Nur2120 CH 51-56
The school nurse is approached by a teenage student. The student says that she learned in science class that the outer layer of the skin is dead cells. The student wants to know which of her cells is going to die so they can be covered with skin. What would be the nurse's best response? (CH51) A) "All cells die and the body replaces most of them. The cells thought to form the barrier of the outer layer of the skin are called keratin cells." B) "All cells die and the body replaces most of them. The cells thought to form the barrier of the outer layer of the skin are called melanocytes." C) "All cells die and the body replaces most of them. The cells thought to form the barrier of the outer layer of the skin are called Merkel cells." D) "All cells die and the body replaces most of them. The cells thought to form the barrier of the outer layer of the skin are called Langerhans' cells."
A) "All cells die and the body replaces most of them. The cells thought to form the barrier of the outer layer of the skin are called keratin cells." Dead cells of the epidermis contain keratin, an insoluble, fibrous protein that forms the outer barrier of the skin. Melanocytes are primarily involved in producing the pigment melanin. Merkel cells are the receptors that transmit stimuli to the axon through a chemical synapse. Langerhans' cells are believed to play a significant role in cutaneous immune system reactions.
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? (CH54) A) "The client is in shock because the blood volume has decreased in the system." B) "The client is in shock because the heart is unable to circulate the body fluids." C) "The client is in shock because your loved one is not responding and brain dead." D) "The client is in shock because all peripheral blood vessels have massively dilated."
A) "The client is in shock because the blood volume has decreased in the system." Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.
A middle-aged female patient has sought care because she has itchy, reddened areas on the backs of both of her hands and most of her fingers. On closer inspection, the nurse notes several cracks in the skin on these regions and observes that the patient's skin is exceptionally dry. What question should the nurse prioritize during this patient's assessment? (Ch51) A) "When did you first begin having this problem?" B) "How would you describe your overall level of hygiene?" C) "Do any of your coworkers have skin problems?" D) "Do you use sunscreen consistently during the summer?"
A) "When did you first begin having this problem?" It is likely relevant to ask this patient questions regarding possible occupational risks, sun exposure or hygiene. However, it is a priority to address the onset and duration of an integumentary problem
The nurse is caring for a client in the intensive care unit who requires mechanical ventilation. To set the ventilator to assist control mode, the tidal volume must first be calculated. The client weighs 154 lb (70 kg). What is this client's tidal volume? (Ch55) A) 350 to 490 mL of air B) 200 to 300 mL of air C) 500 to 700 mL of air D) 1000 mL of air
A) 350 to 490 mL of air The tidal volume (Tv) is the amount of air given in each breath. This is usually between 5 and 7 mL of air per kilogram of body weight. The clent weighs 70 kg. Tv = 70 kg x 5 to 7 mL = 350 to 490 mLs. The correct range of air volume that can be delivered with each breath is 350 to 490 mL of air (tidal volume).
The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. (CH54) A) 60 mm Hg B) 70 mm Hg C) 80 mm Hg D) 90 mm Hg
A) 60 mm Hg Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients.
The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages? (CH54) A) A rapid, bounding pulse B) A slow but steady pulse C) A weak and thready pulse D) A slow and imperceptible pulse
A) A rapid, bounding pulse A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? (CH53) A) A urine output consistently above 40 ml/hour B) A weight gain of 4 lb (2 kg) in 24 hours C) Body temperature readings all within normal limits D) An electrocardiogram (ECG) showing no arrhythmia
A) A urine output consistently above 40 ml/hour In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.
The nurse is caring for a client affected by a nerve agent. The nurse quickly gives a tutorial on the neurotransmitters and nervous system affected. Which couplet is most correct? (CH56) A) Acetylcholine, parasympathetic nervous system B) Serotonin, sympathetic nervous system C) Norepinephrine, sympathetic nervous system D) Dopamine, parasympathetic nervous system
A) Acetylcholine, parasympathetic nervous system Nerve agents cause fatal consequences by inhibiting acetyl cholinesterase. Acetyl cholinesterase is an enzyme that inactivates acetylcholine, a neurotransmitter of the parasympathetic nervous system. No other option is correct.
The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing? (CH53) A) Adduction B) Dorsiflexion C) External rotation D) Plantar flexion
A) Adduction When occlusive dressings are applied, precautions are taken to prevent two body surfaces from touching, such as fingers or toes, ear and scalp, the areas under the breasts, any point of flexion, or between the genital folds.
In a client with burns on the legs, which nursing intervention helps prevent contractures? (CH53) A) Applying knee splints B) Elevating the foot of the bed C) Hyperextending the client's palms D) Performing shoulder range-of-motion exercises
A) Applying knee splints Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.
Which of the following is a clinical characteristic of neurogenic shock? (CH54) A) Bradycardia B) Tachycardia C) Cool skin D) Moist skin
A) Bradycardia The clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.
A public health nurse is presenting an educational event to the local disaster response team on radiation injury. The nurse describes a client whose burns and trauma are evident. What type of radiation injury is this? (CH56) A) External B) Direct C) Internal D) Indirect
A) External External radiologic contamination occurs from exposure to fallout on the skin, hair, and clothing. Direct and indirect are distracors for this question. This does not describe a client with internal radiologic contamination.
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of their body. What would be the nurse's priority concern in the immediate care of this patient? (CH53) A) Fluid status B) Risk of infection C) Body image D) Anxiety
A) Fluid status During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection, body image, and anxiety are significant areas of concern but are less urgent in the short term than fluid status.
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? (CH53) A) inflammatory B) neuroendocrine C) intravascular fluid excess D) hypertension
A) Inflammatory The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.
A client experiencing vomiting and diarrhea for 2 days has a blood pressure of 88/56, a pulse rate of 122 beats/minute, and a respiratory rate of 28 breaths/minute. The nurse places the client in which position? (CH54) A) Modified Trendelenburg B) Trendelenburg C) Semi-Fowler's D) Supine
A) Modified Trendelenburg The client is experiencing hypovolemic shock as a result of prolonged vomiting and diarrhea. The modified Trendelenburg position is recommended for hypovolemic shock because it promotes the return of venous blood. The other positions may make breathing difficult and may not increase blood pressure or cardiac output.
A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? (CH53) A) Risk for Impaired Gas Exchange B) Acute Pain C) Risk for Infection D) Alteration in Tissue Perfusion
A) Risk for impaired gas exchange During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.
A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find? (ch55) A) Spontaneous coughing B) High-pitched noises on inhalation C) Severe respiratory distress D) Cyanosis
A) Spontaneous coughing If a patient can breathe and cough spontaneously, a partial airway obstruction should be suspected. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were a complete airway obstruction.
What is the major clinical use of dobutamine? (CH54) A) increase cardiac output. B) prevent sinus bradycardia. C) treat hypotension. D) treat hypertension.
A) increase cardiac output. Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.
A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits (CH54) A) A change in apical pulse rate from 102 to 88 beats/min B) Adventitious breath sounds C) Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute D) Troponin levels less than 0.35 ng/mL
B) Adventitious breath sounds The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.
A patient who has been admitted to the intensive care unit (ICU) with extensive burns is conscious but unable to speak due to upper airway trauma. When communicating with this patient, the ICU nurse should adopt which of the following strategies? (CH55) A) Provide brief explanations and directions to the patient. B) Ask the patient questions that can be answered with a nod or a shake of the head. C) Defer to a friend or family member of the patient when information is needed. D) Speak to the patient slowly and with increased volume.
B) Ask the patient questions that can be answered with a nod or a shake of the head. Communication strategies for patients who cannot speak include asking yes or no questions to which patients may nod their head. There is no indication that the patient has a deficit in cognition of understanding, so speaking more slowly or loudly than normal is unnecessary. It would be inappropriate to defer to the patient's friend or family member if the patient is conscious.
A patient's skin is examined and the nurse notes the presence of herpes simplex/zoster skin lesions. The nurse describes the lesions as: (CH51) A) Palpable, solid tumors >3 cm. B) Circumscribed and elevated masses >0.5 cm. C) Pus-filled vesicles. D) Flat macules with irregular borders.
B) Circumscribed and elevated masses >0.5 cm.
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: (CH53) A) Epidermal layer only. B) Epidermis and a portion of deeper dermis. C) Entire dermis and subcutaneous tissue. D) Dermis and connective tissue.
B) Epidermis and a portion of deeper dermis. A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn.
Which drug is an oral retinoid used to treat acne? (CH52) A) Estrogen B) Isotretinoin C) Tetracycline D) Benzoyl peroxide
B) Isotretinoin Isotretinoin, an oral retinoid, is used in clients diagnosed with nodular cystic acne that does not respond to conventional therapy. Estrogen, tetracycline, and benzoyl peroxide are not oral retinoids.
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do? (Ch51) A) Apply a special dye to the area. B) Make sure that the room is darkened. C) Protect the patient from the light. D) Obtain samples of the lesion by scraping.
B) Make sure that the room is darkened When performing a Wood's light examination, the nurse would need to ensure that the room is darkened to allow visualization of the fluorescent light so that he or she can differentiate epidermal from dermal lesions. Dye is used for immunofluorescence. There is no need to protect the patient from the light. Skin scrapings involve obtaining samples of the lesion.
Acticoat has been ordered as a component of a burn patient's wound care and infection control regimen. When applying this wound care product, the nurse should: (CH53) A) Allow the Acticoat to dry thoroughly before covering it with a dry dressing. B) Moisten the Acticoat with sterile water and then apply it to the wound bed. C) Use a pad of Acticoat to perform mechanical debridement. D) Change the dressing every 18 to 24 hours.
B) Moisten the Acticoat with sterile water and then apply it to the wound bed. Acticoat is moistened with sterile water and applied directly to the wound. It is then covered with an absorbent secondary dressing and kept moist. This product is not used for debridement and it can be left in place for 3 to 5 days.
Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? (CH53) A) Mechanical B) Natural C) Enzymatic D) Surgical
B) Natural Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.
The nurse is assessing an African American client and notes a streak of pigmentation in the client's fingernails. The nurse determines that this finding indicates (CH51) A) chronic anemia. B) normal variation. C) melanoma. D) smoker's fingernails.
B) Normal variation Variation in skin pigment in clients with dark skin, such as pigmented streaks in the nails, pigmented spots on the sclera of the eye, and a pigmented crease across the bridge of the nose, are considered normal color variations.
The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as (CH51) A) spider angioma. B) petechiae. C) ecchymosis. D) telangiectasia.
B) Petechiae Petechiae are associated with bleeding tendencies or emboli to the skin. Spider angioma is associated with liver disease, pregnancy, and vitamin B deficiency. Ecchymosis is associated with trauma and bleeding tendencies. Telangiectasia is associated with venous pressure states.
Treatment of melanoma includes which of the following? (CH52) A) Cryosurgery B) Radical excision C) Radiation therapy D) Laser surgery
B) Radical excision The treatment of a melanoma involves radical excision of the tumor and adjacent tissues, followed by chemotherapy. Laser surgery and cryosurgery is not used in the treatment of melanoma. Radiation is used in some types of cancer.
A client is brought to the emergency department with suspected genitourinary injury. The nurse prepares the client for insertion of an indwelling urinary catheter for bladder decompression and urine output monitoring. The nurse reviews the client's medical record to ensure that which of the following has been completed? (CH55) A) Computed tomography scan B) Rectal examination C) Diagnostic peritoneal lavage D) Bladder ultrasound
B) Rectal examination In a client with a suspected genitourinary injury, an indwelling urinary catheter is inserted for bladder decompression and urine output monitoring only after a rectal examination has been completed. Computed tomography or bladder ultrasound are not necessary. A diagnostic peritoneal lavage is a backup procedure for evaluating intraperitoneal injury.
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: (CH53) A) Measure hourly urinary output. B) Replace lost fluids and electrolytes. C) Prevent renal shutdown. D) Monitor cardiac status.
B) Replace lost fluids and electrolytes. After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula.
The nurse inspects the appearance of a sacral ulcer and documents "a shallow open ulcer with a red-pink wound with partial thickness loss of dermis." The nurse knows to classify this ulcer as: (CH52) A) Stage I. B) Stage II. C) Stage III. D) Stage IV.
B) Stage II. A stage I ulcer appears as intact skin with nonblanchable erythema of a localized area, usually over a bony prominence. A stage II ulcer appears as partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. A stage III ulcer includes full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. A stage IV ulcer includes a full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? (CH53) A) The client is in hypovolemic shock. B) The client has experienced extensive full-thickness burns. C) The paramedic administered high doses of opioids during transport. D) The client has experienced partial-thickness burns.
B) The client has experienced extensive full-thickness burns. In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.
You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first? (CH56) A) The one who ingested the toxin B) The one who inhaled the toxin C) The one with the skin infection D) Any convenient order
B) The one who inhaled the toxin The nurse should first treat the client who is at greatest risk. The most serious form of anthrax develops upon inhalation. If diagnosed incorrectly and untreated, the infection progresses to severe respiratory distress, and in severe situations, death may also occur. Ingesting the bacteria is less lethal, with symptoms of nausea, vomiting, diarrhea, and abdominal pain. Skin infection is the least deadly form characterized by painless lesions usually on the head, hands, and arms. Therefore, the client who inhaled the toxin should always get first priority.
A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response? (CH52) A) Removes the entire growth B) Through the application of extreme cold, the tissue is destroyed. C) Freezes the growth, so the physician can remove it at the next appointment D) Lasers the growth off
B) Through the application of extreme cold, the tissue is destroyed. Cryosurgery is the application of extreme cold to destroy tissue. The other statements are false.
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? (CH53) A) Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B) Urine output of 20 ml/hour C) White pulmonary secretions D) Rectal temperature of 100.6° F (38° C)
B) Urine output of 20 ml/hour A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.
The diagnosis of a skin disorder is made chiefly by which of the following? (Ch51) A) Palpation B) Visual inspection C) Biopsy D) Culture
B) Visual inspection The diagnosis of a skin disorder is made chiefly by visual inspection. Some disorders may involve additional inspection with other diagnostic procedures.
Which term refers to the tendency for a chemical to become a vapor? (CH56) A) Persistence B) Volatility C) Toxicity D) Latency
B) Volatility The most common volatile agents are phosgene and cyanide. Persistence means that the chemical is less likely to vaporize and disperse. Toxicity is the potential of an agent to cause injury to the body. Latency is the time from absorption to the appearance of symptoms.
The classic lesions of impetigo manifest as (CH52) A) comedones in the facial area. B) honey-yellow crusted lesions on an erythematous base. C) abscessed skin and subcutaneous tissue. D) patches of grouped vesicles on red and swollen skin.
B) honey-yellow crusted lesions on an erythematous base. The classic lesions of impetigo are honey-yellow crusted lesions on an erythematous base. Comedones in the facial area are representative of acne. A carbuncle is an abscess of skin and subcutaneous tissue. Herpes zoster is exhibited by patches of grouped vesicles on red and swollen skin.
A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should: (CH53) A) apply maximum bandages to allow for absorption of drainage. B) wrap elastic bandages distally to proximally on dependent areas. C) wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. D) remove bandages with clean gloves.
B) wrap elastic bandages distally to proximally on dependent areas. Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. The nurse shouldn't use maximum bandages because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.
Expectant (Priority 4) (CH56)
BLACK Dead or minimal chance of survival (massive head injury, 95% coverage w/ 3rd degree burns)
A nurse is performing glucose checks for a client in the progressive stage of shock. What glucose range would the nurse expect to see for the best outcome with the client? (CH54) A) <60 mg/dL B) <80 mg/dL C) <180 mg/dL D) <200 mg/dL
C) <180 mg/dL Tight glycemic control (serum glucose of 80 to 100 mg/dL) is no longer recommended, as hypoglycemic events associated with regulating tight control in critically ill clients have been found to result in adverse patient outcomes. Current evidence suggests that maintaining serum glucose levels lower than 180 mg/dL with insulin therapy and close monitoring is indicated in the management of the critically ill client.
A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: (CH54) A) Valvular damage. B) Cardiomyopathies. C) A myocardial infarction. D) Arrhythmias.
C) A myocardial infarction Cardiogenic shock is seen most frequently as a result of a myocardial infarction.
The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving medications as ordered. What type of medications is the nurse most likely giving to this client? (CH54) A) Hormone antagonist drugs B) Antimetabolite drugs C) Adrenergic drugs D) Anticholinergic drugs
C) Adrenergic drugs Adrenergic drugs are the main medications used to treat shock.
Students are reviewing the cycle of hair growth in people, identifying that rate of hair growth varies on different parts of the body. The students demonstrate understanding of this information when they identify which area as having the most rapid rate? (CH51) A) Thighs B) Eyebrows C) Beard D) Axillae
C) Beard The rate of hair growth varies. Beard growth is the most rapid, followed by hair on the scalp, axillae, thighs, and then eyebrows.
A client is brought to the emergency department with severe hemorrhage requiring masssive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following? (CH56) A) Hyperthermia B) Hemolytic transfusion reaction C) Cardiac arrest D) Fluid overload
C) Cardiac arrest Blood must be warmed in a commercial blood warmer because administration of large amounts of blood that has been refigerated has a core cooling effect that may lead to cardiac arrest and coagulopathy. Hyperthermia, hemolytic transfusion reaction, or fluid overload is not the concern.
A critical care nurse knows to assess the cardiac system for the probable cause of heart disease subsequent to trauma. Which of the following is a major concern? (CH55) A) Heart block B) Pericarditis C) Cardiac tamponade D) Mitral regurgitation
C) Cardiac tamponade Cardiac tamponade is a condition in which fluid accumulates in the pericardium. This can occur as the result of penetrating or blunt chest trauma.
The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? (CH53) A) Elevate the leg on pillows and reassess the leg in 1 hour. B) Document the findings and instruct the client to report numbness of the extremity. C) Contact the primary care provider and prepare for an escharotomy. D) Apply an elastic stocking to the extremity and administer SQ heparin per order.
C) Contact the primary care provider and prepare for an escharotomy. The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.
The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrite, sodium nitrite, and sodium thiosulphate. What chemical agent does the nurse know this client has been exposed to? (CH56) A) Sarin B) Mustard gas C) Cyanide D) Anthrax
C) Cyanide They administer one or all of the following antidotes: amyl nitrite, sodium nitrite, and sodium thiosulfate. Amyl nitrite promotes the formation of methemoglobin, which combines with cyanide to form nontoxic cyanmethemoglobin. Therefore, options A, B, and D are incorrect.
A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke? (CH55) A) Temperature of 101 degrees F (38 degrees C) B) Diaphoresis C) Delirium D) Bradycardia
C) Delirium Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.
Which statement indicates a characteristic of a basal cell carcinoma (BCC)? (CH52) A) It is more invasive than squamous cell carcinoma (SCC). B) It metastasizes through blood or the lymphatic system. C) It begins as a small, waxy nodule with rolled translucent, pearly borders. D) It is a malignant proliferation arising from the epidermis.
C) It begins as a small, waxy nodule with rolled translucent, pearly borders BCC usually begins as a small, waxy nodule with rolled, translucent, pearly borders. It is less invasive than SCC. It does not metastasize through the blood or lymphatic system. SCC is a malignant proliferation arising from the epidermis.
A male patient who presented to the emergency department with severe headache and visual disturbances has been found to be experiencing a hypertensive emergency and has been admitted to the critical care unit. The critical care unit should anticipate the administration of which of the following medications? (CH55) A) Epinephrine B) Dopamine C) Nitroprusside D) Dobutamine
C) Nitroprusside Decreased blood pressure is the major indication for the administration of nitroprusside. Dopamine, dobutamine, and epinephrine would exacerbate this patient's hypertension.
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? (CH52) A) Superficial spreading B) Lentigo-maligna C) Nodular melanoma D) Acral-lentiginous
C) Nodular melanoma A nodular melanoma is a spherical, blueberry-like nodule with a relatively smooth surface and a relatively uniform, blue-black color. A nodular melanoma invades directly into adjacent dermis (ie, vertical growth) and therefore has a poorer prognosis
A new patient has come to the dermatology clinic to be assessed for a reddened rash on his abdomen. What diagnostics would be completed to identify the causative allergen? (CH51) A) Skin scrapings B) Skin biopsy C) Patch testing D) Tzanck smear
C) Patch testing Patch testing is performed to identify substances to which the patient has developed an allergy. Skin scrapings are done for suspected fungal lesions. A skin biopsy is completed to rule out malignancy and to establish an exact diagnosis of skin lesions. A Tzanck smear is used to examine cells from blistering skin conditions, such as herpes zoster.
The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion? (CH51) A) Macule B) Papule C) Vesicle D) Wheal
C) Vesicle A vesicle is a circumscribed, elevated, palpable mass containing serous fluid less than 0.5 cm. Examples include herpes simplex/zoster, varicella, poison ivy, and 2nd-degree burn (blister).
Which of the following is true of positive-pressure ventilators? (CH55) A) a vacuum pulls air into the lungs B) alveoli constrict to conserve air in the bronchi C) expiration occurs passively D) a preset pressure forces expiration
C) expiration occurs passively Positive-pressure ventilators inflate the lungs by exerting positive pressure on the airway, pushing air in and forcing alveoli to expand during inspiration. Expiration occurs passively.
Which statement reflects the nursing management of pulmonary anthrax (Bacillus anthracis)? (CH56) A) Airborne person-to-person transmission occurs with anthrax. B) Diagnosis is done by pulmonary function testing and chest x-ray. C) Treatment with ciprofloxacin or doxycycline is suggested after exposure. D) Pulmonary effects include respiratory failure, shock, and death within 5 to 7 days after exposure.
C)Treatment with ciprofloxacin or doxycycline is suggested after exposure. Treatment with ciprofloxacin or doxycycline is recommended because these easily given oral antibiotic agents are stockpiled and there should be sufficient doses to fully treat many clients who have been exposed to anthrax. Anthracis is a spore-forming bacteria resulting in gastrointestinal, pulmonary, and skin symptoms. Symptoms are dependent upon contact, ingestion, or inhalation of the spores. Routine universal precautions are effective. Anthrax survives in the spore form for long periods, making the body a potential source of infection for morticians. Blood cultures are required to confirm the bacteria's presence and diagnosis. The pulmonary effects can include respiratory failure, shock, and death within 24 to 36 hours after exposure.
The amount of blood pumped to the body each minute is known as cardiac output. Using a stroke volume of 70 mL, which one of the following heart rates would yield a cardiac output outside the normal range? (CH55) A) 80 bpm B) 90 bpm C) 100 bpm D) 110 bpm
D) 110 bpm Cardiac output = HR × SV. The normal value is 4 to 7 L/min. Therefore, 110 × 70 mL = 7,700 mL = 7.7 L/min. This is outside the normal range. The other results are within the normal range.
The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued? (CH56) A) 9% B) 7% C) 6% D) 4%
D) 4% Oxygen is administered until the carboxyhemoglobin level is less than 5%.
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? (CH52) A) 6 to 12 hours B) 12 to 24 hours C) 24 to 36 hours D) 48 to 72 hours
D) 48 to 72 hours The natural wound-healing process should not be disrupted. Unless the wound is infected or has a heavy discharge, it is common to leave chronic wounds covered for 48 to 72 hours and acute wounds for 24 hours.
The nurse has administered a subcutaneous injection of low-molecular-weight heparin to a patient who is recovering from surgery. This injection will be primarily deposited into: (Ch51) A) The epidermis B) The dermis C) Muscle D) Adipose tissue
D) Adipose tissue The subcutaneous tissue, or hypodermis, is the innermost layer of the skin. It is primarily adipose tissue, which provides a cushion between the skin layers, muscles, and bones.
The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? (CH54) A) Administer recombinant human activated protein C (rhAPC) as prescribed. B) Begin a continuous IV infusion of insulin per protocol. C) Initiate enteral feedings as prescribed. D) Administer norepinephrine as prescribed.
D) Administer norepinephrine as prescribed. Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.
While performing perineal care for a female patient who has been recently admitted to the hospital, the nurse notes that the patient's pattern of pubic hair growth is more characteristic of a male's pattern of hair growth. The nurse should know that this could possibly be attributed to: (Ch51) A) A fungal infection of the pubic hair follicles B) Chronic urinary incontinence C) A genitourinary disorder D) An endocrine disorder
D) An endocrine disorder If the pubic hair pattern is more characteristic of the opposite gender, it may indicate an endocrine problem and further investigation is in order. This abnormal assessment finding is not suggestive of a fungal infection, incontinence, or a genitourinary disorder.
A client is being treated for cyanide exposure. The nurse would least likely expect which agent to be used as part of the client's treatment? (CH56) A) Amyl nitrate B) Sodium nitrite C) Sodium thiosulfate D) Atropine
D) Atropine Cyanide exposure is treated with amyl nitrate, sodium nitrite, and sodium thiosulfate. Atropine is used for nerve agent exposure.
The nurse is conducting a community education program on malignant melanoma. The nurse knows that the participants understand the teaching when they identify which characteristic as a risk factor? (CH52) A) History of suntans B) Dark skin C) Mediterranean descent D) Family history of pancreatic cancer
D) Family history of pancreatic cancer A family history of pancreatic cancer is a risk factor for malignant melanoma. Additional risk factors include fair skin, freckles, blue eyes, blond hair, Celtic or Scandinavian descent, history of sunburns, previous melanoma, family history of melanoma, and a family or personal history of multiple atypical nevi.
A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters. The patient is suspected of having herpes zoster. What should the nurse know about the distribution of lesions of herpes zoster? (CH52) A) Grouped vesicles occurring on lips and oral mucous membranes B) Grouped vesicles occurring on the genitalia C) Rough, fresh, or gray skin protrusions D) Grouped vesicles in linear patches along a dermatome
D) Grouped vesicles in linear patches along a dermatome Herpes zoster, or shingles, is an acute inflammation of the dorsal root ganglia, causing localized, vesicular skin lesions following a dermatome. Herpes simplex type 1 is a viral infection affecting the skin and mucous membranes, usually producing cold sores or fever blisters. Herpes simplex type 2 primarily affects the genital area, causing painful clusters of small ulcerations. Warts appear as rough, fresh, or gray skin protrusions.
The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? (CH54) A) The difference between an apical and radial pulse B) The difference between an upper extremity and lower extremity blood pressure C) The difference between the systolic and diastolic pressure D) The difference between the arterial and venous blood pressure
D) The difference between the arterial and venous blood pressure The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? (CH53) A) It helps determine the percentage of the total body surface area (TBSA) that is burned. B) The client's condition is likely to deteriorate after 72 hours. C) The wound is susceptible to infections. D) The early appearance of the burn injury may change.
D) The early appearance of the burn injury may change. The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.
Which is defined as the potential of an agent to cause injury to the body? (CH56) A) Volatility B) Latency C) Persistence D) Toxicity
D) Toxicity The median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed. Persistence means that the chemical is less likely to vaporize and disperse. Volatility is the tendency for a chemical to become a vapor. Latency is the time from absorption to the appearance of symptoms.
Nonprogressive stage of shock (Preshock) (Ch54)
Fight or flight Tachycardia and slight change in BP as well as anxiety are signs of preshock
Minimal (Priority 3) (CH56)
GREEN Ambulatory pts (isolated abrasions, contusions, sprains)
Progressive stage of shock (shock) (CH54)
Loss of ability to compensate.
Immediate (Priority 1) (CH56)
RED, Sucking chest wound, airway obstruction, shock, etc.
Delayed (Priority 2) (CH56)
YELLOW, stable abd. wound, soft tissue injuries, etc.
furuncle (CH52)
boil; suppurative inflammatory skin lesion due to infected hair follicle
Vitiligo (CH51)
localized loss of skin pigmentation characterized by milk-white patches
Kaposi sarcoma (KS) (CH52)
type of skin cancer often seen in patients with AIDS; consists of brownish-purple papules that begin in skin and spread to internal organs
cryosurgery (CH52)
use of cold temperatures to destroy tissue
