skin hesi prep
While assessing a client during an ophthalmic pupillary physical examination, the primary healthcare provider observes a noticeable difference in the size of pupils in the client. Which term should the nurse use to describe this condition? 1 Mydriasis 2 Hyperopia Correct3 Anisocoria 4 Arcus senilis
A noticeable difference in the size of a client's pupils is known as anisocoria, a normal condition in about 5% of people. The normal diameter of the pupil is between 3 and 5 mm; clients with hyperopia have smaller pupils with a diameter of less than 3 mm. Mydriasis is the process of pupillary dilation. Arcus senilis is an opaque bluish-white ring within the outer edge of the cornea caused by the presence of fat deposits.
A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately? Correct1 Small amount of yellowish green oozing 2 Moderate area of serosanguineous oozing 3 Epithelialization under the nonadherent dressing 4 Separation of the edges of the nonadherent dressing
A small amount of yellowish green oozing indicates infection and should be reported immediately. Serosanguineous oozing is expected. Epithelialization under the nonadherent dressing indicates healing and is desirable. Separation of the edges of the nonadherent dressing is not a problem.
A nurse is caring for a client admitted for removal of basal cell carcinoma and reconstruction of the nose. About which contributing factor should the nurse question the client when collecting a health history? 1 Dietary patterns 2 Familial tendencies Amount of tobacco use Correct4 Ultraviolet radiation exposure
Basal cell carcinoma, the most common type of skin cancer, is linked most closely to solar ultraviolet radiation. Diet is not a risk factor. Although skin type is a genetically determined risk factor, it cannot be altered and it is influenced by solar ultraviolet radiation. Smoking is not a risk factor. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.
While assessing the skin of an older adult, the nurse observes that the skin has a dry and uneven color. Which change is responsible for this condition? 1 Decreased subcutaneous fat 2 Decreased extracellular water 3 Decreased proliferation capacity Correct4 Decreased activity of sebaceous glands
Dryness and uneven skin color are caused by a decrease in the activity of sebaceous glands. Wrinkling and sagging are due to a decrease in subcutaneous fat. Dry and flaking skin are due to a decrease in extracellular water. The diminished rate of wound healing is due to a decrease in proliferation capacity.
The nurse is caring for two clients. The first client had a below-the-knee amputation as a result of an accident. The second client had a below-the-knee amputation because of chronic decreased arterial perfusion. The nurse anticipates that the postoperative courses of these two clients may differ because for what reason? 1 First client probably will adjust more quickly Correct2 Second client's incision will take longer to heal Second client is more likely to have phantom limb sensations 4 First and second clients have different occupations
Decreased arterial circulation will delay healing. Clients having an amputation without preoperative preparation for their loss have greater difficulty adapting. Clients with traumatic injuries are more likely to have phantom limb sensations; it is theorized that trauma to the peripheral nerves is associated with phantom limb sensations. Both clients' responses may be influenced by their occupations but there are no data to draw this conclusion. Test-Taking Tip: Pace yourself while taking a quiz or exam. Read the entire question and all answer choices before answering the question. Do not assume that you know what the question is asking without reading it entirely.
A client has a fracture of the tibia, and a cast is applied. Which action will the nurse take? 1 Cover the cast with plastic wrap until dry. 2 Assist with weight bearing when the client ambulates. Correct3 Elevate the affected leg above the level of the heart. Insert a finger inside the edges of the cast to check for skin abrasions.
Elevating the affected leg will help reduce the formation of edema via the principle of gravity. Plastic wrap holds moisture and will interfere with drying of the cast. Full weight bearing should not start until prescribed by the primary healthcare provider. Nothing should be inserted under the cast; this can cause tissue injury.
A health care provider prescribes bed rest, loperamide, and esomeprazole for a client who just had major surgery. After several days of this regimen, the client complains of diarrhea. What does the nurse conclude that the most likely cause of the diarrhea is? Correct1 Loperadine Esomeprazole 3 Bed rest 4 Diet alteratio
Loperadine, a combination antacid, contains magnesium hydroxide, which may cause diarrhea; it also contains aluminum hydroxide, which may cause constipation. Esomeprazole, a proton pump inhibitor, may cause constipation, not diarrhea. Immobility causes constipation, not diarrhea. Although diet can affect elimination, no data are presented to support this conclusion.
A client has a diagnosis of partial-thickness burns. The nurse recalls that the client's burn is different than full-thickness burns in that partial-thickness burns do what? 1 Require grafting before they can heal Correct2 Are often painful, reddened, and have blisters 3 Cause destruction of both the epidermis and dermis 4 Often take months of extensive treatment before healing
Pain is from the loss of the protective covering of the nerve endings; blisters and redness occur because of the injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only the superficial layers of skin, unless they become infected. Recovery from partial-thickness burns with no infection occurs in two to three weeks.
A nurse is assessing a client with a diagnosis of psoriasis. Which clinical findings should the nurse expect to observe? Select all that apply. Correct1 Scaly lesions Correct2 Pruritic lesions Correct3 Reddened papules 4 Multiple petechiae Erythematous macules
Psoriasis is characterized by dry, scaly lesions that occur most frequently on the elbows, knees, scalp, and torso. Pruritus is generally mild. Sharply defined reddened papules or plaques covered by scales occur because of dermal inflammation; the inflammation occurs because of an abnormal growth of epidermal cells related to an autoimmune reaction. Petechiae are not characteristic of psoriasis. Macules are erythematous flat spots on the skin, as in measles. 34%of students nationwide answered this question correctly.
A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force? Correct1 30 degrees 2 45 degrees 3 60 degrees 4 90 degrees
Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and cause this phenomenon. Forty-five, 60, and 90 degrees will raise the head of the bed too high, and the client will slide down in the bed, causing shearing forces.
During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? Correct1 Turn and reposition the client every 2 hours. 2 Cover the ulcer with an occlusive transparent dressing. 3 Clean the ulcer with hydrogen peroxide and leave it open to the air. 4 Provide the client with a diet high in vitamin C, zinc, and protein.
Turning and repositioning immobile clients at least every 2 hours is the best initial nursing action for preventing further skin breakdown. Other measures should also be taken to relieve pressure on the area to prevent progression and promote healing. Covering the area with an occlusive transparent dressing and cleansing the area with hydrogen peroxide are not recommended for this situation. Providing a diet high in vitamin C, zinc, and protein will also aid in tissue healing and help prevent further breakdown, but this is not the priority action.
In response to a client's question, the nurse explains the difference between partial-thickness (second-degree) burns and full-thickness (third-degree) burns. What information about partial-thickness burns should the nurse include in the discussion? Correct1 They are painful, reddened, and have blisters 2 Grafting will be required before they can heal There is destruction of both the epidermis and dermis 4 Months of extensive treatment are required before healing
Pain results from the loss of skin that provides protective covering of the nerve endings; blisters and redness occur because of injury to the dermis and epidermis. Because some epithelial cells remain, grafting is not needed with a partial-thickness burn unless it becomes infected and further tissue damage occurs. Partial-thickness burns involve only superficial layers of skin unless they become infected. Recovery from partial-thickness burns with no infection occurs in two to three weeks.
