NURS 355 Exam 4 Review

The patient with Meniere's disease complains of vertigo. What else do you expect?

Significant inability to function

Which methods are appropriate for management of the skin lesions and discomfort due to impetigo?

Warm saline soaks and topical antibiotics

Which action should the nurse teach about psoralen to a patient diagnosed with cutaneous T-cell lymphoma?

Wear protective eyewear

A patient asks the nurse how chemotherapy works to treat cancer. Which nursing response is appropriate?

"Chemotherapy damages the cellular DNA causing the cancer cells to die"

A patient with a bacterial skin infection. What is the best statement?

"Good hygiene practices can help prevent skin infections"

Which is correct about squamous cell carcinoma?

"I should be prepared to undergo surgery to treat this cancer"

The patient asks if the cancer staging has improved after receiving chemotherapy. Which nursing response is appropriate?

"It does not change even though your condition may be improving"

What is sensorineural hearing loss?

"It is an impairment of one of your cranial nerves"

Patient in ED for Meniere's disease after and acute episode and asks the nurse how long the attack will last?

"These attacks can last for hours to days"

For a 70 kg patient with a 50% TBSA burn, which fluid calculation is correct?

14,000 mL in 24 hours

A patient is diagnosed with actinic keratosis. Which provider order should the nurse question?

A skin excision to determine tumor depth

Which medication blocks chemical mediators in type I hypersensitivity reactions?

Antihistamine

Interventions during the emergent phase of a burn?

Assess and manage the patient's pain, prepare for central line IV placement, and monitor BP continuously

Which nursing action demonstrates secondary prevention of cancer?

Assisting a patient undergoing mammography

The nurse understands that a reddish brown mole in common in which type of skin cancer?

Atypical nevi

When administering a large volume of IV fluids, the nurse must carefully assess

BP, HR, respiratory status, and urine output

Which cancer treatment strategy uses the body's own immune system to fight cancer?

Biological response modifiers

You are caring for a patient with a first-degree thermal burn injury. Which symptom do you expect to see on assessment?

Blanching with pressure

A patient with psoriasis is hospitalized for complications of lupus. Which medication would you question?

Ceftriaxone

Which type of burn is associated with hydrochloric acid?

Chemical

Which medication reduces inflammation in type I hypersensitivity reactions?

Corticosteroids

A nurse is caring for a patient with thermal burns. Why is the patient at risk for burn shock?

Decreased blood volume and increased systemic vascular resistance

Which finding indicated diphenhydramine is effective in treating type I hypersensitivity reactions?

Diminished itching

Patient with basal cell carcinoma is receiving radiation therapy and has a sore mouth. Which are appropriate actions?

Encourage consumption of cool or cold foods, provide the patient with hard candies, and teach the patient to avoid eating meat and spicy foods

Appropriate teaching for primary open-angle glaucome?

Follow treatment plan to prevent damage to optic nerve

Which type of burn is characterized by dry, waxy, leathery or hard skin and has no pain?

Full-thickness skin destruction - 3rd and 4th degree

Common side effect of tacrolimus and cyclosporine - 2 meds given to transplant patients?

Gingival hyperplasia

Which histologic grade is associated with severe dysplasia?

Grade 3

Which intervention should the care team implement during the acute phase of the burn injury?

Graft-donor site care, nutritional therapy, physical and occupational therapy

The nurse knows that which bacteria are responsible for primary and secondary skin infections?

Group A B-hemolytic streptococci and staphylococcus aureus

Which practice is the single most important means of preventing secondary skin infections?

Handwashing

Which complication is the nurse most likely to see during the rehabilitative phase?

Hypertrophic scarring

Phototherapy for a patient with atopic dermatitis has been effective when the nurse notes which assessment finding?

Itching has resolved

What is a side effect of topical immunomodulatory therapy?

Itching, burning, or feeling of warmth

How to prevent age-related macular degeneration (AMD)?

Keep BP under control and quit smoking

The nurse understands that which clinical manifestations are consistent with a diagnosis of shingles?

Linear rash with red pustules and burning and itching on the trunk or lumbar area

Why is the Lund-Browder chart considered more accurate that the rule of nines?

Lund-Browder chart considers age in calculation of TBSA

Which factors determine the severity of a burn?

Medical hx, depth of burn, location of burn, extent of burn calculated as percentage of total body surface area

Should patients with angle-close glaucoma receive medications that cause pupillary dilation>

No

Which intervention will the nurse select to prevent mucositis?

Oral cyrotherapy?

Which type of burn is characterized by red, shiny, or wet fluid-filled vesicles, severe pain, mild to moderate edema?

Partial-thickness skin destruction - deep - 2nd degree

Which type of burn is characterized by erythema, blanching, pain, and mild swelling?

Partial-thickness skin destruction - superficial (1st) and deep (2nd)

Which patient would the nurse expect to be a highest risk for developing graft-versus-host disease (GVHD)?

Patient who has a recent bone marrow transplant

First action for a new mole on upper thigh?

Prepare the patient for biopsy?

Why does a patient with a severe facial burn have swelling to the face?

Swelling is an expected inflammatory response of the body to a burn injury

The nurse is teaching a patient who is newly diagnosed with glaucoma. What information is appropriate?

The importance of compliance with taking medications

Most hospitalized patients with burns in the US have which type of burn injury?

Thermal

On assessment of the client with actinic keratosis, which clinical manifestations would the nurse expect to find?

Thickened papules on the skin

Rationale for lymphocyte immune globulin IV for renal transplant patient?

To prevent hyperacute rejection

Match the symptoms to the correct hypersensitivity disorder: Wheezing, dysrhythmias, cyanosis

Type I: Anaphylaxis

Math the symptoms to the correct hypersensitivity disorder: Fever, hypotension, chills

Type II: Acute hemolytic reaction

Match the symptoms to the correct hypersensitivity disorder: HTN, proteinuria, edema

Type III: Post-streptococcal glomerularnephritis

Match the symptoms to the correct hypersensitivity disorder: Vesiculated blisters, itching, buring

Type IV: Contact dermatits

Which teaching will the nurse include for a patient with low platelets from chemotherapy?

Use a soft-bristle toothbrush

Which nursing action is appropriate to improve nutrition for a patient with cancer?

Use alternative seasonings for food

What are the foundations of proper healing?

Will have pain and can treat with ibuprofen if no allergy, topical antibiotics to prevent infection, and sutures out in 10-14 days