 24 hours

400-600

A patient is brought in an unconscious state to the ED. The primary care provider suspects dehydration and advises lab investigation to find cause. Which parameter in the lab investigations would indicate internal hemorrhage as a reason for dehydration? A. increased osmolarity B. absence of hemoconcentration C. decreased levels of blood hemoglobin

Absence of hemoconcentration

During the follow-up visit, a patient reports the spontaneous disappearance and reappearance of small macule with dry, yellow adherent scales on the skin. Which type of skin cancer does the nurse suspect?

Actinic keratosis

The nurse is providing information to a patient about self-management for the prevention of skin cancer. Which statement made by the patient needs correction?

I will try to avoid sun exposure from 7 am to 11 am

A patient with severe vomiting and diarrhea was brought to ED in a semiconscious condition. What interventions does the nurse implement to stabilize the patient? Select all that apply. A. monitor urine output B. monitor resp rate C. administer oral rehydration salts D. Monitor BP and HR E. administer replacement fluids IV F. Administer drugs to correct the cause of dehydration

Administer IV replacement fluids Administer drugs to correct cause of dehydration

While providing teaching to a patient undergoing excisional biopsy, Which statement does the nurse include?

Administration of local anesthetic agents may cause burning

What should the nurse take into consideration when assessing a patient's fluid balance? Select all that apply. A. Age B. Height C. Gender D. Body fat E. Cholesterol

Age Gender Body fat

The nurse is preparing to assess the skin of an older patient. What actions should the nurse take? Select all that apply. A. palpate skin areas of excessive dryness B. Assess skin turgor on forehead or chest C. Ensure warm hands D. uses standard precautions when skin area is draining E. Rub a finger against the skin to detect different types of rashes

Assess skin turgor on forehead or chest Ensure warm hands Standard precautions

The nurse is teaching a patient about decreasing the risk for melanomas and other skin cancers. Which primary prevention is most important for the nurse to include? A. Avoid tanning beds B. Wear SPF C. Avoiding or reducing skin exposure to sunlight D. being aware of skin markings and performing self-examinations

Avoid or reduce skin exposure to skinlight

Which intervention would the registered nurse (RN) delegate to the nursing assistant in the care of an older adult patient who has areas of breakdown in the skin folds and the perineal area? A. evaluating the patient's ability to provide skin hygiene independently B. assessing the patient's skin weekly C. Bathing the patient and apply a protective barrier to skin folds and perineum

Bathing the patient

A patient with burns has pulmonary edema. which drug would likely be administered to the patient?

Beta blockers

Which blood level must be monitored in a patient who developed metabolic acidosis as a consequence of a burn injury

Bicarb

The nurse notes an area of petechia on the patients lower extremity. Which condition does the nurse suspect?

Chronic venous insufficiency

The patient's nail bed is edematous and spongy. The fingertips have drum-like appearance. What is this condition known as?

Clubbing

A patient with DM who is prescribed diuretic medication reports giddiness and a dry mouth when in dry climates. After assessing the vital signs, the patient is diagnosed with mild dehydration. Which is the best nursing intervention? A. discontinue diuretic B. consume small amounts of sugar-free fluids hourly C. immediately start IV fluid replacement therapy

Consume small amounts of sugar-free fluids hourly

When assessing a patient's nails, the nurse finds that the patient has drumstick-shaped fingertips. Upon palpation, the nail base is visibly edematous and spongy. Which condition does the nurse suspect based on this data?

Cystic Fibrosis

The nurse is providing care to a patient who is admitted with fluid volume overload. Which electrolyte imbalances does the nurse anticipate for this patient based on the admitting diagnosis? Select all the apply. A. hypokalemia B. Hyponatremia C. Hypercalcemia D. hypochloremia E. Hypermagnesemia

Hypokalemia Hyponatremia Hypochloremia

The nurse is caring for an older adult patient that has areas of ecchymosis on the skin that range in size from several millimeters to many centimeters. When reviewing the patient's laboratory results, what does the nurse expect as the most likely cause of the findings

Decreased platelet count

Which consequences of fluid overload may result in seizures, coma and death

Decreased sodium and potassium

Which physiologic effect may indicate mild carbon monoxide poisoning?

Decreased visual acuity

Which condition is least likely to cause fluid overload? A. Heart Failure B. Kidney failure C. diabetes insipidus

Diabetes

Why do blisters not form in the deep partial-thickness wounds?

Due to the thick dead tissue layer which sticks to the underlying dermis

Which will the nurse include when documenting a patient's fluid intake for the shift? Select all that apply A. emesis B. Enemas C. oral fluids D. solid foods E. irrigation fluids

Enemas Oral fluids Irrigation fluids

The patient with a burn injury is receiving treatment in the hospital. There is redness of the skin with moderate edema and pain. The symptoms do not decrease after proper treatment for 6 weeks. Which type of burn injury uses grafting as part of the treatment plan to reduce healing time of the injury? Select all that apply. A. superficial wounds B. full-thickness wounds C. Deep full-thickness wounds D. Deep partial thickness E. Superficial partial thickness wounds

Full thickness Deep full thickness deep partial thickness

A patient is admitted to the ICU with SIADH. Which treatments does the nurse anticipate for this patient? Select all that apply. A. Lanoxin B. Furosemide C. Tolvaptan D. Conivaptan E. Vasopressin F. Norepinephrine

Furosemide (Lasix) Tolvaptan Conivaptan

Which condition could be evident in lab reports of a hypervolemic patient

Hemodilution

The nurse is assessing a patient's nails for color alterations and suspects that the patient has chronic liver disease. Which clinical finding supports that conclusion?

Horizontal white banding

The nurse is reviewing the basic metabolic panel for a patient who was admitted to the med surg unit until the previous day. Which finding would place the patient at risk for fluid volume overload?

Hyponatremia

what is the defense mechanism to combat the effects of isotonic dehydration and maintain blood flow to organs?

Increased blood vessel constriction

A 77-year-old woman is brought to the emergency department by her family after she has had diarrhea for 3 days. The family tells the nurse that she has not been eating or drinking well, but that she has been taking her diuretics for congestive heart failure (CHF). Her laboratory results include a potassium level of 3.0 mEq/L. What does the nurse include in the patient's medication teaching? Select all that apply. A. diuretics increase fluid intention B. Laxatives can lead to fluid imbalance C. It is important to weigh patient at same time daily D. diuretics can lead to fluid and electrolyte imbalances E. Daily weights are a poor indicator of fluid loss or gain

Laxatives can lead to fluid imbalance It is important to weigh patient daily Diuretics can lead to fluid and electrolyte imbalances

While assessing a patient's skin, the nurse observes accentuated markings and palpable thickened areas of epidermis. The patient tells the nurse "my skin has been itching for the past month" which type of skin lesion does the nurse suspect to see

Lichenifications

The nurse is providing education to a patient diagnosed with hypertension. Which statement by the nurse is most appropriate to help the patient maintain a normal fluid balance? A. increase your intake of water each day to increase urine output B. Limit your intake of sodium to decrease the water you are retaining C. Foods rich in potassium, such as bananas, will increase urine output.

Limit your intake of sodium to decrease the water you are retaining

What type of anesthetic is typically used for inserting a catheter for IO therapy

Local

Which risk categories are measured by the Braden Scale? Select all that apply. A. mobility B. incontinence C. mental status D. nutritional status E. pressure distribution

Mobility Incontinence mental status Nutritional status

A patient is diagnosed with squamous cell carcinoma. Which surgical technique would be effective in treating this condition?

Mohls

When planning care for a patient with hypercalcemia. Which intervention does the nurse consider? A. monitor cardiac rhythm for changes B. Limit activities to protect injury C. Assess O2 levels q 4 hours Dd. avoid invasive procedures due to increased bleeding tendency

Monitor cardiac rhythm for changes

A patient with burns has developed sepsis. Which sign or symptom in the patient indicates fungal infection? A. lethargy B. Hypothermia C. occasional diarrhea D. Severe disorientation

Occasional diarrhea

Which sites can be examined to check for pallor? Select all that apply. A. palms B. sclera C. nail bed D. conjunctiva E. upper chest

Palms Nail bed Conjunctiva

The nurse is providing care to several patients on a med surg unit. Which patient is at an increased risk for insensible water loss? A. patient is receiving humidified O2 by nasal cannula B. Patient is receiving continuous GI suctioning post op C. A patient with decreased respirations due to opioid administration for pain D. A patient receiving continuous IV

Patient is receiving continuous GI suctioning

Features associated with basal cell carcinoma?

Pearly papule with a central crater and rolled waxy borders.

The nurse observes the presence of small, reddish-colored lesions less than 0.5mm. The lesions are not affected when pressure is applied. What has the nurse assessed in this patient?

Petechiae

Which skin condition will the emergency department nurse assess first? A. pitting edema B.poor skin turgor C. Red bony prominences D. Localized redness of surgical site

Pitting edema

The healthcare provider writes orders for a patient who is admitted with potassium level of 6.9. What does the nurse implement first? A. place the patient on cardiac monitor B. Administer sodium polystrene sulfonate orally C. Ensure that a K restricted diet is ordered D. teach the patient about foods that are high in K

Place on cardiac monitor

During the post op patient assessment, which skin condition discovered by the nurse requires an urgent response? A. Cool extremities B. Clubbing of the nail beds C. reddish-blue area on the calf

Reddish-blue area on the calf

The patient with fluid overload has been taking a diuretic for the past 2 days and now experiences these changes. Which changes indicate to the nurse that the diuretic resulted in overdiuresis? Select all that apply A. reports of fatigue B. weight loss of 9lbs C. heart rate increase from 70 to 96 D. Heart rate decreases from 80-72 E. reports of light-headedness when first standing from a lying position

Reports of fatigue weight loss of 9lbs heart rate increase from 70-96 Reports of light-headedness

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? A. First B. Second C. Third D. Mixed

Second

Which are common complications of pressure injuries? Select all that apply. A. sepsis B. uremia C. diabetes D. cirrhosis E. kidney failure

Sepsis Kidney failure

During a patient skin examination, the nurse notes decreased turgor on forehead and abdomen, Which predisposing conditions does the nurse suspect is the cause of the skin change? select all that apply. A. trauma B.Anxiety C. inflammation D. severe dehydration E. sudden weight loss

Severe dehydration Sudden weight loss

Nail appearance of a patient with psorasis

Small pits in the nail pit

Which lab parameter would the nurse assess in a patient after providing fluid resuscitation?

Sodium level

What history and assessment findings may be associated with a hypocalcemia in a 22-year old man? Select all that apply. A. absent bowel sounds B. tingling around the mouth C. awakening at night with muscle spasms in the calf D. decreased deep tendon reflexes without paresthesia E. recent blunt trauma to the throat during a football game

Tingling around the mouth Awakening at night with muscle spasms in the calf Recent blunt trauma

Which intervention does the nurse include in caring for a patient with generalized edema who is receiving a loop diuretic? A. encouraging oral fluids B. restricting dietary potassium C. Turning patient every 2 hours

Turning patient

The nurse is administering normal saline IV to a patient who is dehydrated. Which assessments does the nurse perform to evaluate the effectiveness of rehydration therapy? Select all that apply. A. temperature B. Urinary output C. bowel sounds D. pulse rate E> LOC

Urinary output Pulse rate

A patient reports blistering, sloughing and tissue necrosis from the site after an IV drug infusion. Which drug is likely to have caused this?

Vinblastine

patient is brought in an unconscious state to the emergency department. The primary health care provider suspects dehydration and advises laboratory investigation to ascertain the cause. Which parameter in the laboratory investigations would indicate internal hemorrhage as a reason for dehydration?

absence of hemoconcentration

Which medication acts as a strong irritant and causes chemical burns in patients with psoriasis?

anthralin

Which systemic drug is most commonly used to treat psoriasis?

bexarotene

Which topical agent is typically used on a burn wound for rapid debridement?

collagenase

Which external manifestations in a patient indicate a likelihood of skin cancer? Select all that apply. A. skin bleeding B. Skin becomes shiny C. Irregular borders D. asymmetry E. diameter of lesion greater than 6 mm

irregular borders asymmetry Diameter >6 mm

Which conditions may contribute to a patient's insensible water loss? Select all that apply A. severe diarrhea B. Resp rate of 36 C. hot, dry home environment D. body temp of 96.4 E. Large volume of urinary output

severe diarrhea resp rate of 36 hot, dry home

which factor differentiates full-thickness wounds from deep-full thickness wounds

severity of edema

Which burn injury is characterized by desquamation?

superficial burns

A patient is admitted to the hospital after sustaining an electrical burn where more than 25% was burned. Black coloring of skin with exposure of muscles, bones and a fracture hand was observed. What should the nurse infer?

the patient has deep-full thickness wounds

An older adult admitted with dehydration and a history of stress incontinence expresses embarrassment about the disorder and the need for absorbent undergarments. Which question about nutritional metabolic needs would be best to ask this patient related to the reason for admission

what is your typical daily fluid intake and what types of fluids do you drink