PREPU exam 7
An 80-year-old client is brought to the clinic by one of the client's children. The client asks the nurse why the client has gotten so many "spots" on the skin. What would be an appropriate response by the nurse?
"As people age, they normally develop uneven pigmentation in their skin."
A nurse is providing a safety program on childhood poisoning for a group of parents of preschool and school-age children. The nurse determines that the education was successful when the makes which statement?
"Berries and seeds that children find out in the woods are not safe for them to eat."
The nurse is caring for a client with dementia who lives alone at home and has begun wandering. The spouse states, "What can I do? I am afraid the client is going to get lost." What is the appropriate nursing response?
"Consider the Alzheimer Association's Safe Return program."
The nurse is performing an initial assessment of a client who has a raised, pruritic rash. The client denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this client at this time?
"Do you take any over-the-counter (OTC) drugs or herbal preparations?"
A nurse is conducting a health interview and is assessing for integumentary conditions that are known to have a genetic component. What assessment question is most appropriate?
"Does anyone in your family have eczema?"
A client asks why they have a buildup of cerumen despite washing their ears every day. Which statement will the nurse make in response?
"Earwax is made by glands in your ears."
The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?
"I will rescue clients from harm before doing anything else."
A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information?
"I will restrict my diet to fats and carbohydrates."
A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?
"I will squeeze the chamber and apply the cap to maintain negative pressure." the drain must be checked and emptied at least every 4 hours.
The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?
"Is your child breathing at this time?"
The nurse is providing perioperative teaching to a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?
"It provides a way to remove drainage and blood from the surgical wound."
The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What are the appropriate nursing responses? Select all that apply.
"Medical maggots are sterilized before they are introduced to the wound." "I understand your concern; let's talk further about your thoughts about this treatment." "The choice regarding whether to have or decline this treatment is yours."
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?
"That is necrotic tissue, which must be removed to promote healing."
The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?
19-year-old male college student majoring in physics Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use.
A client has a fissure on her finger due to chafing. The client asks, "How long will it be painful?" The nurse explains that the inflammation phase will last:
3 days
Approximately how many pounds of dry skin does the typical person shed in their lifetime?
40 lb
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?
A Penrose drain promotes passive drainage into a dressing.
The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?
A hair dryer is placed next to the sink.
The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take?
Apply saline solution-moistened gauze over the protruding area.
A nurse is caring for a client who is in restraints because they have suicidal tendencies. How should the nurse intervene to decrease the injury risk?
Assess for circulation, movement and sensation.
Which intervention to prevent client falls in the acute care setting requires collaboration with a client's primary care provider?
Avoid the use of medications that increase the likelihood of falls.
Ch 64(integumentary) 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?
Beau's line
What are the two major processes involved in the inflammatory phase of wound healing?
Blood clotting is initiated and WBCs move into the wound.
he nurse is caring for a client with a latex allergy. When the dietary tray arrives, the nurse notes that it contains a hamburger with lettuce and tomato, baked potato, apple, chocolate chip cookie, and a small serving of milk. What is the appropriate nursing action?
Call Nutrition Services for a plain hamburger. The molecular structure of latex is similar to avocados, bananas, almonds, peaches, kiwi, and tomatoes.
The nurse assesses a dark-skinned patient who has cherry-red nail beds, lips, and oral mucosa. What does this assessment data indicate the patient may be experiencing?
Carbon monoxide poisoning
The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply.
Check circulation and skin condition every 2 hours. Offer regular, frequent opportunities for toileting. Obtain order from a licensed provider within minutes of restraint application.
A nurse assesses a client with dark skin and notes new purple-gray cast to the skin on the chest, back, and arms. Which priority nursing intervention should the nurse implement?
Check the client's oral temperature.
After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?
Dermis
An older adult client in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply.
Did you experience dizziness prior to the fall?" "Can you tell what you were doing before you fell?" "Did you have pain in your hip prior to the fall?" "Is it possible you may have tripped over a rug or a cord?"
A nurse is performing a skin assessment on a client with diabetes and notes furuncles and carbuncles to both lower legs. The client states their skin typically has "issues" but eventually heals if left alone. Which of the targeted teaching topics would most benefit this client?
Discuss treatment concerning bacterial infections, blood glucose levels, and basic skin maintenance techniques.
A nurse finds that a fire has broken out in a client's room at the health care facility. Place the steps the nurse should take in the correct sequence, from first to last. Use all options.
Evacuate the client. Raise an alarm. Confine the fire. Extinguish the fire.
A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy. Which interventions should the nurse follow to apply the T-binder? (Select all that apply.)
Fasten the crossbar around the waist. Pass the tails through the client's legs. Pin the tails to the belt of the T-binder.
A client has presented to the emergency department after splashing a caustic chemical in the eyes. When managing the injury, what should be included in the plan of care?
Flush the eyes with water for 10 minutes.
A nurse finds a client in his room asphyxiated with carbon monoxide (CO) inhalation. Which activity should be the priority for the nurse?
Get the victim out of the present environment.
A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client's subsequent care?
Helping the client identify and avoid the offending agent
The nurse is assessing the integumentary system of a client with Cushing syndrome. The nurse anticipates which finding?
Hirsutism or excessive hair growth
Production of melanin is controlled by a hormone secreted by which gland?
Hypothalamus
A 35-year-old kidney transplant client comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposi sarcoma (KS). The nurse caring for this client recognizes that this is what type of KS?
Immunosuppression-related
A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?
Implement a 2-hour repositioning schedule
The nurse is caring for a client whose outer layer of the epidermis has been disrupted. Which of the following is an environmental factor that could have penetrated this outer layer? Select all that apply.
Insect bite Ringworm chemical spill
The nurse is performing a comprehensive assessment of a client's skin surfaces for moisture, temperature, and texture. Which is the best technique to perform this assessment? Select all that apply.
Inspect the skin in a well-lit area Palpate the skin
Which drug is an oral retinoid used to treat acne?
Isotretinoin
An older adult asks about a red papule that is on the right arm that loses color when pressure is applied. In which way will the nurse interpret this finding?
It is a cherry angioma that is a normal age-related skin alteration.
Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?
Local capillary pressure must be lower than external pressure.
The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?
Necrotic tissue is devitalized tissue that must be removed to promote healing." Dry brown or black tissue is necrotic.
An individual calls the telehealth nurse and reports that a family member was just found on the floor of an enclosed garage while a car was still running. The family member is unconscious and cherry red in color. What direction will the telehealth nurse provide?
Open garage doors and windows, and call 911.
A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?
Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs
A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document?
Presence of abnormalities that would impede healing
A postoperative client is recovering from a bowel resection. While the nurse is assisting the client with a transfer, the client states "I feel like something just popped." After returning the client safely to bed, which is the nurse's best action?
Promptly assess for dehiscence.
A nurse is caring for a terminally ill client who refuses to have food due to an inability to swallow solid food. Which of the following nursing interventions should the nurse adopt to promote nutrition in the client?
Pulverize food items.
The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?
Refrain from using extension cords.
Which measure would be most effective at protecting a toddler from accidental poisoning due to the ingestion of medication?
Request childproof caps on all prescription medications.
The parents of an adolescent who is being maintained on life support after a motorcycle crash tell the nurse, "We would like to donate his organs if he dies." What is the nurse's role in organ donation?
Review options and provide consent forms to the family.
A client with a suspected malignant melanoma is referred to the dermatology clinic. The nurse knows to facilitate what diagnostic test to rule out a skin malignancy?
Skin biopsy
An older adult client is diagnosed with a vitamin D deficiency. What would be an appropriate recommendation by the nurse?
Spend time outdoors at least twice per week.
The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?
Supervise your child on the changing table.
Place the steps of using the device shown in the correct sequence for preparing an ice pack
Test the ice bag for leaks. Fill it one-half to two-thirds full of crushed ice or small cubes so it can be molded easily to the injured area. Eliminate as much air from the bag as possible. Pour water over the ice to provide slight melting. Leave the ice bag in place no more than 20-30 minutes. Allow the skin and tissue to recover for at least 30 minutes before reapplying.
Students are reviewing information about the glands of the skin. The students demonstrate understanding of the material when they state which of the following?
The apocrine glands become active at puberty.
The nurse has just admitted a client preoperatively to a surgical unit. The client will undergo a surgical procedure the following day. After reviewing the chart, the nurse will prioritize communication to the care team regarding what client data?
The client has had an anaphylactic response to latex products.
A dying client stated to the nurse that they want to make health care decisions should certain circumstances develop. The nurse initiates a consult with the social worker. What does the nurse state in the consult to notify the social worker about the client's request?
The client wants information about advance directives to guide their choices.
Which are signs of a "good death"? Select all that apply.
The person dies with dignity. The person is prepared for death. The person has a sense of completion of life.
After a fungal culture sample is obtained for a client, the client asks the nurse, "What happens after the specimen is collected?" The nurse begins to review the process with the client from start to finish. Place the steps below in the order the nurse should review them.
The primary provider places the scraped cells into a sterile container and sends it to the laboratory. An analyst spreads the cells on the surface of a nutritive medium such as agar. The specimen incubates at room temperature for 2 to 3 weeks. An analyst examines it microscopically to identify the type of fungus causing the infection.
A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?
The status of the client's tetanus immunization
A 14-year-old adolescent is in the clinic for a well-child exam. The parent states, "My adolescent sleeps so much. I am worried about how lazy my adolescent is." What does the nurse know to be true about sleep in adolescents?
Trying to balance too many activities can result in sleep deprivation.
The nurse is preparing to assess a client's integumentary status. Which charactertistics of the skin will the nurse assess by using the technique of palpation? Select all that apply.
Turgor Edema elasticity
A client presents at the dermatology clinic with suspected herpes simplex. The nurse knows to prepare what diagnostic test for this condition?
Tzanck smear
Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply.
Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible.
The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home?
Use night-lights in bedrooms and bathrooms.
The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom?
Yellowish waxy deposits on the eyelids
A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?
a client 68 years of age who is bedfast related to severe head trauma
When performing a skin assessment, the nurse notes a localized skin infection of a single hair follicle. The nurse documents the presence of
a furuncle.
The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?
administration of an antipsychotic agent to alter the client's behavior
The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound?
alginate dressing
A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle collision. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate will be ordered by the health care provider?
alginate, Alginates are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue.
The client has a minor laceration to the finger, sustained when a client was cutting fruit with a knife in the kitchen. Which nursing concern will the nurse identify for this client's care plan?
altered skin integrity due to open wound
The nurse is participating in the investigation of a series of Centers for Medicare & Medicaid Services (CMS) "never events" that have taken place over the past several months. Which clinical event will the nurse most likely investigate?
an increase in the incidence and prevalence of pressure injuries experienced by clients
The nurse has delegated applying an elastic bandage with clips to the right knee of a 12-year-old client to the unlicensed assistive personnel (UAP). Which action will the nurse determine the UAP needs additional training?
applies wrap from proximal to distal direction
The nurse in the postanesthesia care unit (PACU) is assessing a new client who has just undergone abdominal exploratory laparotomy. Which response should the nurse prioritize after noting the SaO2 is 95% (0.95), blood pressure is 128/80 mm Hg, cardiac monitor is showing rare premature atrial contractions (PAC), and drainage on abdominal dressing is approximately 5 cm × 3 cm of pinkish drainage along the lower edge of the dressing?
apply additional dressing, especially over the lower edge where drainage is occurring
A nurse practitioner working in a dermatology clinic finds an open lesion on a client who is being assessed. What should the nurse do next?
assess the characteristic of the lesion
The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?
assess the need to urinate
A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?
assisting the client in moving to prevent strain on the suture line
The nurse has delegated several parts of basic care for a client who is a fall risk to an unlicensed assistive personnel (UAP) member. Which UAP action requires nursing intervention?
assisting the client to put on slippers prior to ambulation
What is Kübler-Ross's third stage of grief?
bargaining
The nurse is caring for a client that was brought to the emergency department after a building fire. Which assessment finding alerts the nurse to possible smoke inhalation? Select all that apply.
black debris in nasal passages impaired judgment mild cough
According to the Harvard University Medical School committee, what function must be irreversibly lost to define death?
brain function
A patient diagnosed with Addison's disease would be expected to have which of the following skin pigmentations?
bronze
An unresponsive client has been brought to the emergency room by EMS. While assessing this client, the nurse notes that the client's nail beds, lips, and oral mucosa are a cherry-red color. What should the nurse suspect?
carbon monoxide poisoning
The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out a bonfire, what will the nurse identify?
class A
A nurse is providing an in-service program for staff on fire safety and is reviewing the types of fire extinguishers available. Which class of fire extinguisher would the nurse describe as appropriate for use on an electrical fire?
class C
For which client should the nurse include local application of heat in the nursing care plan?
client whose peripheral IV has infiltrated
The nurse is applying a cold towel to a patient's neck to reduce body heat. How does the nurse understand that the heat is reduced?
conduction
The nurse is caring for several clients on medical unit. When planning client care, the nurse anticipates which client will be the most likely candidate for the use of a waist restraint?
confused client who persistently tries to get out of bed following hip surgery
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?
contusion
Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and:
covering the wound area with sterile towels moistened with sterile 0.9% saline.
When planning care for a 55-year-old client with newly diagnosed terminal pancreatic cancer, which nursing concern is most appropriate for the care plan?
death anxiety
A client who has been admitted for weakness and taking fluids poorly is unable to move well in the bed and requires assistance. What are this client's risk factors for developing pressure sores? Select all that apply.
dehydration immobility inactivity
A client reports irritation on the left arm. The physician decides to use a Wood's light to help with the diagnosis. Which statement is not true about a Wood's light?
detects bacterial infections
A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections?
diabetes
A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation?
ecchymosis? or purpura?
The nurse is reviewing data collected during the assessment of a client. Which finding about the client's skin condition is genetically based?
eczema
The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which topic for staff education is most likely to benefit the greatest number of residents?
educating nurses how to prevent falls
The school nurse is providing education on poisoning risks to adolescent students. Which topic does the nurse include in the teaching?
experimentation with drugs & inhalants
The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?
figure-of-eight turn
A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection?
foul-smelling drainage that is grayish in color
The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?
gauze
A nurse is teaching a client about body keratin composition. What body structures would the nurse include in the teaching? Select all that apply.
hair, skin & fingernails
Which nursing intervention best addresses the leading cause of death in the United States?
heart health education
What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?
hydrocolloid
A health care provider orders a dressing to cover a newly developed partial-thickness wound with minimal drainage. What would be the best type of dressing for this wound?
hydrocolloid dressing
A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?
hypoxia
A 66-year-old client is dying of cancer on the palliative unit of the local hospital. The client's husband has asked the nurse why his wife has been requiring higher doses of analgesics in recent days and is concerned that her pain may have been inadequately treated in the past. The nurse should understand that the client's increased analgesic needs are likely the result of:
increasing drug tolerance
What nursing concern is the priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications?
infection risk
Which characteristics would be expected in a "within normal limit" skin assessment? Select all that apply.
intact, warm & dry
During a routine assessment of a client, the nurse notes that the client's nails are concave. Which condition is indicated by this finding?
iron deficiency anemia
A patient has a serum bilirubin concentration of 3 mg/100 mL. What does the nurse observe when performing a skin assessment on this patient?
jaundice
A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching?
keeping medications in clearly labeled containers
The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as?
keloid
A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:
laceration
A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?
lichenification
While reviewing an older adult's medical record, the nurse notes that the patient has solar lentigo. he nurse interprets this as which of the following?
liver spots
Which factor causes wrinkles among older adults?
loss of subcutaneous tissue
Assessment of a patient reveals a flat and nonpalpable skin lesion that is 0.5 cm with a circumscribed border. The nurse documents this lesion as which of the following?
macule
The nurse is preparing to perform a Wood's light examination. Which of the following would be most important for the nurse to do?
make sure the room is darkened
(ch 28 wounds) A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has prescribed fly larvae to debride the wound. Which type of debridement does the nurse understand has been prescribed?
mechanical debridement
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
notify the health care provider and prepare for surgery
Which level of health care provider may make the decision to apply physical restraints to a client?
nurse practitioner
A patient is visiting the physician to determine what type of allergy is causing a rash. What type of testing does the nurse anticipate the physician will schedule?
patch test
The nurse is caring for a 7-year-old who has suddenly developed difficulty hearing in the left ear. Which nursing action is appropriate?
performing a thorough inspection of the ear.
The nurse notes that a client has round red macules over the lower extremities. The nurse documents this finding as
petechiae., associated with bleeding tendencies or emboli to the skin.
The nurse is assessing a patient with a primary skin lesion called a macule. What does the nurse understand is a clinical example of this lesion?
port wine stains
The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force?
preventing the client from sliding in bed
The nurse educator on a hospital's acute medical unit has created a document encouraging nurses to use cold applications when appropriate to clients' plans of care. What benefits of cold application should the educator cite?
prevention of swelling
A 15 year-old pubescent boy is having a sports physical for school. Findings on the face and body indicate that the client is overproducing sebum, which is consistent with the client's age. What is the primary function of sebum?
prevents drying and cracking of the skin and hair
Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?
proliferation
A new client presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the client's fingernail surfaces are pitted. The nurse should suspect the presence of what health problem?
psoriasis, Pitted surface of the nails is a definite indication of psoriasis.
A client with the history of systemic lupus erythematosus underwent a surgical repair of a right inguinal hernia. The client now presents to the emergency department with the report that the incision appears to have opened. Which action should the nurse prioritize after performing the focused assessment?
question the use of prednisone
Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?
raising all side rails while the client is in bed
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and has adhered to the wound bed. Which revision to the nursing care plan is most appropriate?
reducing the interval between dressing changes
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
removing dead or infected tissue to promote wound healing
A nurse has attended a fire safety training program for the facility. The nurse demonstrates understanding of how to prioritize actions during a fire by doing the actions listed below. Place the actions in the sequence that the nurse should perform them. Use all options.
removing the client from immediate danger pulling the alarm and calling "code red" closing all the doors and windows evacuating the clients if directed
Which describes the proliferative phase of the wound healing process?
reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization
Which structure or process does not keep the body warm?
respiration
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?
secondary intention
The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?
stage 2
While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound?
stage 2
A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?
stage 3
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?
stage 4
A nurse is providing end-of-life care for a client. Which symptom indicates brain failure? Select all that apply.
stupor, hyporeflexia, disorientation
Which nursing concern is appropriate for designing educational interventions for a single parent who leaves their toddler unattended in the bathtub?
suffocation risk
A group of nursing students is reviewing the types of wound healing. The students demonstrate understanding of this information when they identify which as healing by primary intention?
surgical incision
A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?
tertiary intention
The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?
transparent film
(ch 19 safety) The goal of evidence-based practice related to restraints is to avoid the use of restraints.
true
Assessment of a client's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
ulcer
A nurse is working as an industrial nurse. Which activity would the nurse suggest that the employers adopt to prevent carbon monoxide (CO) inhalation by the workers?
using carbon monoxide detectors and alarms
The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?
vesicle
A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?
vesicles
An adult with a darker skin tone is admitted to the medical unit with a diagnosis of cirrhosis of the liver. To correctly assess this client for jaundice, which body area will the nurse initially look for a yellow discoloration? Select all that apply.
whites of the eyes & oral cavity
The nurse is assessing clients for risk factors in the workplace. Which client(s) is at risk for injury due to the environment of the workplace? Select all that apply.
worker who operates equipment in an automobile assembly plant gardener who mows and places fertilizer on lawns unlicensed assistive personnel who lifts clients in a long-term care facility
A client with squamous cell carcinoma is scheduled for treatment. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?
Surgical excision
Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?
administer sedation & analgesia
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:
melanoma
The nurse is caring for a client who is making a decision about whether to consent to treatment that carries a high level of risk. The client tells the nurse "I do not know what decision to make." What is the nurse's best response?
"I am here to support you; however, the decision is yours to make."
A patient is diagnosed with seborrheic dermatitis on the face and is prescribed a corticosteroid preparation for use. What should the nurse educate the patient about regarding use of the steroid on the face?
Avoid using the medication around the eyelids because it may cause cataracts and glaucoma.
Hospice nurses provide care in a variety of settings, including clients' homes, long-term-care facilities, and hospice residences. After the client dies, what happens next?
The hospice nurse continues to care for the client's family for up to 1 year
Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?
coping strategies
The nurse is conducting an admission history and physical examination of a client with a history of contact dermatitis. The nurse assesses whether the client uses which medication classification?
corticosteroids
For which persons are death certificates necessary? Select all that apply.
death from an infectious disease death in an institutional setting unexpected death murder victims death before age 65 years U.S. law requires death certificates for all clients who die.
A client is being discharged from the hospital with terminal brain cancer and a life expectancy of 1 month. When planning this client's discharge, it is most important for the nurse to include a referral to which agency?
hospice
The nurse is caring for a client whose spouse died 6 days ago. What assessment finding suggests that the client is in the first stage of Engel's model of grief?
The client has difficulty believing the spouse is actually deceased.
A client who is terminally ill states to the nurse, "My situation is hopeless; I have no control over anything." The nurse implements which interventions to enable hope for the client? Select all that apply.
Encourage the client to discuss feelings. Sit in a chair next to the client. Hold the client's hand.
The nurse should assess all possible causes of pruritus for a patient complaining of generalized pruritus. What does the nurse understand can be another cause for this condition?
End-stage kidney disease
The nurse is conducting a community education program on basal cell carcinoma (BCC). Which statement should the nurse make?
It begins as a small, waxy nodule with rolled translucent, pearly borders.
The nurse is taking care of a client who was hospitalized for an ulcerative colitis exacerbation. Recently, the client's parent died from colon cancer. Which question would be essential to ask this client at the start of the assessment of their loss reaction?
What type of relationship did you have with your parent?
A nurse is providing end-of-life care to a client who spends most of the time praying and talking about a "spiritual connection." The nurse interprets this as indicating which stage of grief?
acceptance
The nurse is caring for a client terminally ill due to cancer whose family members have expressed profound sorrow over the forthcoming loss. Which nursing concern will the nurse apply to the family?
anticipatory grief due to upcoming loss of family member, evidenced by sorrow
A nurse practitioner is seeing a 16-year-old client who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?
benzoyl peroxide & erythromycin
The nurse is providing instruction to a client with acne. The nurse promotes avoidance of which food(s)? Select all that apply.
chocolate & ice cream
Which primary lesions are associated with acne caused by sebum blockage in hair follicles?
comedomes
A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. Which sign would the nurse include in this education plan?
difficulty swallowing
A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the most potential to achieve this goal?
educating patients about early s/s of skin cancer
A day care worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears:
erythematous with raised papules.
A client's blistering disorder has resulted in the formation of multiple lesions in the client's mouth. What intervention should be included in the client's plan of care?
Provide chlorhexidine solution for rinsing the client's mouth.
The nurse is preparing a care plan for a client with dysfunctional grief. Which nursing intervention(s) should the nurse include? Select all that apply.
Provide the client with information regarding a grief support group. Encourage the client to have regular check-ups with the health care provider. Refer the client to a grief specialist.
A nurse is caring for a client admitted to the medical unit with a diagnosis of pemphigus. When writing the care plan for this client, what issues should be included? Select all that apply.
Risk for infection Impaired skin integrity Disturbed body image Acute pain
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?
Scabies
A client has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?
Anticipate the need for, and administer, appropriate analgesic medications.
An older adult client experiences the death of a spouse. Which behavior by the client exemplifies Parkes' grief stage of reorganization?
Appears sad and reaches out to adult children for support.
A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?
"Can you tell me about why you've made this decision?"
Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?
Administer sedation and analgesia.
The admission department at a local hospital is registering an older adult man for an outpatient test. The admissions nurse asks the man if he has an advance directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this client?
Advanced directives are limited only to healthcare instructions and directives.
A nurse educator is teaching a group of medical nurses about Kaposi sarcoma (KS). What would the educator identify as characteristics of endemic KS? Select all that apply.
Affects people predominantly in the eastern half of Africa Affects men more than women Can progress to lymphadenopathic forms
A client has been declared brain dead following a fall from a roof. The client's advance directives state they do not wish to have prolonged life measures, and that only the heart, kidneys, and liver should be donated. The client's spouse wants to also donate the client's corneas. What is the appropriate nursing action?
Contact the organ procurement team to discuss organ donation with the spouse.
The condition of a client with a traumatic brain injury continues to deteriorate despite medical efforts. The decision is made to terminally wean the client from mechanical ventilation. Which statement by the nurse is most significant in educating the family regarding terminal weaning?
"All efforts will be taken to make sure your loved one is comfortable and out of pain."
While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:
"All family members need to be treated." When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
A nurse is caring for a client whose spouse died more than 4 years ago. What assessment question will the nurse ask to determine if the client is experiencing abnormal grief?
"Have you gone through and donated your spouse's clothing?"
A nurse is talking to a client who was just informed of a terminal illness and is responding in an angry manner. What statement by the nurse would best facilitate better client outcomes?
"How much do you know, and what do you want to know?"
The nurse is talking with the family after their loved one died. What words of support and comfort would be most therapeutic for the nurse to say after this event?
"I would like to sit here with you and listen."
A patient has a moisture-retentive dressing for the treatment of a sacral decubitus ulcer. How long should the nurse leave the dressing in place before replacing it?
12 to 24 hours
What percent of those undergoing piercings suffer complications?
31%
Which assessment finding would best support a nursing concern of disordered grieving?
A client is unable to return to work after their sibling's death 18 months ago.
Which situation is most likely to warrant an autopsy?
A client's death involves an allegation of a medical error.
A nurse is planning the care of a client with herpes zoster. Which medication(s), if administered within the first 24 hours of the initial eruption, can arrest herpes zoster? Select all that apply.
Acyclovir & valacyclovir
A client has responded to a recent diagnosis of lung cancer by making extensive plans for overseas travel with family, despite the extremely poor prognosis. The client is adamant about not discussing cancer and is identified by the nurse as experiencing the denial stage of grief. How can the nurse best facilitate the client's healthy grieving?
Address the client's diagnosis and prognosis at a later time or date.
A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?
"In hospice care, nurses take on the responsibility of making care decisions for clients."
The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate?
"It must be very difficult for you."
Which phrase can do much to instill hope in the dying client?
"Let me tell you about your illness"
Ch 38 (end of life) During an interview of the client at the community clinic, the nurse finds that the client is providing care for a parent, who is terminally ill. Which statement by the client indicates anticipatory grieving?
"My parent is suffering with cancer and death will be a relief of the pain."
A client with a terminal diagnosis states, "I am so glad I had a good life. I am ready to die." How will the nurse assist the client to communicate this acceptance of death to the family?
Ask the client how the nurse can best support the discussion with family
A nurse providing care for a client diagnosed with psoriasis is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment?
Assessment of the client's joints for pain and decreased range of motion
A patient has developed a boil on the face and the nurse observes the patient squeezing the boil. What does the nurse understand is a potential severe complication of this manipulation?
Brain abscess Nurses must take special precautions in caring for boils on the face because the skin area drains directly into the cranial venous sinuses. The infection can travel through the sinus tract and penetrate the brain cavity, causing a brain abscess.
A 65-year-old presents at the clinic reporting nodules on both legs. The client tells the nurse that their son, who is in medical school, encouraged them to seek prompt care because the nodules may be related to their Mediterranean heritage. What health problem should the nurse suspect?
Classic Kaposi sarcoma (KS)
A client has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this client, what major nursing diagnosis should the nurse include?
Deficient Knowledge about Early Signs of Melanoma The fact that the client's disease was not reported until an advanced stage suggests that the client lacked knowledge about skin lesions
A client has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this client's care, the nurse should prioritize which issue?
Disturbed body image
A client has undergone dermabrasion to decrease scarring from severe acne as a teen. After completion of the procedure, the nurse reviews the client's home care instructions. Which instruction is appropriate for this client?
Don't touch the area treated
The patient is advised to apply a suspension-type lotion to a dermatosis site. The nurse should advise the patient to apply the lotion how often to be effective?
Every 3 hours Suspensions consist of either a powder in water that requires shaking before application, or clear solutions, which contain completely dissolved active ingredients. A suspension such as calamine lotion provides a rapid cooling and drying effect as it evaporates, leaving a thin, medicinal layer of powder on the affected skin.
A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?
Nits may have to be manually removed from the child's hair shafts.
Ch 65 (skin diseases) A client has had a surgical procedure to correct an ingrown toenail. What would the nurse advise the client to do in order to prevent recurrences?
Use nail clippers to trim toenails.
The nurse is instructing the parents of a child with head lice. Which statement should the nurse include?
Use shampoo with piperonyl butoxide.
A client has recently lost a parent. The client spent about 6 months deeply mourning the loss and is just now able to function at the pre-loss level. During this process, a strong social support network was able to assist the client. What developmental stage of life does the nurse identify the client is in?
adult, they tend to grieve more intensely and more continuously, but for a relatively shorter period of time than children.
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage, according to Kübler-Ross?
anger
A client is diagnosed with terminal kidney failure. The spouse demonstrates loss and grief behaviors. What type of loss is the spouse experiencing?
anticipatory loss
When preparing the care plan for a dying client, it is important for the nurse to include a goal that addresses which needs? Select all that apply.
expression of feelings management of pain use of coping strategies
The client is a young parent whose spouse died 3 months ago. The client is tearful and unkempt, eats a poor diet, and has lost 50 lb (22.6 kg) since the death of the spouse. The client states, "I cannot do this anymore." Which nursing concern is best supported by these data?
ineffective coping related to failure of previously used coping mechanisms
A client with a history of diabetes mellitus has recently developed furunculosis. What is causing the client's condition?
infection
Which infecting agent causes scabies?
itch mite
A client comes to the dermatology clinic requesting the removal of a port-wine stain on their right cheek. The nurse knows that which of the following is the procedure especially useful in treating cutaneous vascular lesions such as port-wine stains?
laser treatment
Which of the following persons is responsible for handling and filing a death certificate with proper authorities?
mortician
A client has developed cancer within 8 months of their spouse's death. The nurse will consider the possibility of what cause?
physical effects of bereavement People experiencing bereavement are known to be at greater risk for mortality and morbidity than are comparable people not experiencing bereavement
A nurse assesses a client with dry, rough, scaly skin without lesions on the legs. The client reports itching in the affected area. What skin assessment would the nurse document?
pruritis (itching)
A client is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have?
psoriasis
Which care environment would the nurse suggest to a client with no family nearby who is diagnosed with end-stage lung disease?
residential care
A client has been diagnosed with shingles. Which is an assessment finding the nurse would expect to see?
vesicles
"My father has been dead for over a year and my mother still cannot talk about them without crying. Is that normal?" How should the nurse respond?
"The inability to talk about one's spouse without crying, even after a year, is still considered normal."
Which assessment finding indicates an increased risk of skin cancer?
deep sunburn
The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf?
durable power of attorney form
The nurse is caring for a client who recently experienced the death of the spouse. The client states, "I am so frustrated with myself because I feel like I should be back to my normal self by now but I am not." How should the nurse respond? Select all that apply.
"You have come a long way in your process. Let's look at all of the progress you have had already." "It would be helpful to discuss what supports you have in your life right now. Please share this information with me." "It is really beneficial to talk about how you are feeling. Tell me more about how you are feeling frustrated." "There are many resources in the community that can be beneficial during this time. I can share these with you."
Which does not coincide with Kübler-Ross's stages related to a dying client?
The dying client usually exhibits anger first.
A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?
private
The nurse is talking with the adult child of a client with end-stage acute kidney injury and late-stage dementia. The client can no longer live at home, and the child states, "I live 500 miles away. I do not know what to do." About which type of living arrangement will the nurse teach the child?
residential care
A nurse is caring for a client whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform?
teach the client self-care after treatment
A client visits the health care facility for a regular check-up. The nurse is aware that the client lost his wife 2 months earlier. What would lead the nurse to suspect dysfunctional grief?
the client begins abusing alcohol
An 81-year-old client is exhibiting many characteristic signs and symptoms of imminent death. What individual should the nurse first inform of the client's change in status?
the client's healthcare provider
A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse?
"I will contact the health care provider to extend services since your family member meets the criteria."
When preparing for palliative care with the dying client, the nurse should provide the family with which explanation?
"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."
A middle-age client is caring for an older adult parent who has end-stage kidney injury. Which statement by the client indicates to the nurse that the client is experiencing anticipatory loss?
"I am feeling so sad when I should be enjoying the time we have remaining."
Which of the following medications is used to reduce turnover time of the psoriatic epidermis?
Methotrexate
While performing an initial assessment of a client admitted with appendicitis, the nurse observes an elevated blue-black lesion on the client's ear. The nurse knows that this lesion is consistent with what type of skin cancer?
malignant melanoma
A client has been declared brain dead following a motor vehicle accident. What assessment data would the nurse anticipate?
no ocular movement
