Medical-Surgical: Dermatological

The nurse is caring for a patient who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the patient indicates an understanding of the teaching?

"i will be on a special shower table" -facilitates examination and debridement of wound during hydrotherapy; advantage of using showering technique is that it can be kept at constant temp and lowers risk of wound infection compared to tub bath -use warm water to help maintain adequate body temp -use soft washcloths or gauze to gently scrub and debride -leave small blisters intact but open larger blisters

A nurse is caring for an adolescent patient who has burned on her face and hands. Which of the following statements by the patient indicates that she has adapted to her change body image?

"may i go with my family to the visitor's lounge?" -demonstrates positive self-image

A nurse is providing teaching to a patient who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include?

"shift your weight in the wheelchair every 15 minutes" -this addresses safety issue of pp ulcer risk, which are most likely to develop if the pt doesn't shift positions frequently to relieve pp -change positions at least once every hour -avoid massaging the skin, especially over bony prominences b/c it will further traumatize fragile tissue -avoid using rubber ring for sitting b/c it reduces circulation to the pts skin

A nurse is assessing the skin of a patient who has frostbite. The patient has small blisters that contain blood and the skin of the affected areas does not blanch. The nurse should classify this injury as which of the following?

3rd degree frostbite -skin of affected area has small blisters that are blood-filled and skin doesn't blanch -1st degree frostbite: affected area is reddened and looks waxy -2nd degree frostbite: affected area has large, fluid-filled blisters 4th degree frostbite: affected area is frozen, blisters don't appear, muscles and bones are affected

The nurse is caring for a patient who has a prescription for silver sulfadiazine cream to be applied to her burn. The nurse should evaluate the patient?

Leukopenia -adverse effect of silver sulfadiazine

A nurse is evaluating the lab values and who's in the resuscitation phase following a major burn. Which of the following lab finding should the nurse expect?

Na 132 mEq/L Expected lab values: -decreased Na: b/c it's trapped in interstitial space -elevated hemoglobin: during the resuscitation phase due to loss of fluid volume -Decreased albumin: during resuscitation phase -elevated potassium: during resuscitation phase

The nurse is assessing a patient who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the patient sacral area. The nurse should document that the patient pressure ulcer at which the following stages?

Stage II pressure ulcer -partial thickness skin loss of the epidermis and the dermis; also is visible and superficial and can appear as an abrasion, blister, shallow crater -edema persists, and ulcer might become infected -pt may report pain, have small amount of drainage -stage I pressure ulcer:

The nurse is assessing a patient who sustained superficial partial thickness and deep partial thickness burns 72 hours ago. Which of the following findings should the nurse report to the provider?

Temperature of 39.1°C -Indicate possible infection which nurse should report to provider; sepsis is a critical findings following a major burn injury -significant edema expected when fluid shifts after injury -superficial partial-thickness and deep partial-thickness burns are painful throughout Burn therapy -decreased urine output expected w/ edema and fluid shifts in or about 4th day following major burn injury

A nurse in a providers office is caring for a patient who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications?

acyclovir -antiviral med that inhibits replication of virus that causes herpes zoster -zoster vaccine: given to older adult pt to prevent herpes zoster -amoxicillin: administered for bacterial infection -infliximab: administered for pts w/ Crohn's dz

A nurse is teaching a group of young adult patients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions to the nurse include?

avoid exposure to the midday sun -pt should avoid skin exposure to sun, especially during midday hrs of 1000 to 1600 b/c sun rays are the strongest at that time -should apply broad-spectrum sunscreen 15 min prior to sun exposure -pt should wear wide-brimmed hat b/c it provides better protection from sun than a visor -pt should avoid sunbathing and tanning booths, sunlamps, and tanning pills

A nurse in the ED is caring for a patient who has a snakebite on her arm. Which of the following intervention should the nurse implement?

immobilize the limb at the level of the heart -to limit spread of venom -constrictive clothing/jewelry should be removed before swelling worsens -contraindicated: tourniquet to affected limb, use sterile scapula to incise wound, apply ice to skin over snakebite wound

The nurse is assessing a patient who has a lesion on the skin. Which of the following findings as a clinical manifestation of the malignant melanoma?

irregularly shaped lesions w/ blue tones -can also be red or white in tone -often occur on upper back and lower legs -manifestations of actinic keratosis: rough, dry, scaly lesions -manifestations of squamous cell carcinoma: firm nodule w/ crust -manifestation of basal cell carcinoma: pearly papule w/ ulcerated center

I community health nurse is providing teaching about malignant melanoma to a group of patients. The nurse should inform the group that which of the following traits places a patient at risk for developing malignant melanoma?

light skin -and less pigmentation place a pt at risk for developing malignant melanoma -brown eyes, black hair, dark skin are all not risks of developing malignant melanoma

A nurse in the providers office is assessing a patient skin lesions. The nurse notes that the lesions are 0.5 cm (0.2 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings which of the following is commissions?

papules -small, solid, elevated lesion w/ distinct borders -macule: flat, variably shaped, discolored, and small, typically smaller than 10 mm in diameter; is a change in color of skin; freckles and rash associated w/ rubella are types of macules -wheals: hives; transient, elevated, irregularly shaped lesions caused by localized edema; common manifestation of allergic rxn -vesicles: circumscribed, elevated lesion or blister containing serous fluid; typically arise w/ herpes simplex, poison ivy, chickenpox

The nurse is going for a patient who has a lesion on the back of his right hand. The patient asked the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate?

melanomas -malignant neoplasms w/ atypical melanocytes in both epidermis, dermis, and sometimes subcutaneous cells -most lethal skin cancer, often causing metastases in bone, liver, lungs, spleen, CNS, and lymph nodes -basal cell carcinoma: most common type of skin cancer, rarely metastasizes; arise from basal cell layer of epidermis or hair follicles and generally appear on sun-exposed areas of body -actinic keratoses: premalignant; can evolve to squamous cell carcinoma, however they're not the most lethal -squamous cell carcinoma: arise from epidermis and are potentially metastatic, however they're not most lethal

A nurse is caring for a patient whose wounds are covered with a heterograft dressing. In response to the patients questions about the dressing, the nurse explains that it is obtained from which of the following sources?

pig skin -heterografts are obtained from an animal, normally a pig -homographs: obtained from cadaver skin -amniotic membranes: used to treat burns, but aren't heterograft dressings -beef collagen: artificial skin that's used to treat burns but aren't heterograft dressings

A nurse is planning care for a patient who has been admitted for treatment of a malignant melanoma of the upper life without many stasis. The nurse should plan to prepare the patient for which of the following procedures?

surgical excision -therapeutic approach: depends on level of invasion and depth of lesion; surgical excision is Tx of choice for small, superficial lesions, deeper lesions require wide, local excision followed by skin grafting -has an extremely high incidence of metastasis -curettage: used for small lesions that are not melanomas -regional/topical chemotherapy: Tx of choice for localized tumors and superficial basal cell carinomas

A nurse on a surgical unit is caring for four patients who have healing wounds. Which of the following would the nurse expect to heal by primary intention?

surgical incision -w/ primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring -partial-thickness burns heal by spontaneous re-epithelialization, it involves the uppermost layers of the dermis and scarring can be minimal or extensive depending on depth of burn -stage III pp ulcer will heal by 2ndary intention -dehisced sternal wound can close by 2ndary or tertiary intention

A nurse is providing discharge instructions to patient who is postoperative following a surgical excision of a basal cell carcinoma. Which the following findings should the nurse include as an indication of a potential malignancy of a mole?

ulceration -bleeding, exudation, increasing size, redness or swelling of the skin around the mole, or darkening of the mole are indications of a mole's potential malignancy

A nurse is caring for a patient who has a large wound healing by secondary intention. The nurse should inform the patient that, in addition to protein, which of the following nutrients promotes wound healing?

vitamin C -diet high in protein and vitamin C recommended b/c they promote wound healing -vitamin B1: promotes functioning of nervous system -Ca: aids in blood clotting and mm contraction -K: necessary for mm activity and fluid balance