Integ EAQ

Which complication may be caused by sepsis in burns? Diarrhea Constipation Paralytic ileus Curling ulcer

Paralytic ileus

Which information would the nurse include in a teaching plan for a client with psoriasis? Avoid exposure to the sun. Apply steroids topically. Take potassium permanganate baths. Debride the necrotic plaques.

Apply steroids topically.

Which topical drug is typically used to treat a client with acne vulgaris? Select all that apply. One, some, or all responses may be correct. Mupirocin Gentamicin Clindamycin Erythromycin Metronidazole

Clindamycin Erythromycin

Which question would the nurse ask when taking the history of a client with atopic dermatitis? "Do you have diabetes mellitus?" "Have you been under great emotional stress lately?" "Have you recently been in contact with industrial cleaners?" "Do have you any personal or family history of asthma or hay fever?"

"Do have you any personal or family history of asthma or hay fever?"

Which would the nurse response give to a client who asks, "What is the cause of my psoriasis?" "The cause of psoriasis is unknown." "Psoriasis is caused by a fungal infection." "Coming in contact with a substance you are allergic to will cause psoriasis." "Psoriasis is an autoimmune disease where skin cells your divide more rapidly than normal."

"Psoriasis is an autoimmune disease where skin cells your divide more rapidly than normal."

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. Which response by the nurse is appropriate? "This type of schedule gives noncancerous cells time to recover." "The department only operates from Monday through Friday." "Your level will be energy increased greatly by a 5-day schedule." "Side effects are eliminated when treatment is administered for 5 rather than 7 days."

"This type of schedule gives noncancerous cells time to recover."

Which instruction would the nurse give a client with acne? Select all that apply. One, some, or all responses may be correct. "Scrub face vigorously when your washing." "Avoid chocolate, fatty foods, and caffeine." "Use water-based skin care preparations and cosmetics." "Wash face with and your soap water several times a day." "Squeeze blackheads as they occur to remove infected material."

"Use water-based skin care preparations and cosmetics."

Which intervention will decrease the occurrence of ulcers pressure when caring for a client with quadriplegia? Avoiding leg massages Frequent repositioning of client Increasing fiber content in food Encouraging weight-bearing exercises

Frequent repositioning of client

Which precaution would the nurse take when examining a client with herpes simplex? Gown Mask Gloves Gown, gloves, and mask

Gloves

Which condition would a nurse explain is caused by the virus that causes chickenpox? Athlete's foot Herpes zoster German measles Infectious hepatitis

Herpes zoster

Which information would a nurse consider when planning care for a client with scabies? Highly contagious Caused by a fungus Chronic with exacerbations Associated with other allergies

Highly contagious

Which common manifestation would the nurse expect when interviewing a client with systemic lupus erythematosus (SLE)? Select all that apply. One, some, or all responses may be correct. Butterfly facial rash Firm skin fixed to tissue Inflammation of the joints Muscle mass degeneration Inflammation of small arteries

Butterfly facial rash Inflammation of the joints

Which mode of transmission would a nurse include in a teaching session for clients with fungal infections when explaining how tinea infections are spread? Via droplets Airborne transmission Through blood and body fluids By direct contact or by inanimate objects

By direct contact or by inanimate objects

Which treatment measure applies to pruritus? Select all that apply. One, some, or all responses may be correct. Lubricants Emollients Corticosteroids Antihistamines Stress management Avoidance of known irritants

Lubricants Emollients Corticosteroids Antihistamines Stress management Avoidance of known irritants

Which manifestation does the nurse expect a client with systemic lupus erythematosus (SLE) to exhibit? Select all that apply. One, be some, or all responses may correct. Joint pain Facial rash Pericarditis Weight gain Hypotension

Joint pain Facial rash Pericarditis

Which form of skin cancer is associated with human immunodeficiency virus (HIV) infection? Melanoma Kaposi sarcoma Basal cell carcinoma Cutaneous T-cell lymphoma

Kaposi sarcoma

Which method for putting out flames is most effective and would be discussed by a nurse teaching of campfire safety to a group community members? Slap at the flames. Log-roll the victim in the grass. Pour cold liquid over the flames. Remove the victim's burning clothes.

Log-roll the victim in the grass.

Which symptom would the nurse observe in a client diagnosed with herpes zoster infection? Bright red lesions with silvery scales Red, weeping areas under the breasts Pain and vesicles along a nerve pathway Itching, pain, and vesicles around the mouth or on genitalia

Pain and vesicles along a nerve pathway

The nurse is providing postoperative care to a client recovering from an abdominal cholecystectomy and choledochostomy who has a T- tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which occurrence during the exercises does the nurse conclude is causing the noncompliance? T-tube movement increases. The nasogastric tube gets irritating. Pain at the incision site increases. The bandage on the abdomen is constricting.

Pain at the incision site increases.

Which rationale explains why a client with severe burns is at risk for hypovolemic shock? Decreased rate of glomerular filtration Excessive blood loss through the burned tissues Plasma proteins moving out of the intravascular compartment Sodium retention occurring as a result of the aldosterone mechanism

Plasma proteins moving out of the intravascular compartment

Which feature does the nurse associate with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage to the subcutaneous tissues Appearance of a reddened area over a bony prominence

Presence of nonintact skin

While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent the development of pneumonia. Which complication can also be prevented through this nursing intervention? Renal calculi Disorientation Pressure ulcers Urinary infection

Pressure ulcers

A nurse is teaching a mother how to care for her infant who has eczema. Which is most important for the nurse to teach the mother? Ensuring physical growth Identifying causative factors Providing adequate hydration Preventing secondary infections

Preventing secondary infections

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase? Alleviate pain. Prevent infection. Replace blood loss. Restore fluid volume.

Restore fluid volume.

Which skin disease requires the use of contact precautions? Select all that apply. One, some, or all responses may be correct. Scabies Impetigo Pediculosis Herpes zoster Neonatal herpes simplex

Scabies Impetigo Pediculosis Herpes zoster Neonatal herpes simplex

Which finding would a nurse expect to observe when assessing a client with psoriasis? Select all that apply. One, some, or all responses may be correct. Scaly lesions Pruritic lesions Reddened papules Multiple petechiae Erythematous macules

Scaly lesions Pruritic lesions Reddened papules

Which monitoring would the nurse determine as a priority for a client with psoriasis who was prescribed etanercept? Assess client's self-concept. Check for presence of scales. Take the client's temperature. Monitor for joint pain or stiffness.

Take the client's temperature.

Which vital sign would be the most important for the nurse to assess in a client in the acute stage of an eczema breakout? Pulse rate Temperature Respiration rate Blood pressure

Temperature

Which rationale explains the use of hypoallergenic tape or Montgomery straps in postoperative skin care? To conserve the client's energy To protect the fragile skin of the older client To maintain the psychosocial health of the older client To improve perfusion to the wound to promote wound healing

To protect the fragile skin of the older client

Which information regarding cellulitis is accurate? Select all that apply. One, some, or all responses may be correct. Treated with antibiotic therapy Characterized by vesicles that may form and rupture Accompanied by chills and fever Starts with local tenderness and redness Usually caused by Streptococcus þyogenes

Treated with antibiotic therapy Characterized by vesicles that may form and rupture Accompanied by chills and fever Starts with local tenderness and redness Usually caused by Streptococcus þyogenes

A sustains deep partial- person thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aide station. The nurse encourages the client to seek medical attention, but the client refuses. Which development would the nurse advise as a reason to go to a health care provider? Blisters appear. Urinary output decreases. Edema and redness occur. Low-grade fever develops.

Urinary output decreases.

Which action by a family member of a client with a wound requiring sterile dressings would indicate the need for additional teaching? Placing the old dressing in a plastic bag Changing the dressing without wearing a mask Donning nonsterile gloves before removing the old dressing Using a back-and-forth motion while cleaning the wound

Using a back-and-forth motion while cleaning the wound

Which additional symptom would the nurse expect in a client who presents to the clinic with a butterfly rash over the bridge of the nose and on the cheeks? Select all that apply. One, some, or all responses may be correct. Weakness Swollen joints Weight loss Extreme fatigue Generalized pain

Weakness Swollen joints Weight loss Extreme fatigue Generalized pain

The nurse in the pediatric clinic is taking the health history of a toddler with an exacerbation of eczema. Which is the nurse's priority assessment of the child? Select all that apply. One, some, or all responses may be correct. Increase in appetite Wearing cotton clothes Tolerance of new foods Exposure to a viral infection Recent contact with someone with eczema

Wearing cotton clothes Tolerance of new foods

Which term describes a skin lesion observed by a nurse to be firm, edematous, and irregularly shaped in a client who reports an insect bite? Wheal Plaque Vesicle Pustule

Wheal

The nurse stops at an accident scene to administer emergency care for a person who has sustained partial- and full- thickness burns to the chest, right arm, and upper legs as the result of a car fire. Which action would the nurse take first when caring for this person? Cover the person with a warm blanket. Wrap the person in a clean, dry sheet. Apply sterile dressings to burned areas to prevent contamination. Remove the person's clothing to prevent further trauma.

Wrap the person in a clean, dry sheet.

Which type of infection would the nurse expect to find in the nails of a client who has artificial nails applied and reports redness, swelling, and pain around the nails? Viral infection Yeast infection Fungal infection Bacterial infection

Fungal infection

Which finding would a nurse expect when assessing a diabetic client receiving long-term corticosteroid therapy admitted to the hospital with leg ulcers? Weight loss Hypoglycemia Decreased blood pressure Inadequate wound healing

Inadequate wound healing

Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? Client with shock Client with anemia Client with epilepsy Client with peripheral vascular disease

Client with epilepsy

Which complication would the nurse state is a serious side effect of x-rays? Vesicles Papules Desquamation Plaque-like lesions

Desquamation

Which statement by a client recovering from a total hip replacement indicates understanding of the discharge instructions? "I will sit in a chair for several hours every day." "I will inspect the incision for healing when I change the dressing." "I will check to see whether the staples have dissolved within a few days." "I will call the health care clinic if I see any clear drainage coming from the incision."

"I will inspect the incision for healing when I change the dressing."

A nurse is teaching skin and basic care to the mother of a 6-month- old infant with eczema. Which statement indicates that the mother needs further teaching? "I'll have to be careful not to cut my baby's nails short." "I gave away my baby's all of woolen blankets." "The baby can't have foods containing whole milk anymore." "I'll need to buy cotton clothing for the baby."

"I'll have to be careful not to cut my baby's nails short."

Which would the nurse response give to a client who asks, "What is causing my acne?" "Eating chocolate" "Eating fatty foods" "Poor hygiene" "Increased androgenic hormones"

"Increased androgenic hormones"

Which would the nurse response give to a client who asks, "What is causing my acne?" "Eating chocolate" "Eating fatty foods" "Poor hygiene" "Increased androgenic hormones"

"Increased androgenic hormones"

A parent asks the nurse how to check for head lice. Which instruction would the nurse provide? "Ask the child where it itches." "Check to see if there are red dots on the back of child's your neck." "Look at your child's head along the scalp line for white dots." "Inspect your child's hands, and look between the fingers for red lines."

"Look at your child's head along the scalp line for white dots."

An older client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" Which response by the nurse is appropriate? "You sound upset but your health care provider knows best. You should do what is prescribed." "Your spouse is very capable, but if your burns get infected a family member can't give you the injections you will need." "Your burns are more serious than you think, and we have specially trained people here just to take care of you." "You may heal more slowly because of your age and may need the special care and equipment available in the hospital."

"You may heal more slowly because of your age and may need the special care and equipment available in the hospital."

A child who was rescued from a house fire is brought to the emergency department with burns of the extremities. Which finding is of most concern to the nurse? Increased temperature Increasing activity level Burns around the mouth Edema distal to the burns

Burns around the mouth

A client with a stage IV pressure ulcer is to receive 0.22 of zinc g sulfate by mouth. Each tablet contains 110 mg. How many tablets should the nurse administer? Record your answer using a whole number.

2 tablets

Which finding is of greatest concern in a 10-year-old child who was rescued from a house fire and is brought into the emergency department with burns on the extremities? Increased temperature Increasing activity level Burns around the mouth Edema distal to the burns

Burns around the mouth

Which recommendation would a nurse include to a client with psoriasis when providing health teaching concerning skin care at home? Shower twice a day. Soak the affected areas in hot water. Apply moisturizing lotion several times a day. Cover affected areas when in contact with others.

Apply moisturizing lotion several times a day.

After finding vesicles on the client's arms and legs, the nurse suspects poison ivy. Which definition best describes a vesicle? A lesion filled with purulent drainage An erosion into the dermis A solid mass of fibrous tissue A lesion filled with serous fluid

A lesion filled with serous fluid

Which intervention for itching would the nurse determine puts the client at risk for injury? Use of lotion after bathing Addition of oils to the bath water Application of topical anesthetics Administration of corticosteroids

Addition of oils to the bath water

Which action would the nurse implement when caring for a client with pruritis to protect the client from injury? Select all that apply. One, some, or all responses may be correct. Apply topical anesthetics. Apply lotion after bathing. Administer corticosteroids. Add bath oil to the bath water. Teach the client stress management techniques. Instruct the client to avoid alcohol, tea, and coffee.

Apply topical anesthetics. Apply lotion after bathing. Administer corticosteroids. Add bath oil to the bath water. Teach the client stress management techniques. Instruct the client to avoid alcohol, tea, and coffee.

Which precaution would the nurse discuss with a client who has systemic lupus erythematosus and is being treated with immunosuppressant drugs and corticosteroids? Select all that apply. One, some, or all responses may be correct. Avoid large crowds. Get a flu shot annually. Use contraception to prevent pregnancy. Refrain from taking aspirin or ibuprofen. Report signs of infection to the health care provider.

Avoid large crowds. Get a flu shot annually. Use contraception to prevent pregnancy. Refrain from taking aspirin or ibuprofen. Report signs of infection to the health care provider.

Which is an example of process third spacing in a burn injury? Blister formation Edema formation Fluid mobilization Fluid accumulation

Blister formation

Which alteration in skin color would be observed in a client diagnosed with methemoglobinemia? Red Blue White Yellow-orange

Blue

Which food would a nurse recommend for a client taking prednisone for systemic lupus erythematosus, because it contains the most potassium per serving to correct possible hypokalemia? Broccoli Oatmeal Fried rice Canned carrots

Broccoli

Which differentiating characteristic would the nurse use when comparing a second-degree burn with a third-degree burn? Local edema occurs. Burned tissue lacks sensation. Capillary permeability is increased. The burn involves the epidermis and dermis.

Burned tissue lacks sensation

Which information about the occurrence of alopecia would a nurse discuss with a client scheduled to receive chemotherapy after for surgery cancer? It is usually rare. It is not permanent. It is frequently prolonged. It is sometimes preventable.

It is not permanent.

Which manifestation is characterized by eczematous eruptions with well-defined geometric margins? Drug eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatitis

Contact dermatitis

Which action would the nurse take for a client with hypertension who states, "My tongue feels thick" after the initial dose of an angiotensin converting enzyme (ACE) inhibitor? Hold the next dose of the client's medication Contact the health care provider immediately Provide ice chips to the client to reduce the swelling Inform the client that swelling after the first dose is expected

Contact the health care provider immediately

Which sign would the nurse observe in a client with an inhalation injury in addition to a burn injury? Select all that apply. One, some, or all responses may be correct. Cough Facial burns Restlessness Black soot around mouth and nose Elevated carboxyhemoglobin levels

Cough Facial burns Restlessness Black soot around mouth and nose Elevated carboxyhemoglobin levels

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which classification would the nurse conclude is appropriate for these burns? Eschar Full-thickness Deep partial-thickness Superficial partial-thickness

Deep partial-thickness

Which degree of burn would be documented by a nurse caring for a client with a scalding burn to the chest and arms assessed as painful, mottled red, weeping, and edematous? Eschar Full-thickness burns Deep partial-thickness burns Superficial partial-thickness burns

Deep partial-thickness burns

Which intervention would a nurse employ when caring for a client with altered self-concept because of lesions and scales on the skin due to psoriasis to address the client's altered self-concept? Demonstrate acceptance through eye contact and touch Call the health care provider and report the client's depression Role-play strategies used in social situations to encourage socialization Apply topical lotions over areas with increased redness or purulent drainage

Demonstrate acceptance through eye contact and touch

Which test would the client undergo to diagnose systemic lupus erythematosus? Patch test Photo patch test Direct immunofluorescence test Indirect immunofluorescence test

Direct immunofluorescence test

Which recommendation would be given by a nurse counseling a client with systemic lupus erythematosus (SLE)? Select all that apply. One, some, or all responses may be correct. Eat foods high in vitamin C. Monitor temperature. Balance periods of rest and activity. Use a strong soap when washing the skin. Expose the skin to the sun as often as possible.

Eat foods high in vitamin C. Monitor temperature. Balance periods of rest and activity.

An adolescent admitted with symptoms of fatigue, weight loss, and mild arthralgia has been diagnosed with systemic lupus erythematous. Which intervention is appropriate for the nurse to take at this time? Administration of intravenous (IV) corticosteroids Education about diet, rest, and exercise Guidance regarding sun avoidance and calcium supplements Caution regarding negative coping mechanisms

Education about diet, rest, and exercise

Which would a nurse response give to a client who has just had a total hip replacement and states that the plan is to go swimming at the community pool the day after discharge? Encourage participation in this activity because it offers excellent range-of-motion exercise. Instruct the client to take a friend along for safety. Explain that the incision should not be immersed in water until it has healed. Tell the client that swimming can be substituted for the prescribed physical therapy.

Explain that the incision should not be immersed in water until it has healed.

Which action would be of immediate concern in the emergency care of a burn victim? Protect the airway. Extinguish the flames. Remove clothing from the victim. Conduct a focused assessment to determine injuries.

Extinguish the flames.

When assessing a client with ringworm, which sign would the nurse report to the health care provider? Fever Pruritus Joint pain or stiffness Scaly skin patches with raised borders

Fever

Which bacterial condition is suspected in a client with vesiculopustular lesions with honey-colored crusts on the face? Cellulitis Impetigo Carbuncle Erysipelas

Impetigo

Which common secondary infection from head lice (pediculosis capitis) is of most concern to the nurse? Eczema Impetigo Cellulitis Osteomyelitis

Impetigo

When would a nurse expect increased pain and limited movement of the joints in a client with rheumatoid arthritis? After assistive exercise When the room is cool In the morning on awakening When the latex fixation test is positive

In the morning on awakening

Which client assessment would the nurse determine represents the highest risk for development of pressure ulcers? Incontinence and inability to move independently Periodic diaphoresis and occasional sliding down in bed Immobility and receiving tube feedings Adequate nutritional intake and spending extensive time in a wheelchair

Incontinence and inability to move independently

Which change is expected by a nurse assessing the skin of an older adult? Select all that apply. One, some, or all responses may be correct. Scaly skin Increased wrinkles Signs of ecchymosis Marked flaking of skin Hyperpigmented patches

Increased wrinkles Hyperpigmented patches

Which factor would be evident in a client that has sustained a major burn? Select all that apply. One, be some, or all responses may correct. Inhalation injury Disfiguring injury to the face High-voltage electrical burn Major trauma in addition to the burn Burn size between 10% to 25% of body surface area

Inhalation injury Disfiguring injury to the face High-voltage electrical burn Major trauma in addition to the burn

Which information would a nurse emphasize when teaching lifelong management of type 1 diabetes to an adolescent? Soaking the feet in hot water each day Inspecting both feet frequently for signs of trauma Drying the feet thoroughly after a bath by rubbing with a towel Treating minor cuts on the feet with an antiseptic such as iodine

Inspecting both feet frequently for signs of trauma

Which information is a priority for a female client initiating treatment with isotretinoin for acne? Signed agreement to terms of IPLEDGE Verbal agreement to refrain from all sexual activity during treatment initiation Laboratory results indicating two negative pregnancy tests within the previous 2 weeks Verification that sexual partner is aware of current treatment and the potential high risk for fetal deformities

Laboratory results indicating two negative pregnancy tests within the previous 2 weeks

A client is admitted with extensive bone and soft-tissue injuries to the leg. Sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. Which action would be taken by the nurse to loosen the dressings? Apply diluted hydrogen peroxide. Pull with gentle but steady traction. Soak the area in a solution of Betadine. Moisten the dressing with sterile saline.

Moisten the dressing with sterile saline.

Which sign during an assessment of a 3-year-old child would cause the emergency department nurse to consult another team member? Select all that apply. One, some, or all responses may be correct. Skin burns with well-defined shapes Bruises in different stages of healing Healing lacerations in the presence of new ones Scars that cannot be explained History of multiple limb fractures

Skin burns with well-defined shapes Bruises in different stages of healing Healing lacerations in the presence of new ones Scars that cannot be explained History of multiple limb fractures

Which factor aggravates psoriasis? Select all that apply. One, some, or all responses may be correct. Stress Overuse of alcohol Streptococcal infections Beta blockers Angiotensin-converting enzyme (ACE) inhibitors

Stress Overuse of alcohol Streptococcal infections Beta blockers Angiotensin-converting enzyme (ACE) inhibitors

Which action by the nurse would promote comfort in a client with burns over 35% of the body complaining of chills? Limit room drafts. Maintain an 80°F room temperature. Place a sterile top sheet over the client. Maintain the room humidity below 40%.

Limit room drafts.

Which does the nurse process identify as the cause of postherpetic neuralgia in a client who developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash? Damage to the nerves Untreated major depression Scarring in the area of the rash Continued presence of the skin rash

Damage to the nerves

Which symptom would the nurse observe in a client with seborrheic dermatitis? Dandruff Red, oozing, crusty rash Dry, silvery patches on elbows and knees Red, weeping areas with clear margins surrounded by vesicles and pustules

Dandruff

Which effect of povidone-iodine does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? Avoids drying the skin Makes the skin more supple Eliminates surface bacteria that may contaminate the culture Provides a cooling agent to diminish the feeling from the puncture wound

Eliminates surface bacteria that may contaminate the culture

Which intervention is the priority for the nurse caring for a client in the emergency department with partial-thickness burns on the chest, abdomen, and leg? Carefully remove the client's clothing. Evaluate for inhalation injury. Apply sterile saline dressings on burned surfaces. Calculate total body surface area that has been burned.

Evaluate for inhalation injury.

Which condition would a nurse suspect in a client with pitting edema? Shock Kidney disease Hypothyroidism Severe dehydration

Kidney disease

For which would aesthetic purpose be performed? Select all surgery that apply. One, some, or all responses may be correct. To repair scars To eliminate benign lesions To correct developmental defects To restore body contours after radical surgery To restore features damaged by trauma or disease To alter a body feature the client perceives as unattractive

To alter a body feature the client perceives as unattractive

Which question would the nurse ask a female client prescribed isotretinoin? "Do you have diabetes mellitus?" "Do have normal menstrual you periods?" "Are you or do you plan to become pregnant?" "What other treatments have you tried for this condition?"

"Are you or do you plan to become pregnant?"

A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he that he has says changed his mind and no longer wants the procedure. Which response by the nurse is appropriate? "Why did you sign the consent?" "Can you tell me why you decided to refuse the procedure?" "You are obviously afraid about something concerning the procedure." "Although the procedure is very important, I understand why you changed your mind."

"Can you tell me why you decided to refuse the procedure?"

A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. At which rate would the nurse calculate that the IV fluid should be infused for the first 8 hours? Record your answer using a whole number.

450 mL/hr

While caring for a client with a burn injury in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. One, some, or all responses may be correct. Providing oxygen immediately Notifying the rapid response team Considering it a normal observation Initiating an intravenous (IV) line and beginning fluid replacement Obtaining an electrocardiogram (ECG) of the client

Providing oxygen immediately Notifying the rapid response team

Which interpretation describes the behavior of a nurse who ties the arms of a toddler with intensely itching arms with eczema to the crib sides and exclaims "I'm going to teach you one way or another"? These actions can be construed as assault and battery. The problem was resolved with forethought and accountability. Skin must be protected, and the actions taken were by a reasonably prudent nurse. The nurse had tried to reason with the toddler and expected understanding and cooperation.

These actions can be construed as assault and battery.

Which action would be taken immediately when a nurse performing an admission assessment discovers that a client has a stage 1 pressure ulcer? Turn and reposition the client every 2 hours. Cover the ulcer with an occlusive transparent dressing. Clean the ulcer with hydrogen peroxide and leave it open to the air. Provide the client with a diet high in vitamin C, zinc, and protein.

Turn and reposition the client every 2 hours.

Which fungal infection is commonly referred to as athlete's foot? Tinea pedis Tinea cruris Tinea corporis Tinea unguium

Tinea pedis

The mother of a kindergartener tells the nurse that her daughter is constantly scratching behind her ears. The nurse suspects pediculosis capitis (head lice). Which would the nurse expect to find during inspection? Small grayish-brown threadlike lines Scaly patches within areas of alopecia Streaked blisters surrounding a larger one White spots attached to the bases of hair shafts

White spots attached to the bases of hair shafts

Which statement made by a client being treated with biologics for psoriasis demonstrates a need for further instruction? "I will report any signs or symptoms of infection to my health care provider immediately." "I am worried that the recent pain and stiffness in my joints could be related to my psoriasis." "I enjoy having several beers with friends a few times a week; it my helps keep stress from triggering outbreaks." "I know I will need to return routinely for liver function testing with the medication that I am taking for my psoriasis."

"I enjoy having several beers with friends a few times a week; it my helps keep stress from triggering outbreaks."

A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be avoided. Which response by the nurse is appropriate? "Scratching causes lesions to become more contagious." "Scratching spreads dermatitis to other areas of the body." "Scratching results in skin breaks that can lead to infection." "Scratching produces changes that are precursors to skin cancer."

"Scratching results in skin breaks that can lead to infection."

Which response by the nurse is appropriate when a client with superficial partial-thickness burns asks which layers of skin are involved with this type of burn? "The epidermis is damaged." "The deeper layers of the dermis are damaged." "Both the epidermis and the dermis are destroyed." "The structures beneath the skin are destroyed."

"The epidermis is damaged."

Which would a nurse response give to a client newly diagnosed with scleroderma who asks, "Where did I get this from?" "The exact cause is unknown, but it is thought to be a result of autoimmunity." "The exact cause is unknown, but it is thought to be a result of ocular motility." "The exact cause is unknown, but it is thought to be a result of increased amino acid metabolism." "The exact cause is unknown, but it is thought to be a result of defective sebaceous gland formation."

"The exact cause is unknown, but it is thought to be a result of autoimmunity."

A client is diagnosed as having cancer of the breast and is admitted to the hospital for a lumpectomy to be followed by radiation. The client has tears in her and her chin is quivering. eyes In a shaky voice the client "I says, can't believe this is happening." Which response by the nurse is appropriate? "You can't believe this is happening?" "This must be a very scary time for you." "Do have you any questions at this time?" "Cancer of the breast has a high cure rate."

"This must be a very scary time for you."

A nurse is caring for an older adult admitted to the hospital for dehydration. While the nurse is providing discharge teaching, the client says, "What should I do about my dry skin? It is so itchy." Which response by the nurse is appropriate? "Wear warm clothes to keep moisture in the skin." "Use a moisturizer on the skin daily to help reduce itching." "Take hot baths only twice a week to reduce drying of the skin." "Expose the skin to the air to help reduce the sensation of itching."

"Use a moisturizer on the skin daily to help reduce itching."

Which would a nurse response give to a woman visiting the clinic for an annual physical examination who is found to have herpes genitalis and asks how it can be diagnosed without any tests? "There's a sore in your vagina." "There's a rash near your vagina." "You have a typical discharge from your vagina." "You have blisters on the skin around your vagina."

"You have blisters on the skin around your vagina."

Which intervention would the nurse implement as directed to prevent infection in a client with second- and third-degree burns? Select all that apply. One, some, or all responses may be correct. Apply topical antimicrobials. Shave body hair around wounds. Administer a tetanus toxoid booster. Cover the wounds with a sterile dressing. Have all visitors wash hands upon entering the room.

Apply topical antimicrobials. Shave body hair around wounds. Administer a tetanus toxoid booster. Cover the wounds with a sterile dressing. Have all visitors wash hands upon entering the room.

Which characteristic of partial- thickness burns that distinguishes them from full-thickness burns would a nurse recall when caring for a client with a partial-thickness burn? Require grafting before they can heal Are often painful, reddened, and have blisters Cause destruction of both the epidermis and dermis Often take months of extensive treatment before healing

Are often painful, reddened, and have blisters

Which action would a nurse explain as the next step to take after the flames are extinguished when a person's clothes catch on fire? Give the person sips of water. Assess the person's breathing. Cover the person with a warm blanket. Calculate the extent of the person's burns.

Assess the person's breathing.

Which method would the nurse use on a client with burns to quickly estimate the percentage of body surface burned? Berkow method Rule of nines method Client's palm method Lund and Browder method

Client's palm method

A 28-year-old woman comes into the clinic and tells the nurse that she fears that she is infertile because she has been trying to become pregnant for 2 years. While collecting the health history, the nurse learns that the client experiences irregular and infrequent menstrual periods. The client is overweight and has severe acne and alopecia. The health care provider diagnoses polycystic ovarian syndrome (PCOS). Which intervention would the nurse provide? Consoling the client over her inability to have children Discussing weight loss, exercise, and a balanced low-fat diet Providing information to the client on how to prepare for surgery Informing the client that there are no long-term complications of PCOS

Discussing weight loss, exercise, and a balanced low-fat diet

Which consideration would the nurse make when caring for a client who is taking isotretinoin and suspects that she is pregnant? It is used to suppress hunger in individuals trying to lose weight, so the client should stop taking the medication. It is often used to treat migraines associated with hormonal changes and should be safe for continued use as needed. It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately. It is an atypical antipsychotic, and the woman needs to make an immediate appointment with her mental health care provider to discuss alternative medications.

It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately.

Which expected response does a nurse need to address in the plan of care of a client with pemphigus vulgaris? Paralysis Infertility Skin lesions Impaired digestion

Skin lesions

Permethrin 1% lotion is prescribed for a 5-year-old child with pediculosis capitis (head lice). Which instruction would the nurse include while teaching the parents about treating the head lice? Personal belongings must be discarded. Side effects are nonexistent with the medicated shampoo. Other children should be kept away from the child for a week. The child's hair must be combed with a fine-toothed comb to remove nits.

The child's hair must be combed with a fine-toothed comb to remove nits.

Which conclusion is made by a nurse who admits a client receiving patient-controlled analgesia (PCA) after surgery? The client is able to self- administer pain-relieving drugs as necessary. The amount of medication received is determined entirely by the client. The amount of drug used for analgesia fluctuates greatly over a given period. Self-administration relieves the nurse of monitoring the client for pain relief.

The client is able to self- administer pain-relieving drugs as necessary.

Which consideration would be used to determine the source of blame for a pressure ulcer that has developed on an emaciated older adult with dementia who refused to change positions for extended periods? The client should have been turned regularly. Older clients often develop pressure ulcers. The nurse is not responsible to the client's family. Nurses should respect a client's right not to be moved.

The client should have been turned regularly.