MS II Quiz 4

A female patient has come into a dermatology clinic and reports that she has a single 1-inch lesion that was scaly with a raised border and a pink center on her chest. Now, a little more than a week later, she has smaller matching spots of the rash on both sides of her chest. The nurse observes pink, oval-shaped spots that are ¼ to ½ inch across. What condition does the nurse suspect the physician will diagnose? A. Herpes zoster B. Herpes simplex type 1 C. Pityriasis rosea D. Impetigo contagiosa

C. Pityriasis rosea Rationale: Pityriasis rosea begins with a single lesion, 1 to 2 inches in diameter, known as a herald patch. This lesion is scaly with a raised border and a pink center, and is typically found on the patient's chest, abdomen, back, groin, or axillae. Seven to 14 days after the initial eruption, smaller matching spots of the rash become widespread on both sides of the body. Herpes zoster, commonly known as shingles, causes a patient's resistance to infection has been lowered. Herpes simplex type 1, commonly known as a cold sore, is characterized by a vesicle at the corner of the mouth, on the lips, or on the nose. Impetigo contagiosa consists of macular lesions that rupture and form a dried exudate on the face, hands, arms, and legs.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? a) Enteric b) Strict c) Contact d) Respiratory

Contact Explanation: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

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 I 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 (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do first? a) Instruct the home health aide to reposition the client every 2 hours while the client is awake. b) Make a home visit to verify the changes in the ulcer. c) Contact the health care practitioner (HCP) to request a hydrocolloid dressing. d) Ask the client's daughter to purchase a foam mattress.

Contact the health care practitioner (HCP) to request a hydrocolloid dressing. Explanation: The pressure ulcer has changed from stage I to stage II and requires the use of a protective dressing.

During nursing rounds, a nurse checks on a client on bed rest who reports an itchy rash. The nurse assesses the client's skin for erythematous, slightly edematous areas on the client's back, posterior lower legs, and posterior elbows. The physician's diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are correct? Select all that apply. a) This is an allergic reaction. b) Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved. c) Based on the location, it is likely that detergents in the bed linens caused the rash. d) Washing with antibacterial soap will help the rash. e) The disorder is contagious. f) The skin is infected wherever the rash has developed.

• Based on the location, it is likely that detergents in the bed linens caused the rash. • Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved. • This is an allergic reaction. Explanation: Contact dermatitis is classified as a reaction to an allergen and can appear when skin, especially if it's moist from perspiring or other reasons, remains in contact with an irritant for an extended time. It is a hypersensitivity reaction but usually requires extended contact. This client has a presentation often seen when clients remain in bed, perspiring on detergent-cleansed bed linens or gowns. This type of sensitivity to detergents may not have produced a reaction with a shorter time contact. The rash is not contagious or infectious, although areas may become exudative and crusted. Treatment varies according to the intensity of the skin reaction and other factors, but oatmeal (Aveeno) baths are frequently prescribed.

On the fourth day after surgery, a client has a postoperative wound infection. Which of the following should the nurse assess? Select all that apply. a) Redness and swelling beyond the incision line. b) 89% segmented neutrophils. c) Incisional pain greater than on day 2. d) Total white blood count (WBC) 10,000/mm (10 X 109/L). e) Temperature of 102° F (38.9° C).

• Redness and swelling beyond the incision line. • Temperature of 102° F (38.9° C). • 89% segmented neutrophils. Explanation: WBC count should be above normal (4,500 to 11,000/mm [4.5 to 11 X 109/L]) with an acute infection or inflammatory response such as a postoperative wound infection. Redness and swelling beyond the incision line is expected with a wound infection. An elevated temperature such as 102° F (38.9° C) on the third to fourth postoperative day indicates an infection process rather than an inflammatory process. An elevation in the segmented neutrophils demonstrates that the most mature WBCs have responded to the invading bacteria at the incision site, which is an expected response. Typically, postoperative pain begins to lessen by the 4th day.

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? a. The patient ate two thirds of breakfast. b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.

B

A nurse is collecting data from an older adult client who is suspected of having type 2 diabetes mellitus. Which of the following findings are commonly seen with clients diagnosed with diabetes mellitus? 1) HbA1c5% 2) A wound that is not healing. 3) Sudden onset of symptoms. 4) Body mass index (BMI) of 20

2) A wound that is not healing.

A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage? a) "Apply sunscreen even on overcast days." b) "Use a sunscreen with a sun protection factor of 6 or higher." c) "When at the beach, sit in the shade to prevent sunburn." d) "Minimize sun exposure from 1 to 4 p.m., when the sun is strongest."

"Apply sunscreen even on overcast days." Explanation: Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days.

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education? a) "I'll shower before coming to the hospital on the day of the surgery." b) "On the morning of surgery, I won't use lotions or cosmetics." c) "On the morning of the surgery, I can shave my surgical area at home to save time." d) "I should begin to use an antibacterial soap a few days before my surgical procedure."

"On the morning of the surgery, I can shave my surgical area at home to save time." Explanation: The client shouldn't shave the surgical area at home. Any necessary clipping of hair will be done at the surgical center. Allowing the client to shave the area with a razor could cause skin abrasions and subsequent infections

A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond? a) "To prevent evaporation of water from the hydrated epidermis." b) "To prevent skin inflammation." c) "To minimize cracking of the dermis." d) "To make the skin feel soft."

"To prevent evaporation of water from the hydrated epidermis." Explanation: The nurse should tell the client that applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer.

A nurse is caring for a client who is postoperative. To support tissue repair the nurse should recommend that the client increase his dietary intake of which of the following? 1) Fats 2) Complex carbohydrates 3) Fiber 4) Vitamin E

2) Complex carbohydrates

A nurse in a provider's office is caring for a client who reports pruritus and reddened, fluid-filled vesicles on her lower leg. The nurse suspects which of the following disorders? 1) Cellulitis 2) Contact dermatitis 3) Folliculitis 4) Seborrheic dermatitis

2) Contact dermatitis

The nurse is completing an assessment of the skin's integrity, which includes a. Pressure points. b. All pulses. c. Breath sounds. d. Bowel sounds.

A

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? a. Complaint by patient that something has given way b. Protrusion of visceral organs through a wound opening c. Chronic drainage of fluid through the incision site d. Drainage that is odorous and purulent

A

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a. Don sterile gloves. b. Provide analgesic medications as ordered. c. Avoid accidentally removing the drain. d. Gather supplies.

B

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is a. Pressure. b. Resistance. c. Stress. d. Weight.

A. Pressure.

What is the initial intervention for relief of the pruritus of dermatitis venenata? A. Apply baking soda to lesions B. Wash area with copious amounts of water C. Apply cool compresses continuously D. Expose area to air

B. Wash area with copious amounts of water Rationale: In dermatitis venenata (poison oak or ivy), the patient should wash the affected part immediately after contact with the offending allergen.

A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complains of pain and pruritis. Why would the nurse use a Woods lamp? A. To dry out the lesions B. To reduce the pruritus C. To kill the fungus D. To cause fluorescence of the infected hairs

D. To cause fluorescence of the infected hairs Rationale: Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a brilliant blue green.

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved him. He tells the nurse, "The nursing assistant on the last shift was rough. I asked her to look at my backside, but she told me she was too busy." What should the nurse do first? a) Document her findings. b) Prepare a disciplinary warning for the nursing assistant. c) Prepare an incident report. d) Contact the shift supervisor.

Document her findings. Explanation: The nurse must first document her assessment findings; timely documentation helps ensure accuracy. The nurse should notify the shift supervisor after completing the documentation. She must follow the chain of command.

A nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do? a) Encourage the client to ambulate in the halls on the unit. b) Cleanse the left lower leg with perfumed liquid soap. c) Instruct the client to elevate the left leg when sitting in the chair. d) Massage the left leg with alcohol to stimulate circulation.

Instruct the client to elevate the left leg when sitting in the chair. Explanation: The client has cellulitis and should elevate the affected area above heart level.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? a) Fluorouracil b) Zinc oxide gelatin c) Minoxidil d) Tretinoin

Tretinoin Explanation: Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.

The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore? a) nutritional status b) orientation status c) circulatory status d) mobility status

mobility status Explanation: The client's mobility status is the best indicator of risk for development of a pressure sore.

The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should: a) monitor the white blood cell count. b) monitor serum albumin. c) insert an indwelling urinary catheter. d) have the client walk at least twice a day.

monitor serum albumin. Explanation: The nurse should monitor the client's serum albumin. A decreased serum albumin indicates malnutrition and is considered a risk factor in the development of pressure ulcers.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. a) Tuck bed covers tightly into the foot of the bed. b) Reposition the client every 2 hours. c) Perform range-of-motion exercises. d) Encourage the client to eat a well-balanced diet. e) Use commercial soaps to keep the skin dry.

• Reposition the client every 2 hours. • Encourage the client to eat a well-balanced diet. • Perform range-of-motion exercises. Explanation: To prevent pressure ulcer formation, the nurse should turn and reposition the client every 2 hours, perform range-of-motion exercises, avoid using commercial soaps that dry or irritate skin, avoid tucking covers tightly into the foot of the bed, and encourage the client to eat a well-balanced diet.

The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in the guide indicate? A. Severity of the symptoms B. Site of the lesions C. Symptomatology of the lesions D. Surface area of the lesions

A. Severity of the symptoms Rationale: The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present).

What should the nurse do when administering a therapeutic bath to a patient who has severe pruritus? A. Use Burow's solution to help promote healing B. Rub the skin briskly to decrease pruritus C. Limit bathing to 3 times a week D. Ensure that bath area is at least 85°F and dehumidified

A. Use Burow's solution to help promote healing Rationale: Pruritus is responsible for most of the discomfort. Wet dressings and using Burow's solution help promote the healing process. A cool environment with increased humidity decreases the pruritus. Give daily baths with an application to cleanse the skin.

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.

D

The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? a. The incision site has started to itch. b. The incision site is approximated. c. The patient has pain at the incision site. d. The incision has a mass, bluish in color.

D

The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply. a) Reposition the client every 2 hours. b) Elevate the head of the bed to 50 degrees. c) Cover with protective dressing. d) Request an alternating-pressure mattress. e) Obtain daily cultures.

• Request an alternating-pressure mattress. • Reposition the client every 2 hours. • Cover with protective dressing. Explanation: The client has a stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees.

A nurse is inspecting a lesion on a client who has basal cell carcinoma. Which of the following is an expected finding? 1) A pearly, shiny nodule 2) A red, edematous macule 3) A rough, scaly tumor 4) A weeping vesicle

1) A pearly, shiny nodule

A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction would be most helpful in managing the pruritus? A. Use cool, wet dressings and baths to promote vasoconstriction B. Trim the fingernails short to prevent skin damage from scratching C. Expose the areas to the sun to promote drying and healing of the lesions D. Wear cotton gloves and cover all other affected areas with clothing to prevent environmental irritation

A. Use cool, wet dressings and baths to promote vasoconstriction Rationale: Wet dressings and using Burow's solution help promote the healing process. Cold compresses may be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skin damage, but not pruritus.

What should the nurse examine in assessing a patient for tinea corporis? A. Soles of the feet B. Scalp C. Armpits D. Abdomen

D. Abdomen Rationale: Tinea corporis is known as ringworm of the body. It occurs on parts of the body with little or no hair.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? a) Irrigate the wounds with water. b) Wash the wounds with soap and water and apply a barrier cream. c) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. d) Do nothing until the chemical agent is identified.

Irrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water

The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care? a) Place the client on a pressure redistribution bed. b) Administer pain medications as ordered. c) Turn the client every 2 to 4 hours. d) Place a foam pad on the existing mattress

Place the client on a pressure redistribution bed. Explanation: A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect? a) Scabies b) Dermatophytosis c) Impetigo d) Contact dermatitis

Scabies Explanation: Signs and symptoms of scabies include gray-brown burrows, epidermal curved or linear ridges, and follicular papules. Clients complain of severe itching that usually occurs at night. Scabies commonly occurs in school-age children. The most common areas of infestation are the finger webs, flexor surface of the wrists, and antecubital fossae.

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? a) The wet-to-damp dressing should be tightly packed into the wound. b) A plastic sheet-type dressing should cover the wet dressing. c) The dressing should be allowed to dry out before removal. d) The dressing should keep the wound moist.

The dressing should keep the wound moist. Explanation: A wet-to-damp saline dressing should always keep the wound moist

A nurse is caring for a client who comes to the office with complaints of a nevus that has increased in size and changed in color. On examination, the nurse notes an elevated two centimeter lesion that is dark brownish-black in color with irregular borders. The nurse should be aware that these findings are consistent with which of the following? 1) Malignant melanoma 2) Basal cell carcinoma 3) Squamous cell carcinoma 4) Kaposi's Sarcoma

1) Malignant melanoma

A nurse in a provider's office is caring for a school-age child whose mother reports dandruff and a rash on the back of her child's neck. On examination, the nurse notices the white flakes don't brush off the hair. The nurse suspects which of the following disorders? 1) Pediculosis captis 2) Psoriasis 3) Seborrheic dermatitis 4) Tinea capitis

1) Pediculosis captis

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes a. Monitoring of the wound. b. Irrigation of the wound. c. Débridement of the wound. d. Management of drainage.

C

A nurse is planning to reinforce teaching for the client who has psoriasis. Which of the following is appropriate to include? 1) Maintain occlusive dressings on the lesions throughout the day. 2) Eliminate the use of products containing salicylic acid. 3) Avoid friction over scaly lesions while bathing. 4) Identify effective stress reduction techniques.

4) Identify effective stress reduction techniques.

A patient has developed a decubitus ulcer. What laboratory data would be important to gather? a. Serum albumin b. Creatine kinase c. Vitamin E d. Potassium

A

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to a. Inspect the wound for bleeding. b. Inspect the wound for foreign bodies. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection.

A

The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? a. Encourage the patient to sit up in the chair. b. Provide analgesic medication as ordered. c. Explain the risks of immobility to the patient. d. Turn the patient every 3 hours while in bed.

B

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step? a. Remove the drain; a drain is no longer needed. b. Call the physician; a blockage is present in the tubing. c. Call the charge nurse to look at the drain. d. As long as the evacuator is compressed, do nothing.

B

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? a) Stage II pressure ulcer b) Stage III pressure ulcer c) Stage I pressure ulcer d) Stage IV pressure ulcer

Stage II pressure ulcer Explanation: A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. Assess the drainage in the dressing. Slowly remove the soiled dressing. Wash hands thoroughly. Put on latex gloves.

Wash hands thoroughly. Put on latex gloves. Slowly remove the soiled dressing. Assess the drainage in the dressing. Explanation: The correct order for a dressing change involves the nurse washing her hands, putting on gloves, removing the dressing, and observing the drainage.

When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing? a) adequate circulatory status b) fluid intake of 1,500 mL/day c) balanced nutritional diet d) scheduled periods of rest

adequate circulatory status Explanation: Adequate circulatory status is the most important factor in the healing process of an infected decubitus ulcer. Blood flow to the area must be present to bring nutrients and prescribed antibiotics to the tissues

A nurse is preparing to replace a client's abdominal dressing which is covering a large incision with a Penrose drain. Which of the following steps is appropriate for the nurse to take? 1) Removing the entire dressing at once. 2) Loosening the dressing by pulling the tape away from the wound. 3) Donning clean gloves to remove the dressing. 4) Opening sterile supplies before removing the dressing.

3) Donning clean gloves to remove the dressing.

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? a. Cotton-tipped applicator b. Disposable measuring tape c. Sterile gloves d. Halogen light

D

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include a. A diet low in calories and fat. b. Alteration in level of consciousness. c. Shortness of breath. d. Muscular pain.

B. Alteration in level of consciousness.

A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower lip and chin. The nurse believes theses lesions most likely are: A. Chickenpox B. Impetigo C. Shingles D. Herpes simplex type 1

B. Impetigo Rationale: Impetigo is seen at all ages, but is particularly common in children. The crust is honey-colored and easily removed and is associated with pruritis. The disease is highly contagious and spreads by contact.

The nurse is reading the progress notes for a client who has a pressure ulcer. Based on the nurse's note in the chart, what stage pressure ulcer does this client have? a) Unstageable. b) Stage I. c) Suspected deep-tissue injury. d) Stage II.

Stage II. Explanation: A stage II pressure ulcer has visible skin breaks and possible discoloration. Penetrating to the subcutaneous fat layer, the sore is painful and visibly swollen. The ulcer may be characterized as an abrasion, blister, or shallow crater.

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? a) cheeseburger and french fries b) cheese omelet and bacon c) gelatin salad and tea d) chicken and orange slices

chicken and orange slices Explanation: Protein and vitamin C are particularly important in promoting wound healing and recovery from infection. A diet high in carbohydrates is also essential. Because the client with an infection commonly does not feel like eating, it is important that what the client eats should be nutritious. Chicken and orange slices would help meet the client's protein and vitamin needs.

When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer? a) the client's gender b) exposure to moisture c) presence of hypertension d) smoking

exposure to moisture Explanation: Exposure to moisture can lead to maceration and the development of pressure ulcers. It is important for the client's skin to be kept clean and dry with prompt attention to cleanliness after incidents of incontinence

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: a) basal cell carcinoma. b) squamous cell carcinoma. c) actinic keratoses. d) melanoma.

melanoma. Explanation: The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma.

A nurse is collecting data from a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? 1) Irregular borders 2) Purulent Drainage 3) Uniform pigmentation 4) Intense pruritus

1) Irregular borders

The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). a. 4 b. 2 c. 1 d. 7

A

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of a. Primary intention. b. Partial-thickness wound repair. c. Full-thickness wound repair. d. Tertiary intention.

C

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E.

C

A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth? A. Angioma B. Keloid C. Melanoma D. Nevus

B. Keloid Rationale: Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in whites.

The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient's Braden scale total score? a. 15 b. 17 c. 20 d. 23

C

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? a) Beau's line b) Splinter hemorrhage c) Clubbing d) Paronychia

Beau's line Explanation: Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth.

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? a. Eschar b. Slough c. Granulation d. Purulent drainage

C

The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? a. Use a low-air-loss therapy unit. b. Consult a dietitian. c. Irrigate with hydrogen peroxide. d. Utilize hydrogel dressing.

C

The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient? a. The patient's family will demonstrate specific care of the wound site. b. The patient will state what to look for with regard to an infection. c. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. d. The patient's family members will wash their hands when visiting the patient.

C

The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? a. Teach the family how to manage the odor associated with the wound. b. Discuss with the family how to prepare for care of the patient in the home. c. Encourage thorough handwashing of all individuals caring for the patient. d. Encourage increased quantities of carbohydrates and fats.

C

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain

C

Which may indicate a malignant melanoma in a nevus on a patient's arm? A. Even coloring of the mole B. Decrease in size of the mole C. Irregular border of the mole D. Symmetry of the mole

C. Irregular border of the mole Rationale: Any change in color, size, or texture and any bleeding or pruritus of a nevus deserves investigation. A malignant melanoma is a cancerous neoplasm in which pigment cells or melanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue.

A nurse can assess cyanosis in a dark-skinned patient by noting the color of the: A. Conjunctiva B. Sclera C. Lips and mucous membranes D. Soles of the feet

C. Lips and mucous membranes Rationale: Assessment of color is more easily made in areas where the epidermis is thin, such as the lips and mucous membranes.

Cultural and ethnic considerations for skin assessment include which of the following? A. Baseline skin color should be assessed in areas with the most pigmentation B. Pallor in black-skinned individuals will appear as a pale pink color C. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation D. The darker the patient's skin, the easier it is to assess for color change

C. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation Rationale: To assess rashes and skin inflammation in dark-skinned individuals, the nurse should be assessed in areas with the least pigmentation. Examples are the palms of the hands, soles of the feet, undersides of the forearms, abdomen, and buttocks. Pallor in black-skinned individuals will appear as ashen or gray. The darker the patient's skin, the more difficult it is to assess for color change. A baseline needs to be established in natural lighting, if possible, or with at least a 60-watt light bulb.

What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for her acne? A. Avoid alcoholic beverages B. Drink at least 1000mL of fluid daily C. Use dependable birth control to avoid pregnancy D. Avoid exposure to the sun

C. Use dependable birth control to avoid pregnancy Rationale: Accutane has a destructive effect on fetal development. Dependable birth control is important to avoid a pregnancy.

Which nursing observation would indicate that a wound healed by secondary intention? a. Minimal scar tissue b. Minimal loss of tissue function c. Permanent dark redness at site d. Scarring can be severe.

D

What is important for the nurse to assess when inspecting the skin of a patient? A. Avoid potentially embarrassing questions about rashes or scars B. Wear gloves only if the skin appears broken or inflamed C. Have artificial, preferably fluorescent, lighting for proper illumination of the skin D. Ask the patient about personal skin care

D. Ask the patient about personal skin care Rationale: The patient should be asked about personal skin care. The nurse should ask about recent color changes, sun exposure (with and without sunscreen), and family history of skin cancer. The nurse should ask the patient about resent skin lesions or rashes, where the lesions first appeared, and how long they have been present. It is important for the nurse to remember to wear gloves when inspecting the skin, mucous membranes, and any involved area. When assessing the skin, the nurse should have natural lighting.

A nurse is caring for a client who is postoperative following a mastectomy and returns to the surgical unit with a closed-wound drainage system in place. Which of the following actions by the nurse ensures proper operation of the device? 1) Recollapse the reservoir immediately after emptying it. 2) Empty the reservoir when it becomes full. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least every 8 hr.

1) Recollapse the reservoir immediately after emptying it.

A nurse is reinforcing teaching to a client about the risk factors of skin cancer. Which of the following statements indicates the client understands the teaching? 1) "Because I'm dark-complected, I won't have to worry about skin cancer." 2) "I really need to use sunscreen-even in winter." 3) "I used to lie in the sun al the time but now I just go to the tanning bed." 4) "My father was treated for melanoma, but skin cancer isn't related to genetics."

2) "I really need to use sunscreen-even in winter."

A nurse is assessing a client who has a new skin lesion. Which of the following is the priority intervention? 1) Documenting the clients history of skin allergies. 2) Identifying when the problem began. 3) Photographing the lesion for the client's medical record. 4) Instructing the client on the use of daily sunscreen products.

2) Identifying when the problem began.

A nurse is caring for a client who is one week postoperative following abdominal surgery. While changing the client's abdominal dressing the nurse notes the presence of serosanguineous drainage. The nurse should recognize which of the following? 1) Serosanguineous drainage at this time is expected after abdominal surgery. 2) Serosanguineous drainage at this time is a manifestation of possible dehiscence. 3) Serosanguineous drainage at this time is a manifestation of hemorrhage. 4) Serosanguineous drainage at this time is a manifestation of infection.

2) Serosanguineous drainage at this time is a manifestation of possible dehiscence.

A nurse is caring for a client who has a wound. The nurse should recognize that which of the following findings is indicative of a wound infection? 1) Copious serosanguineous drainage from the wound. 2) Swelling and tenderness around the wound. 3) Maculopapular rash and itching around the wound. 4) Brownish-green crusting over the wound.

2) Swelling and tenderness around the wound.

A nurse is caring for a client following a bee sting. Which of the following findings indicates an allergic reaction to the venom? 1) Edema at the site of the sting. 2) Urticaria and pruritus 3) Nausea and vomiting 4) Generalized edema

2) Urticaria and pruritus

A nurse is caring for a client who has prates following treatment for scabies. Which of the following is an appropriate intervention to relieve the pruritus? 1) Apply additional scabicide to the affected area. 2) Assist the client to take a hot shower 3) Administer an oral antihistamine 4) Contact the provider for treatment of a possible coexisting transmitted disease.

3) Administer an oral antihistamine

A nurse working in a dermatologist's office is planning an educational session regarding skin cancer. When discussing risk factors the nurse should include which of the following? (Select all that apply.) 1) Being dark-skinned. 2) Age under 40 years. 3) Overexposure to ultraviolet light. 4) Chronic skin irritations. 5) Genetic predisposition.

3) Overexposure to ultraviolet light. 4) Chronic skin irritations. 5) Genetic predisposition.

A nurse is caring for an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following is an appropriate intervention? 1) Note dry, flaky skin as a normal finding. 2) Perform examination of the back before the general inspection of the skin. 3) Pinch up a fold of skin to check for turgor. 4) Use penlight to examine the back in greater detail.

3) Pinch up a fold of skin to check for turgor.

The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a. Ineffective tissue perfusion b. Risk for infection c. Imbalanced nutrition: less than body requirements d. Acute pain

A

The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. b. Notify the charge nurse about the change in status and the potential for infection. c. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). d. Notify the wound care nurse about the change in status and the potential for infection.

A

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? a. Stage I pressure ulcer b. Healing stage II pressure ulcer c. Healing stage III pressure ulcer d. Stage III pressure ulcer

C

Which of the following would be the most important piece of assessment data to gather with regard to wound healing? a. Muscular strength assessment b. Sleep assessment c. Pulse oximetry assessment d. Sensation assessment

C

A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What should the nurse do when administering this drug? A. Apply lightly, being carful not to completely cover the lesion B. After application, wrap in warm wet dressings C. Use gloves D. Rub medications into lesions

C. Use gloves Rationale: The topical application requires that the nurse uses gloves, completely covers the lesion gently, then leaves it open to the air.

A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception? a) Hepatitis B is a possible risk factor. b) Human immunodeficiency syndrome (HIV) is a possible risk factor. c) Tattoos are easily removed with laser surgery. d) Allergic response to pigments is a possible risk factor.

Tattoos are easily removed with laser surgery. Explanation: A common misconception regarding tattoos is that tattoos can be removed. Removing a tattoo is not an easy process, and most people are left with a significant scar. Also, the cost is expensive and not covered by insurance. Because of the moderate amount of bleeding with a tattoo, both hepatitis B and HIV are potential risks if proper techniques are not followed. Allergic reactions are possible when establishments do not use Food and Drug Administration-approved pigments for tattoo coloring. Reactions can also occur in clients who are hypersensitive to the pigments or tools used.

Which nursing interventions are effective in preventing pressure ulcers? Select all that apply. a) If the client uses a wheelchair, seat him or her on a rubber or plastic doughnut. b) Avoid raising the head of the bed more than 90 degrees. c) When turning the client, slide and avoid lifting him or her. d) Turn and reposition the client every 1 to 2 hours unless contraindicated. e) Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. f) Use pillows to position the client and increase comfort.

• Use pillows to position the client and increase comfort. • Turn and reposition the client every 1 to 2 hours unless contraindicated. • Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. Explanation: Nursing interventions that are effective in preventing pressure ulcers include cleaning the skin with warm water and a mild cleaning agent, and then applying a moisturizer; lifting, rather than sliding, the client when turning to reduce friction and shear; avoiding raising the head of the bed more than 30 degrees, except for brief periods; repositioning and turning the client every 1 to 2 hours unless contraindicated; and using pillows to position the client and increase comfort. If the client uses a wheelchair, the nurse should offer a pressure-relieving cushion as appropriate. The nurse should not seat the client on a rubber or plastic doughnut, because these devices can increase localized pressure at vulnerable points

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage a. I. b. II. c. III. d. IV.

A

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client? A negative pressure isolation room A semi private room A positive pressure room A private room

A private room

A nurse is teaching a client who has a new prescription for topical betanethasone to treat contact dermatitis. Which of the following instructions should the nurse include. "Cover areas of excoriated skin with cream" "Use hot water to soothe the lesions" "Cover areas with an occlusive dressing after application" "Use the cream for a few days after the are has healed"

"Use the cream for a few days after the are has healed" The client should continue to apply steroid cream to affected area for a few days after the area has healed to reduce the risk for reoccurrence.

A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements should the nurse include in the teaching? 1. "You will need to take the entire prescription even if your condition improves" 2. "Your provider may recommend a daily antihistamine to help control your symptoms" 3. "You should cleanse your mouth daily with a prescribed mouthwash" 4. "Your provider will remove the lesion with solid carbon dioxide"

"Your provider may recommend a daily antihistamine to help control your symptoms" Atopic dermatitis is commonly related to an allergic reaction; therefore, it is appropriate to treat this condition with an antihistamine.

A nurse is providing teaching to a client who has widespread psoriasis and a prescription for phototherapy. The nurse should include which of the following information in the teaching? - "You will have a morning and afternoon session on each treatment day." - "Treatment might be interrupted if areas of redness and tenderness develop." - "Treatments will be given in a series of three days on and three days off." - "You should purchase dark glasses in case the light bothers your eyes."

- "Treatment might be interrupted if areas of redness and tenderness develop." The nurse should instruct the client that treatment must be interrupted if areas of redness with edema and tenderness develop. Treatment can resume after these manifestations subside.

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan? - Maintain occlusive dressings on the lesions throughout the day and remove them at bedtime. - Eliminate the use of products containing salicylic acid. - Avoid friction over scaly lesions while bathing. - Identify effective stress reduction techniques.

- Identify effective stress reduction techniques. Psoriasis is significantly aggravated by stress. The use of effective stress reduction techniques is appropriate to manage this chronic disorder.

A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings? - Unilateral lesions - Serous drainage - Intense pain - Silvery, white scales

- Silvery, white scales The characteristic lesions of psoriasis are thick, erythematous plaques covered by silvery scales.

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan? - Wash the affected area with hot water. - Treatment focuses on pain management. - Use bath oils to soften and soothe the skin. - Apply warm, moist compresses twice daily.

- Use bath oils to soften and soothe the skin. The nurse should instruct the client to use bath oils or emollient cleansing agents to comfort sore and scaling skin areas. Softening the skin and prevent skin and prevent skin fissures.

A nurse is providing teaching to a client who has psoriasis and a new prescription for the topical corticosteroid cream betamethasone valerate. Which of the following information should the nurse include in the teaching? - The medication should be applied in a thick layer to completely cover the lesions. - The medication should be applied every 2 hr. - Rubbing the medication vigorously into the lesions will increase its absorption. - Wrapping plastic around the site can increase the medication's effectiveness.

- Wrapping plastic around the site can increase the medication's effectiveness. The provider might prescribe occlusive dressings to be applied over the site after the topical corticosteroid is applied in order to increase the medication's effectiveness.

The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.) a. Inspecting the skin for abrasions and edema b. Covering exposed wounds c. Assessing condition of current dressings d. Assessing the skin at underlying areas for circulatory impairment e. Marking the sites of all abrasions f. Cleansing the area with hydrogen peroxide

A, B, C, D

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? a. Gentle cleaners and thorough drying of the skin b. Absorbent pads and garments c. Positioning with use of pillows d. Therapeutic beds and mattresses

A

The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel e. Chaplain f. Pharmacist

A, B, C, D

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. "Can you easily change your position?" b. "Do you have sensitivity to heat or cold?" c. "How often do you need to use the toilet?" d. "Is movement painful?" e. "What medications do you take?" f. "Have you ever fallen?"

A, B, C, D

The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) a. Nutrition b. Evisceration c. Tissue perfusion d. Infection e. Hemorrhage f. Age

A, C, D, F

A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? A. Keep the skin dry and free of perspiration. B. Use hot water and antibacterial soap to bathe the client. C. Massage the skin over bony prominences to promote circulation. D. Limit the use of moisturizers on the skin over bony prominences.

A. Keep the skin dry and free of perspiration.

A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take? A. Minimize the time the head of the bed is elevated. B Apply a sterile gauze dressing to the site. C. Massage the site with moisturizing lotion. D. Place a donut-shaped cushion under the client's sacral area.

A. Minimize the time the head of the bed is elevated.

A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? A. Mohs surgery is a horizontal shaving of thin layers of the tumor. B. Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. C. Mohs surgery is the preferred treatment for melanoma skin cancer. D. Mohs surgery is a palliative treatment for metastatic skin cancer.

A. Mohs surgery is a horizontal shaving of thin layers of the tumor.

A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? A. Perform pin site care daily. B. Remove the overbed trapeze. C. Remove the boot every 2 hr. D. Keep the weights on a stable, flat surface.

A. Perform pin site care daily.

A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? A. Position pillows between the bony prominences. B. Check for incontinence every 3 hr. C. Massage reddened areas of the skin. D.Elevate the head of the bed to 45°

A. Position pillows between the bony prominences.

The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care? a. Sterile technique b. Clean dressings and no touch technique c. Double bagging of contaminated dressings d. Ability of the caregiver

B

The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder? a. The binder creates pressure over the abdomen. b. The binder supports the abdomen. c. The binder reduces edema at the surgical site. d. The binder secures the dressing in place.

B

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? a. Tell the patient to close his eyes. b. Explain the procedure. c. Turn on the television. d. Ask the family to leave the room.

B

The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.) a. Mobility b. Hyperemia c. Induration d. Blanching e. Temperature of skin f. Nutritional status

B, C, D, E

The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.) a. Ask whether patient's expectations are being met. b. Prevent injury to the skin and tissues. c. Obtain the patient's perception of interventions. d. Reduce injury to the skin. e. Reduce injury to the underlying tissues. f. Restore skin integrity.

B, D, E, F

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? A. Visitors should call prior to visiting the client. B. Visitors must don a gown and gloves prior to entering the client's room. C. Visitors need to wear a mask when in close proximity to the client. D. Visitors may not bring fresh flowers into the client's room.

B. Visitors must don a gown and gloves prior to entering the client's room.

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and fresh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer. Squamous cell carcinoma Basal cell carcinoma Malignant melanoma Actinic keratosis

Basal cell carcinoma

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a. At least 3 hours b. Not longer than 30 minutes c. Less than 2 hours d. As long as the patient remains comfortable

C

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? a. Obtain assistance and use the drawsheet to place the patient into the new position. b. Place the patient in a 30-degree supine position. c. Utilize a transfer sliding board and assistance to slide the patient into the new position. d. Elevate the head of the bed 45 degrees.

C

The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement? a. Monitor vital signs every 15 minutes. b. Apply brace to right knee. c. Elevate right knee and apply ice. d. Check pulses in right foot.

C

The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for a. Infection. b. Impaired skin integrity. c. Trauma. d. Imbalanced nutrition.

C

The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? a. Allowing the solution to flow from the most contaminated to the least contaminated b. Scrubbing vigorously when applying solutions to the skin c. Cleansing in a direction from the least contaminated area d. Utilizing clean gauge and clean gloves to cleanse a site

C

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? A.Scaly patches B. Silvery white plaques C. Irregular borders D. Raised edges

C. Irregular borders

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? a. 12 b. 13 c. 20 d. 23

D

A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching? A. "I will sit on the side of the tub and soak my right leg two times every day" B. "Ill keep a heating pad on the calf of my right leg when I am lying down" C. "Il place my leg under a heat map every 3 hours" D. "Ill wrap a warm, wet towel round my right calf every 4 hours"

D. "Ill wrap a warm, wet towel round my right calf every 4 hours"

A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? A. Keep the door of the client's room closed at all times. B. Remove gloves after leaving the client's room. C. Wear a mask when working within 1 m (3 feet) of the client. D. Have a designated stethoscope in the client's room.

D. Have a designated stethoscope in the client's room

A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? A. Administer an analgesic following wound care. B. Irrigate the wound with povidone iodine. C. Cleanse the wound with a cotton-tipped applicator. D. Report purulent drainage to the provider.

D. Report purulent drainage to the provider.

The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature 1. Use the fingertips because they're more sensitive to small changes in temperature. 2. Use the dorsal surface of the hand because the skin is thinner than on the palms. 3. Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. 4. Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.

Dorsal surface of the hand because the skin is thinner than on the palms

A nurse is developing a plan of care for client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan? Enforce strict bedrest for 3 days Apply fresh ice packs every 4 hours Elevate the affected leg on two pillows Apply antibiotic ointment to the wound with dressing change

Elevate the affected leg on two pillows

At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress notes above and begins planning client care based on which nursing diagnosis? a) Readiness for enhanced knowledge of skin care precautions related to benign mole. b) Fear related to potential diagnosis of malignant melanoma. c) Deficient knowledge related to potential diagnosis of basal cell carcinoma. d) Risk for impaired skin integrity related to potential squamous cell carcinoma.

Fear related to potential diagnosis of malignant melanoma. Explanation: Documentation reveals that the client is anxious about the symptoms. These symptoms most closely resemble malignant melanoma. Therefore, fear related to potential diagnosis of malignant melanoma is the most appropriate nursing diagnosis.

A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? HbA1c 6% Prealbumin 12 mg/dL WBC 8,000/mm3 Creatinine 0.8 mg/dL

Prealbumin 12 mg/dL

A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take? Apply additional scabicide to the affected area Assist the client to take a hot shower Provide mittens for the client to wear at night Encourage the client to gently rub the affected area

Provide mittens for the client to wear at night

A nurse is teaching a client who has psoriasis about possible treatment options. Which of the following treatments should the nurse include in the teaching? - Tar preparations - Corticosteroids - Ultraviolet light therapy - Laser therapy - Topical antibiotics

Tar Preparations Corticosteriods UV Light Therapy Tar preparations help reduce the inflammation associated with psoriasis. Corticosteroids help reduce the inflammation associated with psoriasis. UV light therapy is effective in the treatment of psoriasis.

While conducting an admission assessment, the nurse notes a draining ulceration on the patient's lower leg. Which intervention is appropriate? 1.Wash hands and contact the physician. 2.Continue to examine the ulceration and then wash hands. 3.Wash hands, put on gloves, and continue with the examination of the ulceration. 4.Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.

Wash hands, put on gloves, continue with the examination of the ulceration and then proceed with the remainder of the exam.

A nurse is caring for an adult client who has atopic dermatitis. Which of the following findings should the nurse expect? 1. Acute rash following plant allergen exposure 2. Chronic rash with the skin 3. Curving white ridges between the fingers 4. Visible nits on the scalp area

chronic rash with thick skin Atopic dermatitis is a chronic rash. A classic sign in the adult client is lichenification (thick, "leathery" skin).

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer. Which of the following is most important for the nurse to determine? A. The client's ability to communicate B. The client's current weight-bearing status C. The client's height D. The type of equipment used in previous transfers

the clients current weight bearing status

A nurse is caring for a patient with a Jackson Pratt drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? To prevent fluid from accumulating in the wound To limit the amount of bleeding from the surgical site To provide a means for medication administration To eliminate the need for wound irrigations

to prevent fluid from accumulating in the wound

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? A. One nurse lifting as the clients pushes with his feet. B. Two nurses lifting the client under the shoulders. C. One nurse lifting the client's legs as the client uses a trapeze bar. D. Two nursing using a friction reduction device.

two nurses using friction reducing devices

The school nurse recognizes the signs of scabies when a child presents with: A. Small fluid filled blisters that sting when scratched B. Dry scaly patches in body creases that itch C. Wavy threadlike lines on the body and pruritus D. Cluster of papular lesions with pruritus

C. Wavy threadlike lines on the body and pruritus Rationale: Scabies is manifested by brown threadlike lines on the body, especially the hands, anus, and body folds. Pruritus is severe.

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a a. Respiratory therapist. b. Registered dietitian. c. Chaplain. d. Case manager.

B

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage a. I. b. II. c. III. d. IV.

B

The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? a. Standard mattress b. Nonpowered redistribution air mattress c. Low-air-loss therapy unit d. Lateral rotation

B

The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? a. "I think I will be ready to go home early next week." b. "I am so weak and tired, I want to feel better." c. "I am ready for my bath and linen change as soon as possible." d. "I am hoping there will be something good for dinner tonight."

C

A nurse is caring for a school-age child is receiving treatment for a systemic disorder with antibiotics, immunosuppressants, and corticosteroids. Both of the child's parents have a smoking history. The client reports soreness of his mouth and refuses to eat. Inspection his mouth reveals a white, milky plaque that does not come off with rubbing. The nurse suspects which of the following conditions? 1) Candidiasis from antibiotic therapy. 2) Dermatitis from immunosuppressive therapy. 3) Herpes simplex from corticosteroid therapy. 4) Squamous cell carcinoma from exposure to second hand smoke.

1) Candidiasis from antibiotic therapy.

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding? 1) Reports of exposure to a skin irritant 2) Denial of pruritus 3) Systemic symptoms including elevated temperature. 4) Reports of generalized joint discormfort.

1) Reports of exposure to a skin irritant

A patient, age 46, reports to his physician's office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, "It itches like crazy." Which type of lesion would the nurse include in her documentation? A. Macules B. Plaques C. Wheals D. Vesicles

C. Wheals Rationale: Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and pale red border.

A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that: a) some melanomas have a familial component and she should seek medical advice. b) she should not worry, because she did not experience severe sunburn as a child. c) her personal risk is low because most melanomas occur at age 60 or later. d) her personal risk is low because melanoma does not have a familial component.

some melanomas have a familial component and she Explanation: Malignant melanoma may have a familial basis, especially in families with dysplastic nevi syndrome. First-degree relatives should be monitored closely. Malignant melanoma occurs most often in the 20- to 45-year-old age-group

The client phones the outpatient surgery center following skin biopsy on the left shoulder. The client states that the site continues to drain pinkish drainage and is uncomfortable. Which triage questions are appropriate to evaluate the client's concern? Select all that apply. a) "What is your pain level on a 0-10 pain scale?" b) "Did you have any other skin biopsies that day?" c) "How are you cleaning the area?" d) "On which day did you have the biopsy completed?" e) "When is your follow-up appointment?" f) "Can you describe the drainage that you see."

• "What is your pain level on a 0-10 pain scale?" • "Can you describe the drainage that you see." • "On which day did you have the biopsy completed?" • "How are you cleaning the area?" Explanation: When triaging a client's concern following a surgical biopsy, it is most important for the nurse to obtain information about the site and post-operative care. Knowing the date of the surgery allows for the nurse to determine the amount and type of drainage which is normal for that stage of healing. Understanding the characteristics of the drainage helps the nurse assess if the drainage is from a healing process or from a potential infection. Assessing the pain level provides information of the inflammatory and infectious process. The nurse compares the client's pain rating with the rating scale typically noted for this procedure. Lastly, the nurse assesses how the wound is being cleaned. The nurse wants to assess understanding regarding the cleaning process.