Med Surg CH. 55-59

A patient comes to the clinic and asks the nurse why the skin of the forehead, palms, and soles has a yellow-orange tint. There is no yellowing of the sclera or mucous membranes. What should the nurse question the patient regarding?

"Have you been eating a large amount of carotene-rich foods?"

A client is being discharged home after surgery involving the middle ear. Which of the following client statements demonstrates understanding of the instructions?

"If I sneeze or cough during the first few weeks, I should keep my mouth open."

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area?

1

When a patient has been diagnosed with scabies, if the infection has spread, family members may complain of pruritus within which time frame?

1 month

A patient has a moisture-retentive dressing for the treatment of a sacral decubitus ulcer. How long should the nurse leave the dressing in place before replacing it?

12-24 hrs

A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn with 50% of the total given in the first 8 hours postburn. A 176 lb (80 kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?

2,400 ml

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames?

2-4 weeks

A client has undergone tonometry to evaluate for possible glaucoma. Which result would the nurse record as abnormal?

25 mm Hg

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?

36%

The nurse is changing the dressing of a chronic wound. There is no sign of infection or heavy drainage. How long will the nurse leave the wound covered for?

48-72 hrs

The ophthalmologist tells a patient that he has increased intraocular pressure (IOP). The nurse understands that increased pressure resulting from optic nerve damage is indicated by a reading of:

>21 mm Hg.

Which type of glaucoma presents an ocular emergency?

Acute angle-closure glaucoma

Which of the following classification of medications is the most common cause of ototoxicity?

Aminoglycosides

A patient has been diagnosed with hyphemia. Which of the following medication classifications stabilizes clot formation at the site of hemorrhage?

Antifibrinolytics

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?

Antivirals

In a client with burns on the legs, which nursing intervention helps prevent contractures?

Apply knee splints

A client is receiving long-term intravenous therapy with gentamicin for a chronic wound infection. Which of the following would be most important for the nurse to ensure?

Arrange for audiograms twice a week.

A patient has been diagnosed with a fungal infection causing external otitis. What is the most common fungal infection in the ear?

Aspergillus

A nurse is caring for a client scheduled to have angiography of the right eye in 1 hour. What is the highest priority nursing intervention?

Assess blood urea nitrogen (BUN) and creatinine levels.

A 78-year-old client reports decreased hearing in the right ear. The doctor orders irrigation of the right ear to remove cerumen. Which is the priority action by the nurse?

Assess for a ruptured tympanic membrane

The nurse is instructing a client on the benefits of a cochlear implant. The client asks, "How am I able to interpret sound?" The nurse credits which of the following as significant in the production of hearing?

Auditory nerve

A mother brings her daughter to the clinic for an evaluation because the child is complaining of ear pain. Which of the following would lead the nurse to suspect that the child is experiencing otitis externa and not otitis media?

Aural tenderness

A patient is diagnosed with seborrheic dermatitis on the face and is prescribed a corticosteroid preparation for use. What should the nurse educate the patient about regarding use of the steroid on the face?

Avoid using the medication around the eyelids because it may cause cataracts and glaucoma.

A 52-year-old client asks the nurse for interventions for the treatment and prevention of actinic ketatosis. The client is a construction foreman and has actinic ketatosis that is noted only on the right side of the face next to the nose. Which recommendation is appropriate for this client?

Avoidance of direct sunlight with protective clothing measures should be discussed with the client.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL

Which of the following causes odor in perspiration?

Bacteria on skin

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply.

Base-bicarbonate deficit Elevated hematocrit level Sodium deficit

A patient has been brought to the emergency room after being hit in the head with a baseball. The nurse should be alert to which of the following clinical manifestations of a detached retina? Select all that apply.

Bright flashing lights Sudden onset of floaters Cobwebs Sensation of a curtain coming across vision of one eye

A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?

Bronze

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

A nurse assesses a client with dark skin and notes new purple-gray cast to the skin on the chest, back, and arms. Which priority nursing intervention should the nurse implement?

Check the client's oral temperature.

A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following?

Chlamydia trachomatis

Which medication classification increases aqueous fluid outflow in the client with glaucoma?

Cholinergics

When assessing pallor, the nurse understands that it is best observed on which of the following areas?

Conjunctivae

The nurse is conducting an admission history and physical examination of a client with a history of contact dermatitis. The nurse assesses whether the client uses which medication classification?

Corticosteroids

The purpose of melanin is to:

Determine skin color

The nurse is assessing a client's skin when the client points out a mole. The nurse brings the mole to the physician's attention when which characteristic is noted?

Diameter exceeding 6 mm

A client has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. What intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?

Early enteral feeding

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted?

Elevated and palpable

The nurse should assess all possible causes of pruritus for a patient complaining of generalized pruritus. What does the nurse understand can be another cause for this condition?

End stage kidney disease

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Epidermis and a portion of deeper dermis.

The nurse asks a client to follow the movement of a pencil up, down, right, left, and both ways diagonally. The nurse is assessing which of the following?

Extraocular muscle function

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing

Facial nerve paralysis

Which of the following nonsedating antihistamines is appropriate for daytime pruritus?

Fexofenadine (Allegra)

A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply.

Fluid loss Fluid shift Hypotension

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following?

Freckles

Which symptoms may a client with Ménière disease report before an attack?

Full feeling in ear

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

Full-thickness

The nurse should monitor for which manifestation in a client who has undergone LASIK?

Halos and glare

The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply.

Heart rate Urine output

Which sedative medication is effective for treating pruritus?

Hydroxyzine

Which of the following is to be expected soon after a major burn? Select all that apply.

Hypotension Tachycardia Anxiety

The nurse is obtaining a visual history from a client who has noted an increase in glare and changes in color perception. Which assessment would the nurse anticipate to confirm a definitive diagnosis?

Identification of opacities on the lens

During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding?

Iron deficiency anemia

Which drug is an oral retinoid used to treat acne?

Isotretinoin

An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding?

It is a cherry angioma that is a normal age-related skin alteration.

You are doing discharge teaching with a client after a stapedectomy. Why would it be important for you to advise the client to refrain from blowing the nose?

It may dislodge the prosthesis.

Which infecting agent causes scabies?

Itch mite

The nurse assesses the client and observes reddish-purple to dark blue macules, plaques, and nodules. The nurse recognizes that these manifestations are associated with which condition?

Kaposi Sarcoma

Which action should the nurse recommend to a client with blepharitis?

Keep lid margins clean

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

Lactated Ringers solution

Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?

Laser-assisted stromal in situ keratomileusis (LASIK)

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:

Loss of accommodative power in the lens.

The nurse is assessing a client using an Amsler Grid. The nurse is assessing for which of the following?

Macular problems

Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following?

Macule

The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do?

Make sure that the room is darkened.

To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treat inflammatory conditions of the eyes?

NSAIDs

A patient is diagnosed with malignant melanoma that directly invades the adjacent dermis (vertical growth). The nurse knows that this type of melanoma has a poor prognosis. Which of the following is most likely the type of melanoma described in this scenario?

Nodular Melanoma

A client receives treatment for a dermatophyte infection of the toenail. How would the nurse document this condition in the chart?

Onychomycosis

The nurse is providing teaching to a client with acne who is using isotretinoin therapy. Which statement should the nurse make?

Teratogenic in humans

Prior to an eye exam for possible macular degeneration, the nurse completes a history of symptoms. The nurse is aware that a diagnostic sign of age-related dry macular degeneration is:

The appearance of tiny, yellow spots in the field of vision.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

The client's urinary output is 0.5 to 1 mL/kg/hour.

The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?

The skin is ashen gray and dull.

An older adult patient informs the nurse, "I don't see as well as I used to." What should the nurse explain to the patient about why vision becomes less efficient with age? Select all the apply.

There is a decrease in pupil size. There is slowing of accommodation. There is an increase in lens opaqueness.

Petechiae are associated with which of the following disorders?

Thrombocytopenia

Which term describes a fungal infection of the scalp?

Tinea Capitis

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

To keep fire and smoke from airway

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?

Tretinoin (retinoic acid [Retin-A])

Which term refers to surgical repair of the tympanic membrane?

Tympanoplasty

Which diagnostic test is used to examine cells from herpes zoster?

Tzanck smear

A client is being treated for acne vulgaris. What warning must be given to this client regarding the application of benzoyl peroxide?

Use gloves with application

Acoustic neuromas are benign tumors of which of the following cranial nerves?

VIII

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?

Vesicles

The clinical manifestations of motion sickness are caused by an overstimulation in what system?

Vestibular

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin?

Vitiligo

Which term refers to yellowish waxy deposits on the upper and lower eyelids?

Xanthelasma

When performing a skin assessment, the nurse notes a localized skin infection of a single hair follicle. The nurse documents the presence of

a furuncle

Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client?

allograft

Which term refers to the absence of the natural lens?

aphakia

Three female students share an apartment. They notice after several months that their menstrual cycles are coordinating. What is speculated to be responsible for the synchronization of their monthly cycles?

apocrine secretions

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called:

conductive hearing loss.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to

decrease catabolism

The patient is advised to apply a suspension-type lotion to a dermatosis site. The nurse should advise the patient to apply the lotion how often to be effective?

every 3 hours

Which of the following is a surgical procedure that removes the eyelids, eye, and various amounts of orbital contents?

exenteration

A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would not be included?

eyelids

A client has undergone enucleation. What complication of enucleation should be addressed by the nurse?

hemorrhage

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?

homografts

The classic lesions of impetigo manifest as

honey-yellow crusted lesions on an erythematous base.

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury?

hyperkalemia

A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition?

hyperopia

Production of melanin is controlled by a hormone secreted by which of the following?

hypothalamus

A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent:

increased intraocular pressure (IOP).

The nurse notes that the client's lower extremities are covered with very dry skin and that the horny layer of the skin has become thickened. The nurse notes the finding as

lichenification

A client diagnosed with benign paroxysmal positional vertigo is experiencing an acute attack. The client is prescribed a vestibular suppressant. Which medication would the nurse anticipate being used?

meclizine

A client is diagnosed with a conductive hearing loss. When performing a Weber test, the nurse expects that this client will hear sound:

on the affected side by bone conduction.

Which term refers to swelling of the optic disc due to increased intracranial pressure?

papilledema

A client with multiple sclerosis is being seen by a neuro-ophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:

perimetry test

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include

premedicating the client with an analgesic prior to application.

Which terms refers to the progressive hearing loss associated with aging?

presbycusis

A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?

private room

A nurse notices that a client's left upper eyelid is drooping. The nurse has observed:

ptosis

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?

retinal angiography

After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms?

retinal detachment

Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear?

scleral buckle

When the client tells the nurse that his vision is 20/200 and then asks what that means, the nurse informs the client that a person with 20/200 vision

sees an object from 20 feet away that a person with normal vision sees from 200 feet away.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of:

stasis

Which of the following occurs when there is deviation from perfect ocular alignment?

strabismus

To straighten the ear canal in an adult for examination, the nurse practitioner would grasp the auricle and pull it:

up and back

A client is diagnosed with Meniere's disease. The nurse would most likely expect the client to report which of the following?

vertigo

Which of the following types of conjunctivitis is preceded by symptoms of an upper respiratory infection?

viral

A client has undergone diagnostic testing and has been diagnosed with otosclerosis. What ear structure is primarily affected by this diagnosis?

Stapes

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?

Sulfadiazine, silver (Silvadene)

A nurse is caring for a 24-year-old female client diagnosed with otosclerosis. Which teaching by the nurse is most accurate?

Symptoms may be accelerated by pregnancy.

Nursing students are reviewing the structure and function of the ears in preparation for class the next day. The students demonstrate understanding of the information when they describe which of the following as a middle ear structure?

Ossicles

A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?

Patch test

The nurse is assisting an older adult client with performing activities of daily living (ADL) and is brushing her hair. What does the nurse document as an abnormal finding?

Pearly white substance that is attached to the hair shaft that is not removed with brushing

The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as

Petechiae

Following a burn injury, the nurse determines which area is the priority for nursing assessment?

Pulmonary system

A 68-year-old client reports a change in vision when driving during the night. Which strategies would the nurse recommend to mitigate this problem?

Recommend contrast sensitivity testing measures to determine visual function.

A patient is scheduled for Mohs microscopic surgery for removal of a skin cancer lesion on his forehead. The nurse knows to prepare the patient by explaining that this type of surgery requires:

Removal of the tumor, layer by layer.

Which of the following tests uses a tuning fork between two positions to assess hearing?

Rinne

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

The nurse is examining the area behind the patient's auricle and sees a flaky scaliness. What disorder does the nurse suspect the patient has?

Seborrheic dermatitis

During his annual physical examination, a retired airplane mechanic reports noticeable hearing loss. The nurse practitioner prescribes a series of hearing tests to confirm or rule out noise-induced hearing loss, which is classified as a:

Sensorineural loss

What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids?

Serous otitis media