Delmars Integumentary disorders

17. the nurse should inform a client taking fluconazole (Diflucan) to be aware of which of the following adverse reactions? select all that apply: [ ] 1. tremors [ ] 2. headache [ ] 3. constipation [ ] 4. skin rash [ ] 5. pruritus [ ] 6. Abdominal pain

. 17. 2. 4. 6. fluconazole (Diflucan) is an antifungal used in the treatment of candidiasis. Adverse reactions include diarrhea, headache, skin rash, and abdominal pain.

12. when teaching a client about using salicylic acid as a drug to promote shedding of the horny layer of skin, the nurse should explain which of the following about salicylic acid? 1. it is not absorbed through the skin 2. it may burn the skin 3. it is not advised for dandruff 4. it may cause acne

12. 1. salicylic acid has its effect on the keratin layer of the skin. the acid is too mild to burn the skin. it can be used for dandruff. it may also be used to treat acne, because it causes drying and sloughing.

20. the nurse is planning to debride and remove scales and crusts of skin lesions to the left leg of a client. Which of the following is a priority intervention for this client? 1. cool oatmeal bath 2. Warm saline dressings 3. cool sodium bicarbonate bath 4. Warm magnesium sulfate dressings

20. 2. debridement is best accomplished using a warm solution. saline is the best choice. a cool oatmeal or sodium bicarbonate bath is best used for pruritus. magnesium sulfate will not be helpful for the person with scaly and crusty skin.

20. the client with a rash in the axilla is prescribed amcinonide (cyclocort) topical. for which of the following adverse reactions should the nurse monitor the client? 1. gastrointestinal manifestations 2. cracking and splitting of the skin 3. thinning of the skin 4. loss of pigmentation

20. 3. Amcinonide (cyclocort) is a topical steroid. regular use of topical steroids is associated with the adverse effect of thinning of the skin and appearance of "stretch marks."

20. a client with molluscum contagiosum has read on the internet that no treatment is required and asks why the molluscum should be treated. the nurse's most appropriate response is which of the following? 1. "it will not clear spontaneously." 2. "it is contagious, and your child cannot attend school until the molluscum is treated." 3. "the lesions may resolve spontaneously, but they may continue to spread." 4. "if the lesions are not treated, they grow larger."

20. 3. molluscum contagiosum is a viral infection of the skin characterized by flesh-colored, domeshaped papules with central umbilication. although molluscum will eventually resolve, lesions spread easily, may become infected, may be itchy or irritated, and are sometimes cosmetically objectionable. for these reasons, they are usually treated with cantharidin applied directly to the lesion.

21. A female client with herpes genitalis is receiving education about the medication regimen. which of the following would be most appropriate to include in the teaching? 1. use one applicator of terconazole intravaginally at bedtime for 7 days 2. use topical acyclovir every 4 hours five times a day for 10 days 3. use sulconazole nitrate twice a day and massage in 4. use one applicator of tioconazole intravaginally at bedtime for 7 days

21. 2. Acyclovir (zovirax) is an antiviral used in the treatment of genital herpes. it is used every 4 hours five times a day for 10 days. terconazole, sulconazole nitrate, and tioconazole are all antifungal drugs.

29. Which of the following nursing interventions should the nurse include in the rehabilitative phase of burn care? 1. establish and maintain a patent airway 2. insert two large-bore catheters percutaneously 3. administer range-of-motion exercises 4. use Parkland formula to calculate fluid requirement

29. 3. administering range-of-motion exercises is an appropriate intervention for the rehabilitative phase of burn care. establishing and maintaining a patent airway, inserting two large-bore catheters percutaneously, and using the Parkland formula to calculate fluid requirement are interventions reserved for the emergent and acute phase of burn management.

6. which of the following should the nurse include when instructing the mother of a child with pediculosis capitis on the use of permethrin 1% (nix)? 1. apply the nix and cover the hair with a shower cap 2. after rinsing the hair, comb to remove the nits 3. apply the nix at bedtime 4. leave the nix on for 8 to 14 hours

6. 2. permethrin 1% (nix) is both pediculocidal and ovicidal and generally considered the treatment of choice. nix should be applied to clean, damp hair. it should be left on for 10 minutes followed by rinsing and combing with fine-toothed comb to remove nits.

1. which of the following instructions should the nurse include in the teaching plan for a 16-year-old client with comedonal acne being treated with topical retin-a? 1. avoid sun exposure 2. severe headaches may be experienced 3. improvement will be seen in 24 hours 4. scrub the skin prior to application

1. 1. tretinoin (retin-a) is a retinoid used in the treatment of acne vulgaris. an adverse reaction of topical tretinoin (retin-a) is photosensitivity. it is important to avoid excessive sun exposure. retin-a does not cause headaches. improvement with use of any acne treatment usually takes 6 to 8 weeks. scrubbing the skin prior to application irritates and inflames the skin.

Which of the following nursing activities should the registered nurse delegate to a licensed practical nurse? 1. instruct a client with acne vulgaris on the use of tretinoin (retin-a) 2. develop a plan of care on the irrigation of a skin ulcer with normal saline 3. obtain a health history from a client admitted with a pressure sore on the coccyx 4. monitor the vital signs of a client with cellulitis for evidence of sepsis

1. 4. a licensed practical nurse may not instruct, develop a teaching plan, or obtain a health history. those are activities reserved for the registered nurse. a licensed practical nurse may monitor the vital signs of a client with cellulitis for evidence of sepsis. a licensed practical nurse is trained to monitor vital signs for deviations from normal and then report those changes to a registered nurse.

1. which of the following should the nurse include in the plan of care for a client taking isotretinoin (Accutane)? select all that apply: [ ] 1. Avoid letting cream come in contact with eyes [ ] 2. inform the client about the risks of taking Accutane [ ] 3. instruct the client to wear protective clothing and eyewear for protection from photosensitivity [ ] 4. cover treated area with a thin dressing [ ] 5. monitor for salicylism [ ] 6. instruct the client to practice reliable method of birth control for 1 month before and 1 month after treatment

1.[ ] 2. inform the client about the risks of taking Accutane [ ] 3. instruct the client to wear protective clothing and eyewear for protection from photosensitivity [ [ ] 6. instruct the client to practice reliable method of birth control for 1 month before and 1 month after treatment 2. 3. 6. nursing interventions for isotretinoin (Accutane) include informing the client of the associated risks, practicing protective clothing and eyewear for protection from photosensitivity, and instructing the client to practice a reliable method of birth control for 1 month before and 1 month after treatment with Accutane. superficial fungal infections should not come in contact with the eyes. After applying a drug to a burn site it is covered with a thin dressing. A client taking a drug for keratin-containing lesions should be monitored for salicylism

10. the nurse is instructing a client with herpes zoster on self-care. Which of the following statements by the client indicates the teaching has been successful? 1. "i will stay away from my young grandchildren." 2. "Frequent cool baths will help my herpes heal more quickly." 3. "i will use topical diphenhydramine to dry up the lesions." 4. "i will avoid using fabric softener in the laundry."

10. 1. People who have not had chickenpox may get it from exposure to those with herpes zoster. cool baths, although soothing, do not speed up the healing process. topical diphenhydramine is useful for itching but will not accelerate the healing process. the use of fabric softener is unrelated to herpes zoster.

10. the physician prescribes ketoconazole (nizoral) to treat systemic candidiasis. the client asks, "what are the main advantages of this drug?" the nurse's best response is which of the following? 1. "it can be given orally and is safer than amphotericin b." 2. "it is less expensive than other medications." 3. "it is the physician's choice." 4. "it can be used once a week instead of daily."

10. 1. ketoconazole (nizoral) is just as effective to treat systemic candidiasis and not as dangerous as amphotericin b. Amphotericin b is highly toxic and used for progressive and potentially fatal infections. Although expense is a consideration, safety is the most important factor.

10. the nurse should inform a child with atopic dermatitis that which of the following may cause a flare? 1. Bathing with mild soap 2. moisturizing the skin 3. wearing cotton clothing 4. sudden changes in temperature

10. 4. atopic dermatitis is a chronic inflammation of the dermis and epidermis resulting in pruritus, erythema, edema, papules, serous discharge, and crusting. cotton clothing, daily baths, and moisturizing are all part of the plan of care for atopic dermatitis. sudden temperature changes can cause dryness or sweating, which may contribute to a flare.

11. the parent of a child infested with scabies asks the nurse how the child got scabies. Based on the nurse's knowledge of scabies, the most likely method of contracting scabies is 1. swimming in a pool. 2. being in close contact with an infested individual. 3. having contact with an infected pet. 4. airborne

11. 2. scabies is an infestation of the scabies mite with sarcoptes scabiei and is dependent on a human host for survival. it is transmitted by skin-to-skin contact with an infested individual. it is less likely to contract through fomites. animals do not carry scabies. the mite can survive for 24 to 36 hours away from the host.

11. the nurse should monitor a client taking a drug to remove keratin-containing lesions for which of the following adverse reactions of salicylism? select all that apply: [ ] 1. leukopenia [ ] 2. ulcerative stomatitis [ ] 3. Dizziness [ ] 4. impaired hearing [ ] 5. Drowsiness [ ] 6. hair loss

11. 3. 4. 5. Dizziness, impaired hearing, and drowsiness are adverse reactions of salicylism. leukopenia and ulcerative stomatitis are adverse reactions of methotrexate (rheumatrex). hair loss is n adverse reaction to etretinate (tegison).

11. When assessing for changes in skin color in an african-american client, the nurse should assess which of the following first? 1. soles of the feet 2. Palms of the hand 3. conjunctiva or sclera 4. nail beds or oral mucosa

11. 4. assessment of the skin of those with naturally darker pigmentation should be done in an area where the epidermis is thin or in areas of least pigmentation, such as the nail beds or oral mucosa. the soles of the feet and palms of the hands are the second best options. it would not be appropriate to inspect the conjunctiva or sclera of an african-american client for skin color because of the possibility of yellowing.

12. the nurse is preparing to teach a class on the prevention of skin problems. Which of the following is a priority for the nurse to instruct clients to avoid? 1. sunlight 2. radiation 3. alkaline soaps 4. vitamin e

12. 1. limiting exposure to the sun is the most important preventive measure in reducing the risk of developing skin cancer and premature aging. radiation and alkaline soaps are less common causes of skin problems. overexposure to vitamin e does not cause skin problems.

. 12. which of the following assessments does the nurse conclude supports a diagnosis of a second-degree burn? select all that apply: [ ] 1. skin is red and dry [ ] 2. skin is moist, bright red, and extremely painful [ ] 3. wide variations in depth, healing, and scar formation [ ] 4. commonly caused by exposure to hot liquids [ ] 5. results in scarring and contacturess [ ] 6. heaaling spontaneously in about 5-10 days without scarring

12. 2. 3. 4. characteristics of second-degree burns include moist skin, bright red, and extremely painful. there are wide variations in depth, healing, and scar formation. the most common cause is exposure to hot liquids. the skin of a first-degree burn is red, dry, and heals in 5-10 days spontaneously. third-degree burns appear waxy and dry and have a decreased pain sensation.

13. the nurse should assess a child suspected of having tinea capitis for which of the following? select all that apply: [ ] 1. scalp scaling with alopecia [ ] 2. warts on the periungual regions [ ] 3. orolabial lesions [ ] 4. presence of kerions [ ] 5. scale and black dots [ ] 6. creamy-white plaques on the buccal mucosa

13. 1. 4. 5. scalp scaling with alopecia is a clinical manifestation of tinea capitis. kerions are moist, boggy scalp nodules. scale and black dots may also be present. warts on the periungual region around the nail are seen in verrucae. orolabial lesions occur in the herpes simplex virus type 1. creamy-white plaques on the buccal mucosa are characteristic of candidiasis.

13. the nurse is caring for a pressure ulcer using a topical debriding agent. Another nurse asks the nurse the type of drug typically used for this purpose. which of the following is the best response? 1. An enzyme ointment 2. A corticosteroid cream 3. An antipsoriatic lotion 4. A topical antihistamine

13. 1. An enzyme ointment best describes the classification of agents used for debriding pressure ulcers. corticosteroids do not have debridement properties. Drugs used for psoriasis do not debride. topical antihistamines are used for itching and inflammation rather than debridement.

13. the nurse is caring for a client during the emergent phase of a burn injury. Which of the following assessments would provide the nurse with the most accurate information regarding this client's full-thickness burns? 1. leathery, dry, hard skin 2. red, fluid-filled vesicles 3. massive edema at the injury site 4. serous exudates from a shiny, dark-brown wound

13. 1. a burn that has leathery, dry, and hard skin describes a full-thickness burn in the emergent phase. a burn that is a red, fluid-filled vesicle with massive edema at the injury site describes a deep partial-thickness burn during the emergent phase. serous exudate from a shiny, dark-brown wound describes a partialthickness burn in the acute phase.

14. Prioritize the emergency management of a burn, from highest to lowest priority, with 1 as the highest priority. ____ 1. establish and maintain an airway ____ 2. assess for associated injuries ____ 3. establish an iv line with a large-gauge needle ____ 4. remove the client from the burn source

14. 4. 1. 3. 2. it is a priority to remove a client from the burning source, followed by establishing and maintaining an airway. establishing an iv line with a large-gauge needle and assessing for associated injuries would follow in priority.

14. the nurse should monitor a client taking betamethasone for which of the following adverse reactions? select all that apply: [ ] 1. weight loss [ ] 2. Decreased appetite [ ] 3. hypotension [ ] 4. muscle wasting [ ] 5. edema [ ] 6. skin thinning

14. 4. 5. 6. betamethasone (Diprolene) is a superhigh-potency corticosteroid that causes weight gain, increased appetite, hypertension, muscle wasting, edema, and skin thinning.

14. the client with tinea capitis asks the nurse what the treatment for a kerion is. Based on the treatment of tinea capitis, the nurse replies 1. "apply warm, moist soaks." 2. "apply permethrin 1% (nix)." 3. "shave the hair." 4. "oral corticosteroids (orapred, prelone, pediapred)."

14. 4. oral corticosteroids (orapred, prelone, pediapred) are used to treat a kerion. it is not necessary to shave the hair or apply soaks. topical treatment is ineffective.

15. using an open method of skin care, which of the following should the nurse include when caring for a client with deep partial-thickness burns of both legs? 1. ensure that sterile water is used in the debridement tank 2. apply topical silver sulfadiazine (silvadene) with clean gloves 3. use clean gloves to remove the dressings and wash the wounds 4. Wear a cap, mask, gown, and gloves when caring for the client

15. 2. the open method requires cleansing the wounds, applying a topical antimicrobial, and leaving the wounds open to air. either saline or an electrolyte solution is best to use in the debridement tank. it would be inappropriate to use the open method with a partial-thickness burn because there are no dressings in place.

15. which of the following should the nurse include in the medication instructions for a child with tinea capitis for whom griseofulvin (grifulvin v, fulvicin p/g, grisactin) has been prescribed? 1. stop taking the drug when the scalp improves 2. take the drug on an empty stomach 3. take the drug with a fatty meal 4. take the drug at bedtime only

15. 3. griseofulvin (grifulvin v, fulvicin p/g, grisactin) is the standard treatment for tinea capitis. it is best absorbed when taken with fatty foods. treatment generally lasts for a minimum of 8 weeks.

15. the registered nurse is preparing to make out the clinical assignments for the day. which of the following nursing tasks may the nurse delegate to a licensed practical nurse? 1. inform a client taking etretinate (tegison) to use birth control when taking the drug 2. instruct a client using isotretinoin (Accutane) 3. Administer acyclovir (zovirax) intravenously to a client 4. Ask the client if stinging occurs when applying topical acyclovir (zovirax)

15. 4. A licensed practical nurse may ask a client if stinging occurs when a topical drug is applied. informing or instructing a client about certain effects of a drug are nursing tasks that should be performed by a registered nurse. Administering a drug intravenously is also a task that belongs to a registered nurse.

16. the mother of a 4-week-old infant with a small hemangioma asks the nurse if the hemangioma will get any bigger. which of the following is the most appropriate response by the nurse? 1. "hemangiomas generally grow rapidly during the first year of life, followed by a gradual spontaneous involution." 2. "the hemangioma will not grow and get any bigger." 3. "the hemangioma will fade over time, leaving just a pink scar." 4. "hemangiomas gradually get smaller with each passing month of life, until there is normal skin where the hemangioma was."

16. 1. hemangiomas are benign proliferations of the blood vessels of the skin. although rarely present at birth, most appear by 1 to 4 weeks of life. they grow rapidly during the first year of life and then have a spontaneous involution that may begin as early as 6 to 10 months. they become soft and gray. about 50% of hemangiomas are gone by age 5 years and 90% are gone by age 12 years.

16. the nurse notifies the physician that a client who is 12 hours postburn has abdominal distention and faint, intermittent bowel sounds. Which of the following should the nurse perform? 1. Withhold oral intake except water 2. insert a nasogastric tube 3. administer a histamine-blocking medication 4. reposition the client in preparation for an enema

16. 2. Paralytic ileus is common in the postburn phase and is best treated with a nasogastric tube to suction for decompression. all oral intake should be withheld. administering a histamine-blocking medication will not improve peristalsis, although it may be given to reduce the possibility of aspirating acidic stomach contents. it would not be appropriate to prepare the client at this time for administration of an enema. once there is evidence of peristalsis (bowel sounds are present, the client passes flatus), an enema may be administered.

16. the nurse is teaching the client about using tretinoin (retin-A) for treatment of acne vulgaris. which of the following indicates that the teaching has been successful? 1. the client avoids washing the skin with drying soap 2. the client limits exposure to sunlight 3. the client reduces the intake of caffeinecontaining foods 4. the client stops using the medication if a stinging feeling occurs

16. 2. tretinoin (retin-A) is a retinoid that causes sensitivity to sunlight and susceptibility to sunburn, so limiting exposure and using sunscreen of at least 15 spf are advised. the use of a drying soap assists the client in treating the acne. Although the use ofcaffeine has no relationship to the medication itself, some clients find that certain foods aggravate their acne and are advised to avoid them or reduce the amount consumed. A stinging sensation is normal for clients with sensitive skin. Avoiding abrasive soaps and keratolytic agents, like benzoyl peroxide and salicylic acid, can reduce this sensation

17. which of the following nursing interventions should the nurse include in the plan of care for a child with tinea pedis? 1. apply warm soaks to the feet 2. keep the feet dry 3. wear wool socks 4. administer oral steroids

17. 2. tinea pedis is a dermatophyte infection of the feet. Because it is generally acquired from shower room floors, the feet should be kept dry. it must be treated for 4 to 6 weeks with topical antifungals. clients should avoid tight-fitting shoes and wear cotton socks.

17. the nurse is caring for a client with a burn injury who has a nursing diagnosis of impaired physical mobility related to limited range of motion secondary to pain. Which of the following is the priority nursing intervention for this client? 1. encourage the client to perform range-ofmotion exercises in the absence of pain 2. instruct the client on the importance of exercise to prevent contractures 3. Provide an analgesic medication before physical activity and exercise 4. arrange for the physical therapist to increase activity during hydrotherapy

17. 3. control of pain is crucial before clients will participate in their prescribed exercise routine. this is best facilitated by administering an analgesic medication before physical activity. controlling the pain should be followed by encouraging range of motion and instructing the client on the importance of exercise to prevent contractures. arranging for a client to see a physical therapist does not address pain control. in fact, most burn patients find hydrotherapy to be very painful because of the debridement that must occur at that time.

18. After instructing a client on the application of anthralin, the client states, "i want to apply the medication to the nonaffected areas to prevent other lesions from developing." which of the following responses by the nurse is most appropriate? 1. "the medication can cause chemical burns, so it should be used on the psoriatic lesions only." 2. "Anthralin is very expensive, so limit its use to the psoriatic lesions." 3. "As long as you leave it on for a maximum of 2 hours, it should be all right." 4. "because anthralin promotes fluid and electrolyte loss, you should limit the areas that are treated."

18. 1. Anthralin may be used in the treatment of psoriasis. it inhibits DnA synthesis to suppress the overgrowth of epidermal cells. it is a strong irritant and should be applied only to affected skin. it may be very irritating to unaffected skin. it also stains clothing, skin, and hair.

18. which of the following should the nurse include in the information given to the parents of an infant born with a port-wine stain? 1. the port-wine stain does not grow bigger with age 2. most port-wine stains are the result of a medical condition 3. port-wine stains generally become darker and thicker with age 4. the port-wine stain becomes raised over time

18. 3. a port-wine stain is a capillary malformation present at birth. it generally is not associated with any medical condition. port-wine stains usually grow with the child, but do not become raised.

18. Which of the following statements by a client who received instructions on pain control prior to a dressing change indicates the instructions were understood? 1. "i will ask for my midazolam (versed) 1 hour before the dressing change." 2. "i will ask for acetaminophen (tylenol) 2 hours before my dressing change." 3. "i will put on my favorite music to take my mind off my pain." 4. "i will ask the nurse for iv morphine 5 minutes before my dressing change."

18. 4. Pain control in a burn injury includes administering iv morphine just prior to the dressing change. midazolam (versed) is a good drug for pain control but it must be administered too far in advance to be of maximal benefit. acetaminophen (tylenol) is not an adequate analgesic for pain associated with full-thickness burns. listening to music may be a good adjunct therapy to medication to control pain prior to a dressing change for a burn, but it is usually not enough by itself to control a client's pain.

19. the client who has burns on the face, neck, and chest asks why a pressure garment must be worn so many hours a day prior to dressing changes. Which of the following statements by the nurse provides the most accurate explanation? 1. "the pressure garment protects your skin from sunlight and further damage." 2. "it provides support and splinting to keep your body in alignment." 3. "it reduces the thickness of the scar tissue." 4. "the pressure garment helps trap the oils in your skin."

19. 3. Pressure garments flatten scar tissue, giving the client more mobility and resulting in a better cosmetic appearance. Wearing a pressure dressing does protect the site from further injury, but this is not the major reason for wearing a pressure garment. Wearing a pressure dressing does not support or splint the body part, nor does it trap the oils in the skin.

19. the nurse prepares to include which of the following in the plan of care of a child with molluscum contagiosum? 1. instruct the child to scratch with the knuckles instead of the fingers 2. instruct the parents to keep the child out of school as long as the child is contagious 3. administer cantharidin directly to the lesion 4. administer oral prelone

19. 3. molluscum contagiosum is a viral infection of the skin caused by a Dna pox virus. the main feature is a flesh-colored, dome-shaped papule with central umbilication. cantharidin is applied with a wooden applicator directly to the lesion. although contagious, the child does not have to be kept out of school. corticosteroids, such as prelone, are used in the treatment of tinea capitis.

19. the client is being treated with haloprogin (halotex) for tinea pedis (athlete's foot). which of the following statements by the client indicates the client understands the teaching about the medication? 1. "i will apply the ointment daily for 6 weeks." 2. "i will use the powder three times a day." 3. "i will soak my feet in cold water before each application." 4. "i will apply the medication every morning and evening for 2 to 4 weeks."

19. 4. haloprogin (halotex) is an antifungal. treatment for tinea pedis (athlete's foot) requires twice-a-day application of halotex. soaking the feet in cold water will not improve absorption of the medication.

2. which of the following should the nurse include in the discharge instructions for a child who had a punch biopsy done on the back? 1. leave the site open to air 2. make an appointment to have the sutures removed in 5 days 3. keep the site clean, dry, and covered for 24 hours 4. avoid physical activity

2. 3. following a punch biopsy, the area should be kept clean, dry, and covered for 24 hours to protect the wound and promote healing. no physical restrictions are necessary following a skin biopsy. sutures should be removed in 10 to 14 days.

2. the nurse should instruct a client taking an oral retinoid to avoid which of the following? 1. Dairy products 2. carbonated drinks 3. extremely cold air 4. vitamin A supplements

2. 4. 4. vitamin A supplements oral retinoids are derived from vitamin A; hence, taking supplemental vitamin A could cause an overdose of this fat-soluble vitamin.

2. Which of the following is a priority to include when instructing a client to perform a skin assessment? 1. "evaluate the evenness of skin color, moisture, and temperature." 2. "look for any changes in moles, especially color and size." 3. "begin performing skin examinations after age 40." 4. "assess the entire body and look for changes in skin or moles."

2. 4. skin self-examination includes the entire body, looking for any changes in skin color as well as changes in moles. although evaluating the evenness of skin color, moisture, and temperature is an appropriate intervention, it is limited in its focus to two insignificant characteristics of skin moisture and temperature. these do not change with development of skin cancer. inspecting moles is also an important part of a skin examination, but limits the skin assessment to moles only and negates the rest of the assessment. Performing a skin examination is an ongoing assessment and not just something that begins after age 40.

21. a client with chronic skin lesions on the face and arms admits to the nurse of being unable to look in the mirror. based on this information, which of the following nursing diagnoses would the nurse identify? 1. anxiety related to personal appearance 2. disturbed body image related to perception of unsightly lesions 3. social isolation related to poor self-image 4. deficient knowledge related to lack of understanding of use of cover-up techniques

21. 2. defining characteristics for disturbed body image include verbalization of self-disgust and inability to look at oneself in the mirror. anxiety would be an appropriate nursing diagnosis only if the client verbalizes or demonstrates anxiety related to appearance. social isolation or deficient knowledge would be an appropriate diagnosis only if the client verbalizes these as problems.

21. the child with molluscum contagiosum is going to be treated with cantharidin. the parents of the child ask the nurse how the cantharidin is given. the nurse's response would be which of the following? 1. "it is injected into each lesion." 2. "an oral tablet is given twice a day." 3. "a wooden applicator is used to apply the cantharidin directly to each lesion." 4. "you will receive a prescription for the topical ointment to rub on twice a day."

21. 3. molluscum contagiosum is a viral infection of the skin that causes flesh-colored, dome-shaped papules with central umbilication. cantharidin is very potent and can cause significant burns if not used properly. it must be applied carefully to each lesion with a wooden applicator. this treatment is only done in the doctor's office. a prescription is never given and the drug is never administered in the home by the client.

22. the nurse is caring for a client with fullthickness burns who is receiving fluid replacement. Which of the following would indicate to the nurse that the client's condition is deteriorating? 1. systolic blood pressure (bP) of 86 2. 30 to 50 ml/hr urine output 3. respiratory rate of 18/minute 4. Pulse rate of 85

22. 1. a decrease in the systolic blood pressure to less than 90 mm hg indicates evaporation, plasma loss, and a fluid shift into the interstitium secondary to the burn injury. a urinary output of between 30 and 50 ml per hour, respiration rate of 18, and a pulse rate of 85 are all considered normal.

22. During the early emergent phase of a burn injury, clients are at risk for infection. which of the following prescribed drugs would the nurse anticipate administering to prevent infection? 1. mafenide acetate (sulfamylon) 2. lindane (kwell) 3. Acitretin (soriatane) 4. Azelaic acid (Azelex

22. 1. sulfamylon is a topical anti-infective that is used to prevent infections in burn wounds. lindane (kwell) is used to treat pediculosis. Acitretin (soriatane) is a retinoid used in the treatment of psoriasis. Azelaic acid (Azelex) is used in the treatment of acne.

22. the nurse prepares a 10-year-old child who presents with a single wart on the hand for which of the following treatments? 1. liquid nitrogen 2. tagamet 3. aldara 4. retin-a

22. 1. verrucae, or cutaneous warts, are benign tumors of the epidermis caused by a human papillomavirus. for a 10-year-old child with a single wart, the most likely treatment would be liquid nitrogen. cryotherapy with liquid nitrogen is reserved for children over the age of 8 years. tagamet is given for multiple warts and is often used in younger children who cannot tolerate liquid nitrogen. aldara and retin-a are used to treat flat warts on the face. in addition, aldara is used to treat genital warts.

23. during the acute phase of a burn injury, the nurse assists a client with deep partialthickness burns of the left arm to make which of the following menu choices that are most appropriate? select all that apply: [ ] 1. Fried chicken [ ] 2. turkey sandwich with lettuce and tomato [ ] 3. barbecued pork on a roll [ ] 4. mashed potatoes [ ] 5. milkshake [ ] 6. cola beverage

23. 2. 4. 5. a turkey sandwich with lettuce and tomato, mashed potatoes, and a milkshake provide the highest-quality protein with the best representation of food groups for a client who has a partial-thickness burn of one arm. it is also manageable by a client who has only one hand that is usable. Fried chicken is high in fat, and barbecued pork is spicy and may not be tolerated well. a cola beverage, although high in calories, is void of nutrients.

23. the nurse should monitor a client receiving mafenide acetate (sulfamylon) for which of the following adverse reactions? select all that apply: [ ] 1. petechiae [ ] 2. constipation [ ] 3. pain [ ] 4. Acidosis [ ] 5. rash [ ] 6. erythema

23. 3. 4. 5. 6. mafenide acetate (sulfamylon) is a sulfonamide used in the treatment of burns. the topical application is painful and may result in acidosis. rash and erythema are other adverse reactions.

23. the parents of a 3-month-old infant who has a hemangioma on the nasal tip asks the nurse what the treatment is. Based on an understanding of hemangiomas, which of the following is the nurse's response? 1. "hemangiomas are generally not treated because they are never life threatening." 2. "liquid nitrogen is usually applied to nasal tip hemangiomas." 3. "surgical excision is generally performed within the first year of life." 4. "nasal tip hemangiomas are treated with oral corticosteroids."

23. 4. hemangiomas are benign proliferations of the blood vessels in the skin. they are rarely present at birth. most of them develop within 1 to 4 weeks after birth. to prevent excessive tissue growth on the nasal tip (cyrano nose deformity) in a nasal tip hemangioma, oral corticosteroids (prelone, pediapred, orapred) are given. surgical intervention is recommended only after the hemangioma has involuted. it will continue to grow for up to 1 year of age. some hemangiomas can be life threatening.

24. the nurse is admitting a 4-month-old infant with an irregularly shaped reddish-purple macular vascular lesion on the face. the mother states it was present at birth. the nurse documents this as which of the following? 1. hemangioma 2. port-wine stain 3. congenital melanocytic nevus 4. pyogenic granuloma

24. 2. port-wine stains are capillary malformations present at birth. they are generally irregularly shaped reddish-purple macular vascular lesions. hemangiomas are not usually present at birth and grow rapidly during the first year of life. congenital nevi are brown. pyogenic granulomas are raised reddish-purple papules that bleed profusely with trauma.

24. A client with sebhorrheic dermatitis of the face is being treated with topical ketoconazole (nizoral). which of the following behaviors by the client indicates that teaching has been effective? 1. Application of a thick layer of cream; washing the area once a week 2. removal of any dry scales prior to application of the cream to aid absorption 3. Applying an emollient before applying the ketoconazole 4. Applying moisturizing cream sparingly after applying the ketoconazole

24. 2. topical ketoconazole (nizoral) is best absorbed through skin that is free of scales. gentle washing with soap and water to remove scales will aid in absorption of the topical antifungal. A thin layer that is rubbed in will be more effectively absorbed. the old cream and dead skin must be removed daily. Application of an emollient prior to application of the antifungal will reduce absorption of the antifungal. moisturizing creams are of no value in treating the fungal infection that caused the dermatitis to begin with.

24. a client with psoriasis is being treated with psoralen plus uva light phototherapy. during the course of therapy, the client is instructed to wear protective eyewear to block all uv rays. Which of the following statements by the client indicates a correct understanding of the teaching? 1. "i should wear sunglasses continuously for 6 hours after taking the medication." 2. "i should wear sunglasses until my pupils can constrict when exposed to light." 3. "i will wear sunglasses for 12 hours after treatment to prevent retinal damage." 4. "i should wear sunglasses for 24 hours following treatment when indoors near a bright window."

24. 4. Psoralen is absorbed by the lens of the eye, so protective eyewear must be used for 24 hours after taking the medication. because uva penetrates glass, the sunglasses must also be worn inside.

25. Which of the following assessments would provide the nurse with the most accurate information regarding a client in the emergent phase of burn care? select all that apply: [ ] 1. extreme thirst [ ] 2. decreased pulse [ ] 3. Warm and flushed feeling [ ] 4. decreased bowel sounds [ ] 5. dehydration [ ] 6. decreased blood pressure

25. 1. 4. 6. the emergent phase of a burn injury is also called the resuscitative phase. it begins with the onset of the burn and generally lasts 1 to 2 days but may continue for approximately 5 days. initially there is fluid loss and the presence of edema. it continues until diuresis begins. the client will exhibit thirst and chilling due to fluid and heat loss. decreased bowel sounds or even absent bowel sounds may be present from an adynamic ileus resulting from trauma or a potassium shift. signs of hypovolemic shock would include decreased blood pressure and increased pulse.

25. the nurse should prepare a child with a pyogenic granuloma on the chin that has been bleeding for which of the following treatments? 1. elliptical excision 2. punch biopsy 3. shave excision and electrodessication 4. pulsed dye laser

25. 3. pyogenic granulomas are benign growths of blood vessels that can bleed profusely with trauma. treatment is to shave the lesion and cauterize the base to prevent recurrence. a pulsed dye laser is used to destroy wart tissue.

26. a client with burns over the face, arms, and trunk is requesting pain medication. When intervening in this situation, the nurse should administer which of the following drugs of choice for pain control in burn management? 1. meperidine (demerol) 2. morphine 3. oxycodone/aspirin (Percodan) 4. Propoxyphene/acetaminophen (darvocet)

26. 2. morphine sulfate is the drug of choice in the treatment of burns. meperidine (demerol) may also be used but is not the drug of choice. oxycodone/aspirin (Percodan) and propoxyphene/ acetaminophen (darvocet) are not strong enough drugs to provide adequate pain relief.

26. the registered nurse is delegating nursing tasks for the day. which of the following tasks should the nurse delegate to a licensed practical nurse? 1. instruct the parents of a child with a wart to wash off the podophyllin used in the treatment in 4 to 6 hours 2. inform the parents of a child with a hemangioma that generally no treatment is required 3. administer prelone to a child with tinea capitis who has a kerion 4. assess and report the characteristics of a child's port-wine stain

26. 3. instructing, informing, and assessing are all nursing skills that are most appropriately performed by the registered nurse. a licensed practical nurse may administer a

27. in planning the care for a severely burned client, the nurse should select which of the following as the priority nursing diagnosis? 1. Pain related to burn injury and treatments 2. impaired physical mobility related to contractures 3. risk for deficient fluid volume related to a fluid shift, evaporation, and plasma loss 4. imbalanced nutrition: less than body requirements related to the body's need for an increased calorie intake

27. 3. the priority nursing diagnosis for a client with burns is risk for deficient fluid volume related to a fluid shift, evaporation, and plasma loss.

28. the nurse implements which of the following nursing measures as preventing dilutional hyponatremia in a client with burns? 1. instruct the client on the sodium content in foods 2. administer a diuretic 3. encourage the client to drink fluids other than water 4. encourage the client to exercise vigorously

28. 3. the client is encouraged to drink fluids other than water as a means of preventing dilutional hyponatremia, also known as water intoxication. Fluids rich in electrolytes and calories are offered.

4. the nurse should prepare an 18-year-old adolescent with acne who has not responded to antibiotic therapy for which of the following tests prior to starting treatment with isotretinoin (accutane)? 1. skin biopsy 2. hearing test 3. pregnancy test 4. urinalysis

4. 3. isotretinoin (accutane) is a retinoid used in the treatment of severe recalcitrant nodular acne that does not respond to standard therapies. it has severe teratogenic effects. two negative pregnancy tests are required prior to starting accutane therapy.

3. the nurse assesses a client's skin and finds an elevated, solid lesion on the client's great toe. it is pink, nontender, and 0.5 cm in size. Which of the following is the most appropriate action by the nurse? 1. notify the physician immediately 2. gather more information about the lesion from the client 3. instruct the client to cover the lesion with an adhesive bandage 4. determine what the client has been doing to treat the lesion

3. 2. more information is needed about the lesion to help determine an appropriate course of action. the findings do not require immediate attention from the physician. it is inappropriate to determine a plan of action without completing a thorough assessment. determining what the client has been doing to treat the lesion only gathers part of the data needed to determine a plan of action.

3. the nurse is caring for a client who has been taking isotretinoin (Accutane) for the past 2 months. which of the following is a priority for the nurse to report? 1. pruritus 2. Depression 3. Dry skin 4. headache

3. 2.2. Depression isotretinoin (Accutane) is a retinoid used in the treatment of acne. Adverse reactions include pruritus, dry skin, and headache and should be reported, but the priority adverse reaction to report is depression. there have been reports of depression and possibly suicidal ideation associated with the use of isotretinoin.

30. Which of the following nursing tasks should the nurse delegate to unlicensed assistive personnel? 1. remove a dressing on a skin tear of a client's leg 2. advise a client with acne to use water-based cosmetics 3. assist with bathing of a client with a burn 4. encourage a client with acne rosacea to verbalize feelings

30. 3. removing a dressing, providing client instruction, and encouraging a client to verbalize feelings are all activities that require the skills of a qualified nurse. although socialization is a skill that unlicensed assistive personnel may perform, encouraging a client to verbalize feelings is a skill that requires the expertise of the nurse in assisting the client to deal with the expressed feelings. unlicensed assistive personnel may assist with the bathing of a client who sustained a burn.

4. the nurse instructs a client with pruritus to apply an emollient immediately after bathing. the nurse understands that the rationale for this intervention is to 1. prevent evaporation of water from the epidermis. 2. cause vasodilation that will reduce the symptoms of pruritus. 3. provide extra fat to the subcutaneous tissue. 4. protect the skin from further irritation.

4. 1. emollients seal in water and hydrate the skin. emollients do not affect the blood vessels. the emollient is not in contact with the subcutaneous tissue. the primary function of an emollient is to rehydrate the skin. intact skin is the best defense against irritation.

4. the nurse instructs a client with pruritus to take an oral antihistamine to relieve the itching. which of the following should be included in this instruction? 1. "the effects will be best if you take the medication around the clock." 2. "take the medication only when the itching is at its worst." 3. "use the oral medication in combination with a topical antihistamine." 4. "increase the dosage of the oral medication as needed if the itching is severe."

4. 1.1. "the effects will be best if you take the medication around the clock." oral antihistamines have their maximal effect when taken regularly around the clock. Drowsiness is an adverse reaction that is also minimized by this dosing.

5. a mother calls the pediatric office and states that her 8-year-old child is complaining of intense itching around the nape of her neck. which of the following is the priority intervention? 1. inspect the child for lice or nits 2. cut the child's nails shorter 3. wash the hair with a mild shampoo 4. administer a topical steroid ointment

5. 1. the main clinical manifestation of pediculosis capitis, or head lice, is intense pruritus. nits are commonly found on the hairs of the occipital area of the scalp.

5. the nurse is discharging a client who has second-degree burns on the hands and arms. treatment includes application of silver sulfadiazine (silvadene) to the burn area twice a day. which of the following must be included in wound care instructions for this client? 1. "wash the area with warm water before the application of silvadene." 2. "Apply salve after the silvadene to seal the medication into the burned area." 3. "Apply the silvadene using sterile technique." 4. "Apply the medication only at bedtime."

5. 1.1. "wash the area with warm water before the application of silvadene." burn wounds should be cleansed prior to application of silvadene cream. this helps remove dead tissue and old cream. there is no need to apply salve over the silvadene. silvadene provides a protective cover by itself. the client should use a clean technique at home rather than a sterile technique. the treatment must be twice a day, generally in the morning and evening.

5. the nurse is discharging a client who developed a skin tear while hospitalized for surgery. the nurse instructs the client in wound care for the skin tear. Which of the following would be essential to include in the wound care instructions for this client? 1. cover the skin tear with a transparent dressing 2. use a nonadherent dressing over the wound 3. eat a high-fat diet to help the wound heal more quickly 4. drink 3000 ml of water every day to keep the skin hydrated

5. 2. use of a nonadherent dressing is the most helpful in treatment of skin tears. a transparent dressing causes maceration of the skin and may cause further skin trauma with removal. a diet high in fat does not help with healing. a diet high in protein and vitamin c is more likely to help healing. the primary treatment of skin tears is protecting them from further trauma so they can heal.

6. A 22-year-old has been diagnosed with acne vulgaris and is to start on tetracycline. which of the following is a priority question to ask this client before therapy is started? 1. "how long have you had the cystlike nodules on your face?" 2. "when was your last menstrual period?" 3. "how many times a day do you scrub your face? 4. "have you been taking any oral medication for acne?"

6. 2.2. "when was your last menstrual period?" because tetracycline is teratogenic, it is a priority to establish that the client is not pregnant before starting the drug. tetracycline is not the drug of choice for a cystlike type of acne. scrubbing of the face has no impact on the use of tetracycline systemically. Although asking a client if an oral medication for acne has been taken is appropriate, it is not the priority because of the teratogenic effects of the tetracycline.

6. the nurse is teaching a mother about caring for her 4-year-old with atopic dermatitis. Which of the following statements by the mother indicates that the teaching has been successful? 1. "i prevent the spread of dermatitis by using separate towels for the children." 2. "We will all switch to soy milk." 3. "i will keep my child out of the sun." 4. "i will avoid using fabric softeners in the laundry."

6. 4. Fabric softeners often contain chemicals or components that are irritants for those with atopic dermatitis. dermatitis is not a contagious condition, so using separate towels is not necessary. avoidance of certain foods in treating atopic dermatitis is controversial. it is recommended that only known allergens be avoided. the sun is not a trigger for atopic dermatitis.

7. the nurse is instructing a client about use of benzoyl peroxide to treat acne. which of the following should be included? 1. overuse can cause extreme dryness of the skin 2. use caution when driving or operating heavy machinery 3. nausea and vomiting may occur 4. A decrease in appetite may occur

7. 1.1. overuse can cause extreme dryness of the skin benzoyl is an effective drying agent that can cause too much drying if overused. benzoyl peroxide is topical and does not have systemic adverse reactions. benzoyl peroxide is not associated with the adverse reactions of nausea, vomiting, or a decrease in appetite.

7. the nurse is teaching a class on the treatment of psoriasis with methotrexate. Which of the following should the nurse include in her teaching? 1. methotrexate is recommended only for those over the age of 50 2. it is important to monitor serum albumin, total protein, and blood glucose 3. an effective birth control for both men and women must be taken 4. topical steroids used with methotrexate

7. 3. because methotrexate is associated with chromosomal abnormalities, both men and women must use highly effective birth control during therapy. methotrexate may be used in clients with very severe disease who have been unresponsive to other therapies, regardless of age. the appropriate lab work to monitor when a client is taking methotrexate includes blood chemistry and liver and renal function studies. methotrexate is only used when all other treatment options fail.

7. following application of permethrin 5% (elimite) for scabies, the nurse should anticipate that the pruritus will 1. subside within 24 hours. 2. be relieved immediately. 3. continue for 12 hours. 4. subside within 14 to 21 days.

7. 4. permethrin 5% is considered the treatment of choice for scabies. the pruritus is a hypersensitivity response to the nit and its ova and feces. following application of elimite, the pruritus may continue for 14 to 21 days. emollients may help to relieve the discomfort.

8. the nurse is providing instruction to a client about use of lindane (kwell) shampoo for treatment of Pediculus humanus capitis (head lice). which of the following should be included in the teaching? 1. Apply the shampoo to dry hair and leave on for 4 to 5 minutes 2. wet the hair first and massage the shampoo in for 1 minute 3. use the shampoo on dry hair, rinse, then shampoo with regular shampoo 4. Apply the shampoo to wet hair and rinse thoroughly

8. 1. 1. Apply the shampoo to dry hair and leave on for 4 to 5 minutes the kwell shampoo should be applied to dry hair and left on the scalp for 4 to 5 minutes to allow for maximal effect. treatment should be repeated in a week.

8. the nurse is providing diet instructions for a client with acne rosacea. Which of the following describes the most appropriate dietary restrictions? select all that apply: [ ] 1. avoid spicy foods [ ] 2. limit the intake of foods rich in omega-3 fatty acids [ ] 3. avoid chocolate [ ] 4. avoid caffeine [ ] 5. restrict the use of products containing phenylalanine [ ] 6. avoid fried foods

8. 1. 4. spicy foods, hot and cold drinks with caffeine, and alcohol all worsen acne rosacea. Foods rich in omega-3 fatty acids, chocolate, fried foods, and products containing phenylalanine are unrelated to controlling rosacea.

8. which of the following is a priority for the nurse to include in the plan of care for a child using a pediculocide? 1. apply a cream rinse following the application of the pediculocide 2. avoid washing the hair for two days following treatment with the pediculocide 3. shampoo the hair with a mild shampoo before using the pediculocide 4. wash the hair with a combination shampoo and conditioner before the use of a pediculocide

8. 2. following the use of a pediculocide for pediculosis capitis, or head lice, the hair should not be washed for 1 to 2 days. a combination shampoo and conditioner or a cream rinse should not be used before using a pediculocide.

9. the nurse is evaluating the following four clients for the development of a pressure ulcer. Which of the following clients is at greatest risk for the development of a pressure ulcer? 1. a 52-year-old obese female, 2 days post-op for a knee replacement, who has an indwelling urinary catheter 2. a 74-year-old thin male, who is awaiting surgery for a fractured left hip 3. a 91-year-old emaciated female with a blood sugar of 160 mg/dl, who is sitting in a wheelchair 4. a 67-year-old obese male, who has cellulitis of his right lower leg

9. 2. risk factors for the development of pressure sores include bony prominences, inability to change position independently, and a bed-rest status. these factors pose the highest risk for the client.

9. the nurse is instructing the mother of four children on how to treat all of the children for Pediculus humanus capitis (head lice) with kwell shampoo. the ages of the children are 8 years, 5 years, 2 years, and a premature infant who now weighs 6 pounds. which one of the following is the priority to include in the instructions given to this mother? 1. the cost associated with purchasing shampoo for four children may lead to undertreatment 2. lindane (kwell) may cause seizures in premature babies 3. there is an increased incidence of reinfection from one child to another 4. help will be needed to apply the shampoo

9. 2.2. lindane (kwell) may cause seizures in premature babies it is a priority to inform the parent that applying kwell shampoo to premature infants may cause seizures. purchasing kwell shampoo for three children may be costly, but it is essential to prevent the spread of Pediculus humanus capitis (head lice). Although an increased incidence of reinfection of the children from one child to another is a minor concern, it is not the priority. securing help to apply the shampoo may be beneficial, but it is not the priority.

9. following excision of a nevus on the arm, which of the following should the nurse include in this child's discharge instructions? 1. shower after 24 hours 2. remove the dressing after 24 hours, leaving the wound open to the air 3. all activities may be resumed 4. take acetaminophen (tylenol) for discomfort

9. 4. following excision of a nevus, the wound should be kept dry until sutures are removed to avoid infection. physical activity should be avoided for 2 to 4 weeks to prevent wound dehiscence.