Med Surg 2 - Integumentary Test
Which skin conditions are more common in immunosuppressed patients? Select all that apply a. acne b. lentigo c. candidiasis d. herpes zoster e. herpes simplex 1 f. kaposi sarcoma
c,e,f
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I can't wait to have surgery to reconstruct my face so I look normal again. What would be the nurse's best response? a. that's something that you and your doctor will likely talk about after your scars mature b. that is something for you to talk to your doctor about because its not a nursing responsibility c. I know this is really important to you, but you have to realize that no one can make you look like you used to d. unfortunately its likely that you will have most of these scars for the rest of your life
a
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life threatening complications? a. a 4 year old scald victim burned over 24% of the body b. a 27 year old male burned over 36% of his body in a car accident c. a 39 year old female patient burned over 18 percent of her body d. a 60 year old male burned over 16 % of his body in a brush fire
a
A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in lab values a. sodium deficit b. decreased prothrombin time (PT) c. potassium deficit d. decreased HCT
a
A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? a. 2 days b. 3 days c. 5 days d. 1 week
a
A patient has been admitted to a burn intensive care unit with extensive full thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate priority concern when planning this patient's care? a. fluid status b. risk of infection c. nutritional status d. psychosocial coping
a
A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions a. cataract development is possible b. the ointment is likely to cause weeping c. corticosteroid use is contraindicated on these lesions d. the patient may develop glaucoma
a
A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor in her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include? a. deficient knowledge about early signs of melanoma b. chronic pain related to surgical excision and grafting c. depression related to reconstructive surgery d. anxiety related to lack of social support
a
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? a. early enteral feeding b. administration of prophylactic antibiotics c. bowel cleansing procedures d. administration of stool softeners
a
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? a. hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis b. hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis c. hyperkalemia, hypernatremia, decreased hematocrit, and metabolic acidosis d. hypokalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
a
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to bother upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? a. ischemia b. referred pain c. cellulitis d. venous thromboembolism
a
A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn is what? a. hemodynamic instability b. GI hypermotility c. respiratory arrest d. hypokalemia
a
A patient presents at the free clinic with a black, wart like lesion on his face, states, "I've done some research, and I'm pretty sure I have malignant melanoma. Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis? a. The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable. b. the patient's lesion will be closely observed for 6 months before a plan of treatment is chosen c. the patient has one of the few dermatologic malignancies that respond to chemotherapy d. the patient will likely require wide excision
a
A patient who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this patient's needs? a. a PCA system b. oral opioids supplemented by NSAIDs c. distraction and relaxation techniques supplemented by NSAIDs d. a combination of benzodiazepines and topical anesthetics
a
A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? a. education about home safety b. education about safe storage of chemicals c. education about workplace health threats d. education about safe driving
a
Acne, impetigo, furuncles, carbuncles are examples of a. pustule b. cyst c. bulla d. papule
a
An ER nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? a. the causative agent b. the patients preinjury health status c. the patient's prognosis for recovery d. the circumstances of the accident
a
An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started large-bore IV and covered the burn in cool towels. the burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn shock period? a. administer IV fluids b. administer broad-spectrum antibiotics c. administer IV potassium chloride d. administer packed red blood cells
a
Elevated palpable solid mass extending deeper into the dermis than a papule a. nodule/tumor b. macule/patch c. vesicle/bulla d. papule/plaque
a
Pus-filled vesicle or bulla a. pustule b. cyst c. bulla d. papule
a
The nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? a. A patient is in the acute phase of burn injury. One of the nursing diagnoses in the plan of care is ineffective coping related to trauma of burn injury. What interventions appropriately address this diagnosis? Select all that apply a. promote truthful communication b. avoid asking the patient to make decisions c. teach the patient coping strategies d. administer benzodiazepines as ordered e. provide positive reinformcement
a,c,e
A flat nonpalpable lesion with a change in skin color (brown, white, tan, purple, red) a. nodule/tumor b. macule/patch c. vesicle/bulla d. papule/plaque
b
A home care nurse is performing a visit to a patient's home to perform wound care following the patient's hospital treatment for severe burns. While interacting with the patient, the nurse should assess for evidence of that complication? a. psychosis b. post-traumatic stress disorder c. delerium d. vascular dementia
b
A nurse is caring for a patient whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform? a. teach the patient about early signs of secondary blistering diseases b. teach the patient about self care after treatment c. assess the patients risk for recurrent malignancy d. assess the patient for adverse effects of radiotherapy
b
A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A) ìHe's on a calorie-restricted diet in order to divert energy to wound healing.î B) ìHis body has consumed his fat deposits for fuel because his calorie intake is lower than normal.î C) ìHe actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat.î D) ìHe lost many fluids while he was being treated in the emergency phase of burn care.î
b
A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? a. Silvadene - water soluble cream b. Sulfamylon hydrophilic based cream c. silver nitrate 0.5% aqueous solution d. acticoat
b
A patient has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the patient's subsequent care? a. teaching the patient to safely and effectively administer immunosuppressants b. helping the patient identify and avoid the offending agent c. teaching the patient how to maintain meticulous skin hygiene d. helping the patient perform wound care in the home environment
b
A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? a. monitoring fluid and electrolyte imbalances b. providing education to the patient and family c. treating infection d. promoting thermoregulation
b
A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response? a. perform mechanical debridement to remove the exudate and prevent further infection b. inform the primary care provider promptly because the graft may need to be removed c. perform range of motion exercises to increase perfusion to the graft site and facilitate healing d. document this finding as an expected phase of graft healing
b
Encapsulated fluid-filled or semisolid mass in SQ tissue or dermis a. pustule b. cyst c. bulla d. papule
b
Skin scraping is used to diagnose a. allergy b. fungal lesion c. skin cancer d. psoriasis
b
freckles, flat moles, petechia, rubella, vitiligo, port wine stains and ecchymosis are examples of a. nodule/tumor b. macule/patch c. vesicle/bulla d. papule/plaque
b
large lipoma and carcinoma are examples of a. bulla b. tumor c. nodule d. papule
b
the nurse is preparing the patient for mechanical debridement and informs the patient that this will involve which of the following procedures? a. a spontaneous separation of dead tissue from the viable tissue b. removal of eschar until the point of pain and bleeding occurs c. shaving burned skin layers until bleeding, viable tissue is revealed d. early closure of the wound
b
When caring for a patient with TEN, the critical care nurse assess frequently for high fever, tachycardia, and extreme weakness and fatigue. the nurse is aware that these findings are potential indicators of what? Select all that apply a. possible malignancy b. epidermal necrosis c. neurologic involvement d. increased metabolic needs e. possible GI mucosal sloughing
b,d,e
A nurse is developing a care plan for a patient with a partial thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? a. to prevent neuropathies b. to prevent wound breakdown c. to prevent contractures d. to prevent heterotypic ossification
c
A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma a. teaching participants to improve their overall health through nutrition b. encouraging participants to identify their family history of cancer c. teaching participants to limit their sun exposure d. teaching participants to control exposure to environmental and occupational radiation
c
A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment? a. assessment of the patient's stool for evidence of intestinal sloughing b. assessment of the patient's apical heart rate for dysrhythmias c. assessment of the patient's joints for pain and decreased range of motion d. assessment for cognitive changes resulting from neurologic lesions
c
A nurse is teaching a patient with a partial thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear the garment a. 4-6 hours per day for 6 months b. during waking hours for 2 to 3 months after injury c. continuously d. at night while sleeping for a year after the injury
c
A nurse who provides care on a burn unit is preparing to apply a patient's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? a. apply a new ointment without disturbing the existing layer of ointment b. apply the ointment using a sterile tongue depressor c. apply a layer of ointment approximately 1/16 inch thick d. gently irrigate the wound bed after applying antibiotic ointment
c
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action a. instruct the patient to keep the wound site in a dependent position b. administer PRN analgesia as ordered c. assess the patient's peripheral pulses distal to the dressing d. assist with passive ROM exercises to set the new dressing
c
A patient is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). when assessing the health history of the patient, the nurse would be alert to what precipitating factor? a. recent heavy UV exposure b. substandard hygienic conditions c. recent administration of new medication d. recent varicella infection
c
A patient with 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? a. obtain an order to reduce the rate of the patient's IV fluid infusion b. report the patient's early signs of acute kidney injury c. recognize that the patient is experiencing an expected onset of diuresis d. administer sodium chloride as ordered to compensate for this fluid loss
c
A triage nurse in the ER receives a phone call from a frantic father who saw his 4 year old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ER receiving the call instruct the father to do? a. cover the burn with ice and secure with a towel b. apply butter to the area that is burned c. immerse the child in a cool bath d. avoid touching the burned area under any circumstances
c
An older adult resident of a long term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care? a. avoid the application of skin emollients b. apply antibiotic ointment as ordered following baths c. avoid using hot water during the patient's baths d. administer acetaminophen 4 times daily as ordered
c
Assess a patch test a. 4-8 hours b. 24-48 hours c. 48-72 hours d. 24-36 hours
c
The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? a. emergent b. immediate resuscitative c. acute d. rehabilitation
c
a patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? a. confusion b. high fever c. decreased blood pressure d. sudden agitation
c
circumscribed elevated palpable mass containing serous fluid a. nodule/tumor b. macule/patch c. vesicle/bulla d. papule/plaque
c
herpes simplex/zoster, varicella, poison ivy, second-degree burn (blister) are examples of a. macule b. nodule c. vesicle d. bulla
c
lipoma, squamous cell carcinoma, poorly absorbed injection, dermatofibroma are examples of a. bulla b. tumor c. nodule d. papule
c
A nurse is caring for a patient who has sustained a deep partial thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? a. activity intolerance b. anxiety c. ineffective coping d. acute pain
d
A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. the nurse enters the room and observes that the patient is performing active range of motion exercises with the affected hand. How should the nurse best respond? a. Liaise with the physical therapist to ensure that the patient is performing exercises safely b. validate the patient's efforts to increase blood perfusion to the graft site c. remind the patient that ROM exercises should be passive, not active d. Remind the patient of the need to immobilize the graft to facilitate healing
d
A nurse is performing a home visit to patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? a. assess the patient for signs of electrolyte imbalances b. administer fluids as ordered c. assess the risk for injury recurrence d. assess the patient's psychosocial state
d
A patient arrives in the ER after being burned in a house fire. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have? a. 13% b. 25% c. 9% d. 18%
d
A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters and is suspected of herpes zoster. What presentation is most consistent with herpes zoster? a. grouped vesicles occurring on lips and oral mucous membranes b. grouped vesicles occurring on the genitalia c. rough, fresh or gray skin protrusions d. grouped vesicles in linear patches along a dermatome
d
A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized? a. maintain the patient on bed rest for the first 24 hours postoperative b. apply distraction techniques to relieve pain c. provide soft or liquid diet in protein to assist with healing d. anticipate the need for, and administer, appropriate analgesic medications
d
A patient is brought to the ER by paramedics who report that the patient has partial thickness burns on the chest and legs. That patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? a. pain b. fluid balance c. anxiety and fear d. airway managment
d
A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection the skin appears charred. Based on these assessment findings, what is the depth of the burn patient's arm? a. superficial partial thickness b. deep partial thickness c. full partial thickness d. full thickness
d
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to cool the burn. How should the nurse cool the burn? a. apply ice to the site of the burn for 5-10 minutes b. wrap the patient's affected extremity in ice until help arrives c. apply an oil based substance or butter to the burned areas until help arrives d. wrap cool towels around the affected extremity intermittently
d
Elevated palpable solid mass with circumscribed border a. nodule/tumor b. macule/patch c. vesicle/bulla d. papule/plaque
d
The ER nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? a. the length of time since the burn b. the location of burned skin surfaces c. the source of the burn d. the total body surface area (TBSA) affected by the burn
d
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: a. correct water and electrolyte imbalances b. allow the GI tract to rest c. provide supplemental vitamins and minerals d. ensure adequate caloric and protein intake
d
The nurse caring for a patient who is recovering from full thickness burns is aware of the patient's risk for contracture and hypertrophic scarring. How can the nurse best mitigate this risk? a. apply skin emollients as ordered granulation has occurred b. keep injured areas immobilized whenever possible to promote healing c. administer oral or IV corticosteroids as ordered d. encourage physical activity and ROM exercises
d
Tzanck smear is used to diagnose a. skin cancer b. allergy c. fungal condition d. blistering conditions
d
While performing a patient's wound care for treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patient's behavior? a. the patient may be experiencing an adverse drug reaction that is affecting his cognition and behavior b. the patient may be experiencing neurologic or psychiatric complications of his injuries c. the patient may be experiencing inconsistencies in the care that he is being provided d. the patient may be experiencing anger about his circumstances that he is deflecting toward the nurse
d
a patient's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? a. 0.45% NaCl with 20 mEq/L b. 0.45% NaCl with 40 mEq/L c. normal saline d. lactated ringers
d
elevated nevi, warts, lichen plants are examples of a. plaque b. vesicle c. macule d. papule
d
pemphigus, contact dermatitis, large burn blister, poison ivy, bullies impetigo are examples of a. macule b. nodule c. vesicle d. bulla
d
Psoriasis, actinic keratosis are examples of a. plaque b. vesicle c. macule d. papule
plaques
A nurse caring for a disheveled patient with poor hygiene observes that the patient has small red lesions flush with the skin on the head and body. The patient complains of severe itching at the sites. for what should the nurse further assess the patient? a. nits at the shafts of his head hair b. a history of sexually transmitted diseases c. the presence of ticks attached to the scalp d. the presence of burrows in the interdigital webs
a
A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan? a. use caution when taking nonprescription medications b. avoid public places until symptoms subside c. wash skin frequently to prevent infection d. liberally apply corticosteroids as needed
a
A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. what assessment question is most appropriate? a. does anyone in your family have eczema or psoriasis b. have any of your family members been diagnosed with malignant melanoma c. do you have a family history of vitiligo or port wine stains d. does any member of your family have a history of keloid scarring
a
A patient is admitted to the emergency department at 10:15 pm following a flame burn at 9:30 pm. The patient has 40% TBSA deep partial thickness and full thickness burns and weighs 132 lb. How much fluid should be given for fluid resuscitation and for how long? a. 300mL/hour for 8hour - then 150 ml/hour for 16 hours b. 400mL/hour for 8hour - then 200 ml/hour for 16 hours c. 650mL/hour for 8hour - then 325 ml/hour for 16 hours d. 150mL/hour for 8hour - then 75 ml/hour for 16 hours
a
A patient with deep partial-thickness burns over 45% of his trunk and legs is going for debridement in the cart shower 48 hours post burn. What is the drug of choice to control the patient's pain during this activity? a. IV morphine b. Versed c. Demerol d. long-acting oral morphine
a
A priority nursing diagnosis for an adult female who has pruritus and is continuously scratching the affected areas and demonstrates agitation and anxiety regarding the itching sensation would be: a. risk for infection related to pruritus b. ineffective health maintenance related to lack of knowledge of the disease process c. impaired skin integrity related to dehydration from the treatment medications d. social isolation related to poor self-image
a
An 80-year old patient is brought to the clinic by her son. the son asks the nurse why his mother has gotten so many spots on her skin. What would be an appropriate response by the nurse? a. as people age, they normally develop uneven pigmentation in their skin b. these spots are called liver spots or age spots c. older skin is more apt to break down and tear, causing sores d. these are usually the result of nutritional deficits earlier in life
a
An unresponsive caucasian patient has been bought to the emergency room by EMS. While assessing this patient, the nurse notes that the patient's face is cherry-red in color. What should the nurse suspect? a. carbon monoxide poisoning b. anemia c. jaundice d. uremia
a
During the early emergent phase of burn injury, the patient's laboratory results would most likely include a. increased Hct, decreased serum albumin, decreased sodium, increased potassium b. decreased Hct, decreased albumin, decreased sodium, decreased potassium c. decreased Hct, increased serum albumin, increased sodium, increased potassium d. increased Hct, increased serum albumin, decreased sodium, decreased potassium
a
During the emergent (resuscitative) phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation? a. serum creatinine level of 2.5 b. little fluctuation in daily weight c. hourly urine output of 60 ml d. serum albumin level of 3.8
a
During the rehabilitation phase of a burn injury, what can control the contour of the scarring? a. pressure garments b. avoidance of sunlight c. splinting joints in extension d. application of emollient lotions
a
Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects a health maintenance activity for an otherwise healthy older adult? a. drinks 1500 mL of fluids per day b. consumes a balanced diet of 1200 calories per day c. walks briskly for 10 minuets three times per week d. sleeps at least 8 hours each night
a
The burn patient has developed an increasing dread of painful dressing changes. what would be the most appropriate treatment to ask the health care provider to prescribe? a. Versed to be used with morphine before dressing changes b. morphine in a dosage range so that more may be given before dressing changes c. buprenex to be administered with morphine before dressing changes d. patient controlled analgesia so that the patient may have control analgesic administration
a
The nurse initially suspects the possibility of sepsis in the burn patient based on what changes? a. Vital signs b. Urinary output c. Gastrointestinal function d. Burn wound appearance
a
What are the appropriate dressings to use to promote for a patient with an inflamed, pruritic dermatitis? a. cool tap water dressings b. cool acetic acid dressings c. warm sterile saline dressings d. warm potassium permanganate dressings
a
What is the initial cause of hypovolemia during the emergent phase of burn injury a. increased capillary permeability b. loss of sodium to the interstitium c. decreased vascular oncotic pressure d. fluid loss from denuded skin surfaces
a
What skin condition has keratitis and firm lesions, a precursor of squamous cell carcinoma, and is treated with topical fluorouracil? a. Actinic keratosis b. basal cell carcinoma c. malignant melanoma d. squamous cell carcinoma
a
When assessing a patient's full-thickness burn injury during the emergent phase, what would the nurse expect to find? a. leathery, dry, hard skin b. red, fluid filled vesicles c. massive edema at the injury site d. serous exudate on a shiny, dark brown wound
a
When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what a. Impaired skin integrity related to scaly lesions b. acute pain related to blistering and erosions of the oral cavity c. impaired tissue integrity related to epidermal shedding d. anxiety related to risk for melanoma
a
Which of the following factors places a client at greatest risk for skin cancer a. fair skin and history of chronic sun exposure b. caucasian race and history of hypertension c. dark skin and family history of skin cancer d. dark skin and history of hypertension
a
Which skin condition occurs as an allergic reaction to mite eggs? a. scabies b. impetigo c. folliculitis d. pediculosis
a
the nurse is applying a hand mitt restraint for a client with pruritus. The nurse should first: a. verify the physician order to use the restraint b. secure the mitt with ties around the wrist tied to the bed frame c. place a folded pillow under the wrist d. place the mitt on top of the hand
a
The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. the patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time? a. Is anyone in your family allergic to anything b. how long have you had this abrasion c. do you take any over the counter drugs or herbal preparations d. what do you do for a living
c
After the initial phase of the burn injury, the client's plan of care will focus primarily on: a. helping the client maintain a positive self concept b. promoting hygiene c. preventing infection d. educating the client regarding care of the skin grafts
c
An 82 year old female has several ecchymiotic areas on her left arm. The nurse should further assess the client for: a. elder abuse b. self-inflicted injury c. increased capillary fragility and permeability d. Increased blood supply to the skin
c
At the end of the emergent phase and the initial acute phase of burn injury, a patient has a sodium level of 152 and a potassium level of 2.8. What could have caused these imbalances? a. free oral water intake b. prolonged hydrotherapy c. mobilization of fluid and electrolytes in the acute phase d. excessive fluid replacement with dextrose in water without potassium supplementation
c
How is the immune system altered in a burn injury? a. bone marrow stimulation b. increase in immunoglobulin levels c. impaired function of WBCs d. overwhelmed by microorganisms entering denuded tissue
c
How should the nurse position the patient with ear, face and neck burns? a. prone b. one the side c. without pillows d. with extra padding around the head
c
The nurse is assessing a client with dark skin for presence of stage 1 pressure ulcer. The nurse should a. use a fluorescent light source to assess the skin b. Inspect the skin only when the Braden score is above 12 c. Look for skin color that is darker than the surrounding tissue d. avoid touching the skin during inspection
c
The nurse is the immediate care clinic is assessing an 80 year old client who lives with his son's family and has scald burns on his hands and both forearms (first and second degree burns on 10% of his BSA) What should the nurse do first? a. clean wounds with warm water b. apply antibiotic cream c. refer the client to a burn center d. Coner the burns with sterile dressing
c
A patient has a 20% TBSA deep partial-thickness and full-thickness burn to the right anterior chest and entire right arm. What is important for a nurse to assess in this patient? a. presence of pain b. swelling of the arm c. formation of eschar d. presence of pulses in the arms
d
A patient who has sustained third degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of disturbed body image related to disfigurement. What would be an appropriate nursing intervention related to this diagnosis? a. referring the patient to a speech therapist b. gradually adding soft foods to diet c. administering analgesics as prescribed d. teaching the patient how to use and care for the prosthesis
d
A priority nursing diagnosis for a client with burns during the emergent period would be: a. Exces fluid volume b. Imbalanced nutrition: less than body requirements c. Risk for injury (falling) d. Risk for infection
d
An 82 year old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patient's course of treatment? a. increased thickness of the subcutaneous skin layer b. increased vascular supply to superficial skin layers c. changes in the character and quantity of bacterial skin flora d. increased time required for wound healing
d
During the early phase of burn care the nurse should assess the client for a. hypernatremia b. hyponatremia c. metabolic acidosis d. hyperkalemia
d
Palpation of the skin provides the nurse useful information regarding: a. bruising of the skin b. color of the skin c. hair distribution d. turgor of the skin
d
The nurse in conducting a focused assessment of the GI system of a client with a burn injury. the nurse should assess the client for: a. paralytic ileus b. gastric distention c. hiatal hernia d. curling's ulcer
d
What characteristic is commonly seen with dysplastic nevus syndrome? a. associated with sun exposure b. precursor of squamous cell carcinoma c. slow-growing tumor with rare metastasis d. lesion has irregular color and asymmetric shape
d
What is the name for papillomavirus infection seen on the skin? a. furuncle b. carbuncle c. erysipelas d. plantar wart
d
Which of the following factors would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? a. absence in infection in the wounds b. adequate vascularization in the grafted area c. immobilization of the area being grafted d. use of analgesics as necessary for pain relief
d
While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patient's ear. the nurse knows that this lesion is consistent with that type of skin cancer? a. basal cell carcinoma b. squamous cell carcinoma c. dermatofibroma d. malignant melanoma
d
Put in order the following actions the way they should be done in the emergency management of a burn of any type a. establish and maintain an airway b. assess for other associated injuries c. establish an iv line with a large-gauge needle d. remove the patient from the burn source and stop the burning process
d,a,c,b
What characteristics are true about chemical burns? Select all that apply? a. metabolic asphyxiation may occur b. metabolic acidosis occurs immediately following the burn c. the visible skin injury often does not represent the full extent of tissue damage d. lavaging with large amounts of water is important to stop the burning process with these injuries e. alkaline substances that cause these burns continue to cause tissue damage even after being neutralized
d,e
The nurse is developing a program on skin cancer prevention for a community group. Which of the following should be included in the program? a. purchase sunscreen contenting benzophenones to block UVA and UVB rays b. use sunscreen with a minimum of 15 SPF c. Obtain genetice screening to identify risk of melanoma d. apply sunscreen only on sunny days, especially between 10 am and 2 pm e. have a pigmented lesion biopsied by shaving if it looks suspicious f. rub baby oil to lubricate skin before going out in the sun
a,b
There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. a. An 8 year old with third degree burns over 10% of his BSA b. A 20-year old who inhaled the smoke of the firs c. A 50 year old diabetic with first and second degree burns on his left forearm (about 5% of his BSA) d. A 30 year old with second degree burns on the back of his left leg e. A 40 year old with second degree burns on his right arm (about 10% of his BSA)
a,b,c
A nurse is providing teaching to a client about skin cancer. Which of the following should the nurse explain are risk factors for skin cancer? Select all that apply a. increasing age b. exposure to chemical pollutants c. long-term exposure to the sun d. increased pigmentation e. genetics f. immunosuppression
a,b,c,e,f
Which of the following should the nurse expect to assess as normal skin changes in an elderly client? Select all that apply a. diminished hair on scalp and pubic areas b. dusky rumor of left lower extremity c. solar lentigo d. wrinkles e. xerosis f. yellow pigmentation
a,c,d,e
A 46 year old African American patient is scheduled to have a basal cell carcinoma on his cheek excised in the health care provider's office. What factor is most important for the nurse to obtain in the patient's history? a. protected from sun exposure b. radiation treatment for acne c. prior treatments for the lesion d. exposure to harsh irritants such as ammonia
b
A burn patient has a nursing diagnosis of impaired physical mobility related to a limited ROM resulting from pain. What is an appropriate nursing intervention for this patient? a. have the patient perform ROM exercises when pain is not present b. provide analgesic medications before physical activity and exercise. c. teach the patient the importance of exercise to prevent contractures d. arrange for the physical therapist to encourage exercise during hydrotherapy
b
A dermatologist has asked the nurse to assist with examination of a patient's skin using a Wood's light. This test will allow the physician to assess for which of the following? a. the presence of minute regions of keloid scarring b. unusual patterns of pigmentation on the patients skin c. vascular lesions that are not visible to the naked eye d. the presence of parasites on the epidermis
b
A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning? a. By avoiding the use of moisturizing lotions on older adults skin b. by protecting older adults against shearing injuries c. by avoiding the use of ice packs to treat muscle pain d. by protecting older adults against excessive sweat accumulation
b
A patient is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the patient develops fine blisters, papule, and severe itching. the nurse knows that this is indicative of what strength reaction? a. weak positive b. moderately positive c. strong positive d. severely positive
b
A patient with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy? a. Tzanck smear b. skin biopsy c. patch testing d. skin scrapings
b
A patient's deep partial-thickness burns are treated with the open method. What should the nurse do when caring for the patient? a. ensure that sterile water is used in the debridement tank b. wear a cap, mask, gown, and gloves during patient contact c. use sterile gloves to remove the dressings and wash the wounds d. apply topical antimicrobial ointment with clean gloves to prevent wound trauma
b
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they appear to help: a. encourage formation of tough skin b. promote the growth of epithelial tissue c. provide a permanent wound closure d. facilitate development of subcutaneous tissue
b
An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? a. keep all the lights on in the bathroom b. use a nightlight in the bathroom c. keep all four side rails up at all times d. place the client in a room with a camera monitor
b
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? a. oral analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol) b. IV opioids c. IM opioids d. oral anti anxiety agents such as Ativan
b
Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to a. altered balance b. altered protective pressure sensation c. impaired hearing ability d. impaired visual acuity
b
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the: a. similarities from one side to the other b. changes from the normal expected findings c. appearance of age-related wrinkles d. skin turgor
b
The nurse should plan to begin rehabilitation efforts for the burn client: a. immediately after the burn has occured b. after the client's circulatory status has been stabilized c. after grafting of the burn wounds has occured d. after the client's pain has been eliminated
b
The rate at which I.V. fluids are infused is based on the burn client's: a. lean muscle mass and BSA b. total body weight and BSA burned c. totally BSA and BSA burned d. height and weight and BSA burned
b
What is an appropriate intervention to promote debridement and removal of scales and crusts of skin lesions? a. warm oatmeal baths b. warm saline dressings c. cool sodium bicarbonate baths d. cool magnesium sulfate dressings
b
What is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body? a. Fever b. Shivering c. Severe pain d. Unconsciousness
b
What is the most common skin cancer and has pearly borders? a. actinic keratosis b. basal cell carcinoma c. malignant melanoma d. squamous cell carcinoma
b
What should the nurse include in the instructions for a patient with urticaria? a. apply topical benzene hexachloride b. avoid contact with the causative agent c. gradually expose the area to increasing amounts of sunlight d. use over the counter antihistamines routinely to prevent the condition
b
Which description characterizes seborrheic keratosis? a. white, patchy yeast infection b. warty, irregular papules or plaques c. excessive turnover of epithelial cells d. deep inflammation of subcutaneous tissue
b
Which of the following changes are associated with normal aging? a. the outer layer of skin is replaced with new cells every 3 days b. subcutaneous fat and extracellular water decrease c. the dermis becomes highly vascular and assists in the regulation of body temperabture d. collagen becomes elastic and strong
b
Which of the following characteristics would put a client at the greatest risk for impaired wound healing after abdominal surgery? a. age 75 years b. age 30 years, with poorly controlled diabetes c. age 55 years, with myocardial infarction d. age 60 years with peripheral vascular disease
b
Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube? a client who has: a. electrical burns of the hands and arms causing arrhythmias b. thermal burns to the head, face, and airway resulting in hypoxia c. chemical burns on the chest and abdomen d. secondhand smoke inhalation
b
Which type of burn injury would cause myoglobinuria, long bone fractures, and cardiac dysrhythmias and/or cardiac arrest? a. thermal b. electrical c. chemical d. smoke and inhalation
b
the nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" x 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note in the chart? a. stage 1 pressure ulcer b. stage 2 pressure ulcer c. stage 3 pressure ulcer d. stage 4 pressure ulcer
b
the patient was admitted to the burn center with a full thickness burn 42 hours after the thermal burn occurred. The nurse will apply actions related to which phase of burn management for this patient's care a. acute b. emergent c. post acute d. rehabilitative
b
An older adult client in stage 2 of Parkinson's disease is being discharged with cellulitis of the right lower extremity. Which of the following nursing diagnoses will guide the discharge teaching? Select all that apply a. ineffective tissue perfusion related to decreased cardiac output b. impaired skin integrity related to barrier changes of the skin c. risk for injury related to environmental hazards d. impaired verbal communication related to dysarthria e. activity intolerance related to painful lower extremity
b,c
The nurse plans care for a patient with a newly diagnosed malignant melanoma based on the knowledge that initial treatment may involve: select all that apply a. shave biopsy b. Moh's surgery c. surgical excision d. localized radiation e. fluorouracil (5-FU) f. topical nitrogen mustard
b,c
Which statements characterize malignant melanomas? Select all that apply a. lesion is keratitis and firm b. neoplastic growth and melanocytes c. skin cancer with highest mortality rate d. irregular color and asymmetric shape e. frequently occurs on previously damaged skin
b,c,d
identify the factors that increase nutritional needs of the patient during the emergent and acute phases of burn injury? Select all that apply a. electrolyte imbalance b. core temperature elevation c. calories and protein are used for tissue repair d. hypo metabolic state secondary to decreased GI function e. massive catabolism characterized by protein breakdown and increased gluconeogenesis
b,c,e
A 24-year old female patient does not want the wound cleansing and dressing change to take place. She states, "What difference will it make anyway?" What will the nurse encourage the patient to do? a. have the wound cleaned and the dressing changed b. have a snack before having the treatments completed c. talk about what is troubling her with the nurse and/or her family d. call the chaplain to come and talk to her and convince her to have the care
c
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. the shaded areas in the illustration indicated the burned areas on the client's body. Using the "rule of nines", the nurse would determine that about what percentage of the client's body surface has been burned? a. 18% b. 27% c. 45% d. 64%
c
A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostic test would most likely be ordered to identify the causative allergen? a. skin scrapings b. skin biopsy c. patch testing d. tzanck smear
c
A new patient presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the patient's fingernail surfaces are pitted. the nurse should suspect the presence of what health problem? a. eczema b. SLE lupus c. psoriasis d. COPD
c
A nurse is reviewing gerontologic considerations relating to the care of patients with dermatologic problems. What vulnerability results from the age-related loss of subcutaneous tissue? a. decreased resistance to ultraviolet radiation b. increased vulnerability to infection c. diminished protection of tissues and organs d. increased risk of skin malignancies
c
A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment? a. chemotherapy b. immunotherapy c. wide excision d. radiation therapy
c
A patient has the following mixed deep partial thickness and full thickness burn injuries; face, anterior neck, right anterior trunk, and anterior surfaces of the right arm and lower leg - what percentage of TBSA is burned according to the rule of nines? a. 4.5+18+4.5+9= 40.5% b. 9+9+4.5+9= 31.5% c. 4.5+9+4.5+4.5= 22.5% d. 4.5+9+4.5+9= 27%
c
A patient presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition? a. skin biopsy b. patch test c. tzanck smear d. examination with a woods light
c
A patient with a contact dermatitis is treated with calamine lotion. What is the rationale for using this base for a topical preparation? a. a suspension of oil and water to lubricate and prevent drying b. an emulsion of oil and water for lubrication and protection c. insoluble powders suspended in water that leave a residual powder on the skin d. a mixture of a powder and ointment that causes drying when moisture is absorbed
c
A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate the treatment for this type of cancer will primarily consist of what intervention? a. chemotherapy b. radiation therapy c. surgical excision d. biopsy of sample tissue
c
A stage 2 pressure ulcer is characterized by a. redness in the involved area b. muscle spasms in the involved area c. pain in the involved area d. tissue necrosis in the involved area
c
The nurse is using home Telehealth monitoring to manage care for an 80 year old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness and the area was classified as a stage 1 pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago to the assessment made at this visit. Upon comparing the change of the pressure ulcer from this visit to the previous visit. Upon comparing the change of the pressure ulcer from this visit to the previous visit, the nurse should do which of the following first? a. instruct the home health aid to reposition the client every 2 hours while the client is awake b. ask the client's daughter to purchase a foam mattress c. contact the physician to request a hydrocolloid dressing d. suggest that the client ask a neighbor to purchase antibiotic cream at the drugstore
c
The nurse will anticipate which of the following problems that can result for the older adult undergoing abdominal surgery? a. increased scarring b. decreased melanin and melanocytes c. decreased healing d. increased immunocompetence
c
What are the ABCDE's of malignant melanoma? a. Altered size, Border, Color, Depth, Edges b. Assymmetry, Bruising, Color, Diameter, Edges c. Assymmetry, Border, Color, Diameter, Edges d. Advanced stage, Brown, Coated, Diameter, Edges
c
Which burn patient should have nasotracheal or endotracheal intubation? a. Carbon monoxide poisoning b. Electrical burns causing cardiac dysrhythmias c. Thermal burn injuries to the face, neck, or airway d. Respiratory distress from eschar formation around the chest
c
Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about a half hour before the daily whirlpool bath and dressing change? a. soak the dressing b. remove the dressing c. administer an analgesic d. slit the dressing with blunt scissors
c
a client is receiving fluid replacement with lactated ringer's after 40% of his body was burned 10 hours ago. The assessment reveals: temperature 36.2; heart rate 122, BP 84/42; CVP 2 mm; and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/hour. using the SBAR technique for communication, the nurse calls the healthcare provider with the recommendation for: a. Furosemide (Lasix) b. fresh frozen plasma c. IV rate increase d. dextrose 5%
c
The nurse has received the change of shift report on his group of patients. Indicate the priority order in which the nurse should see the patients a. a 40 year old female who is returning from the PACU following surgical debridement of her back and legs b. a 76 year old male with partial thickness burns of his arms and abdomen who is complaining of severe pain c. a 62 year old female who was just admitted following partial thickness burns to her anterior chest, face, and neck d. An 18 year old male with full thickness burns of his lower extremities who is refusing to go for his scheduled dressing change
c,b,a,d
The nurse is planning care for an 80 year old client with a pressure ulcer. The nurse should do which of the following? Select all that apply? a. elevate the head of the bed to 50 degrees b. obtain daily cultures c. cover with protective dressing d. reposition the client every 2 hours e. request an alternating-pressure mattress
c,d,e
A 90 year old male complains of feeling cold in his room even though the thermostat is set at 75 degrees. The client probably feels cold because older adults have: a. increased cellular cohesion b. increased moisture content of the stratum corneum c. slower cellular renewal time d. decreased ability to thermoregulate
d
A client with malignant melanoma asks the nurse about the prognosis. The nurse should base a response that informs the client that the prognosis depends on: a. the amount of ulceration of the lesion b. the age of the client c. the location of the lesion on the body d. the thickness of the lesion
d
