Tissue Integrity

Impetigo ordinarily results in: a. No scarring b. Pigmented spots c. Slightly depressed scars d. Atrophic white scars

ANS: A A Impetigo tends to heal without scarring unless a secondary infection occurs. B Hyperpigmentation may occur; however, only in dark skinned children. C No scarring usually occurs. D No scarring usually occurs

What nursing assessment and care holds the highest priority in the initial care of a child with a major burn injury? a. Establishing and maintaining the child's airway b. Establishing and maintaining intravenous access c. Inserting a catheter to monitor hourly urine output d. Inserting a nasogastric tube into the stomach to supply adequate nutrition

ANS: A A Establishing and maintaining the child's airway is always the priority focus for assessment and care. B Establishing intravenous access is the second priority in this situation, after the airway has been established. C Inserting a catheter and monitoring hourly urine output is the third most important nursing intervention. D Nasogastric feedings are not begun initially on a child with major or severe burns. The initial assessment and care focus for a child with major burn injuries is the ABCs.

When assessing the child with atopic dermatitis, the nurse should ask the parents about a history of: a. Asthma b. Nephrosis c. Lower respiratory tract infections d. Neurotoxicity

ANS: A A Most children with atopic dermatitis have a family history of asthma, hay fever, or atopic dermatitis, and up to 80% of children with atopic dermatitis have asthma or allergic rhinitis. B Complications of atopic dermatitis relate to the skin. The renal system is not affected by atopic dermatitis. C There is no link between lower respiratory tract infections and atopic dermatitis. D Atopic dermatitis does not have a relationship to neurotoxicity.

A child experiences frostbite of the fingers after prolonged exposure to the cold. Which intervention should the nurse implement first?: a. Rapid rewarming of the fingers by placing in warm water b. Placing the hand in cool water c. Slow rewarming by wrapping in warm cloth d. Using an ice pack to keep cold until medical intervention is possible

ANS: A A Rapid rewarming is accomplished by immersing the part in well-agitated water at 37.8° C to 42.2° C (100° F to 108° F). B The frostbitten area should be rewarmed as soon as possible to avoid further tissue damage. C Rapid rewarming results in less tissue necrosis than slow thawing. D The frostbitten area should be rewarmed, as soon as possible, to avoid further tissue damage.

When changing an infant's diaper, the nurse notices small bright red papules with satellite lesions on the perineum, anterior thigh, and lower abdomen. This rash is characteristic of: a. Primary candidiasis b. Irritant contact dermatitis c. Intertrigo d. Seborrheic dermatitis

ANS: A A Small red papules with peripheral scaling in a sharply demarcated area involving the anterior thighs, lower abdomen, and perineum are characteristic of primary candidiasis. B A shiny, parchment-like erythematous rash on the buttocks, medial thighs, mons pubis, and scrotum, but not in the folds, is suggestive of irritant contact dermatitis. C Intertrigo is identified by a red macerated area of sharp demarcation in the groin folds. It can also develop in the gluteal and neck folds. D Seborrheic dermatitis is recognized by salmon-colored, greasy lesions with a yellowish scale found primarily in skin-fold areas or on the scalp.

What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the child's mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. b. Clean the rash vigorously with Betadine three times a day. c. Notify the physician for any itching. d. Keep the child home from school until the lesions are healed.

ANS: A A To prevent the spread of impetigo to others, the child should be kept home from school for 24 hours after treatment is initiated. Good handwashing is imperative in preventing the spread of impetigo. B The lesions should be washed gently with a warm soapy washcloth three times a day. The washcloth should not be shared with other members of the family. C Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the child's nails to prevent maceration of the lesions. D The child may return to school 24 hours after initiation of antibiotic treatment.

The client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care B. Encouraging visitors C. Reassuring the client that he or she will be fine D. Telling the client that these feelings are normal

ANS: A A. Encouraging participation in wound care will offer the client some sense of control. B. Encouraging visitors may be a good distraction but will not help the client achieve a sense of control. C. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. It does nothing to help the client achieve a sense of control. D. Telling the client that his or her feelings are normal may be reassuring but does not address the issue of restoring a sense of control.

A client with partial-thickness wounds of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which physician request first? A. Give oxygen per non-rebreather mask at 100% FiO2. B. Infuse lactated Ringer's solution at 150 mL/hr. C. Give morphine sulfate 4 to 10 mg IV for pain control. D. Insert a 14 Fr retention catheter.

ANS: A A. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. B. Although fluid hydration is important, the nurse's first priority is the client's airway. C. Pain control is important, but the nurse's first priority is the client's airway. D. Monitoring output is important, but the nurse's first priority is the client's airway.

The newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white blisters B. Painless, brownish-yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

ANS: A A. Painful red and white blisters accompany a deep partial-thickness burn. B. Painless, brownish-yellow eschar accompanies a full-thickness burn. C. A painful reddened blister accompanies a superficial partial-thickness burn. D. Painless black skin with eschar accompanies a deep full-thickness burn.

To position the client's burned upper extremities appropriately, how will the nurse position the client's elbow? A. In a neutral position B. In a position of comfort C. Slightly flexed D. Slightly hyperextended

ANS: A A. The neutral position is the correct placement of the elbow to prevent contracture development. B. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. C. The slightly flexed position increases the risk for contracture development. D. The slightly hyperextended position is not indicated and can be painful.

The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

ANS: A A. Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds. B. Topical antimicrobials such as sulfadiazine do not prevent cross-contamination from other clients in the unit. C. Topical antimicrobials such as sulfadiazine do not enhance cell growth. D. Use of topical antimicrobials such as sulfadiazine does not minimize the need for a skin graft.

A nurse assesses a client who has a chronic wound. The client states, "I do not clean the wound and change the dressing every day because it costs too much for supplies." How should the nurse respond? a."You can use tap water instead of sterile saline to clean your wound." b."If you don't clean the wound properly, you could end up in the hospital." c."Sterile procedure is necessary to keep this wound from getting infected." d."Good hand hygiene is the only thing that really matters with wound care."

ANS: A For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a.Place the client in a single room. b.Administer an antihistamine. c.Assess the client's airway. d.Apply gloves to minimize friction.

ANS: A The client's presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the client's infectious disorder

A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a.Recent wound assessment, including size and appearance b.Insurance information for billing and coding purposes c.Complete health history and physical assessment findings d.Resources available to the client for wound care supplies

ANS: A The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.

The client with 45% burns has a hematocrit of 52% 10 hours after the burn injury and 6 hours after fluid resuscitation was started. What is the nurse's best action? A. Assess the client's blood pressure and urine output. B. Notify the physician or the Rapid Response Team. C. Document the report as the only action. D. Increase the IV infusion rate.

ANS: A The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to assess whether the fluid resuscitation at the current rate is adequate. The best ways to determine adequacy by noninvasive measures is by blood pressure measurement and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, it may need adjustment and the physician should be called.

A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care? a.Change the dressing every 6 hours. b.Assess the wound bed once a day. c.Change the dressing when it is saturated. d.Contact the provider when the dressing leaks

ANS: A Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum débridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.

A nurse is teaching parents about prevention of diaper dermatitis. Which should the nurse include in the teaching plan?( Select all that apply.): a. Clean the diaper area gently after every diaper change with a mild soap. b. Use a protective ointment to clean dry intact skin. c. Use a steroid cream after each diaper change. d. Use rubber or plastic pants over the diaper. e. Wash cloth diapers in hot water with a mild soap and double rinse.

ANS: A, B, E Correct: Prompt, gentle cleaning with water and mild soap (e.g., Dove, Neutrogena Baby Soap) after each voiding or defecation rids the skin of ammonia and other irritants and decreases the chance of skin breakdown and infection. A bland, protective ointment (e.g., A&D, Balmex, Desitin, zinc oxide) can be applied to clean, dry, intact skin to help prevent diaper rash. If cloth diapers are laundered at home, the parents should wash them in hot water, using a mild soap and double rinsing. Incorrect: Occlusion increases the risk of systemic absorption of a steroid; thus steroid creams are rarely used for diaper dermatitis because the diaper functions as an occlusive dressing. Rubber or plastic pants increase skin breakdown by holding in moisture and should be used infrequently. A steroid cream is not recommended.

A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a.Use a lift sheet when moving the client in bed. b.Avoid tape when applying dressings. c.Avoid whirlpool therapy. d.Use loose dressing on all wounds. e.Implement pressure-relieving devices.

ANS: A, B, E Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin won't tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.

A nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? (Select all that apply.) a.Client with a left heel ulcer with slight necrosis - Whirlpool treatments b.Client with an eschar-covered sacral ulcer - Surgical débridement c.Client with a sunburn and erythema - Soaking in warm water for 20 minutes d.Client with urticaria - Wet-to-dry dressing changes every 6 hours e.Client with a sacral ulcer with purulent drainage - Transparent film dressing

ANS: A, B Necrotic tissue should be removed so that healing can take place. Whirlpool treatment can gently remove the necrosis. A wound covered with eschar most likely needs surgical débridement. Warm water would not be recommended for a client with erythema. A wet-to-dry dressing and a transparent film dressing are not appropriate for urticaria or pressure ulcers, respectively.

A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a.Prepare a room for reverse isolation. b.Assess staff for a history of or vaccination for chickenpox. c.Check the admission orders for analgesia. d.Choose a roommate who also is immune suppressed. e.Ensure that gloves are available in the room.

ANS: B, C, E Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this client in a private room. Herpes zoster is a disease of immune suppression, so no one who is immune-suppressed should be in the same room.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a."Have you eaten a large amount of chocolate lately?" b."Have you been under a lot of stress lately?" c."Have you recently used a public shower?" d."Have you been out of the country recently?" e."Have you recently had any other health problems?" f."Have you changed any medications recently?"

ANS: B, E, F Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.

A burned client newly arrived from an accident scene is prescribed 4 mg of morphine sulfate intravenously. What is the most important reason the nurse administers the analgesic to this client by the intravenous (IV) route? A. The drug will be effective more quickly than if given IM or subcutaneously. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client has delayed gastric emptying.

ANS: C Although providing some pain relief is a high priority and giving the drug by the IV route instead of the IM, subcutaneous, or oral routes does increase the rate of effect, the most important reason is to prevent an overdose from the accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed while the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? a.Turn the mattress overlay to the opposite side. b.Do nothing because this is an expected occurrence. c.Apply a different pressure-relieving device. d.Reinforce the overlay with extra cushions.

ANS: C "Bottoming out," as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.

Treatment for herpes simplex virus (types 1 or 2) includes: a. Corticosteroids b. Oral griseofulvin c. Oral antiviral agent d. Topical and/or systemic antibiotic

ANS: C A Corticosteroids are not effective for viral infections. B Griseofulvin is an antifungal agent and not effective for viral infections. C Oral antiviral agents are effective for viral infections such as herpes simplex. D Antibiotics are not effective in viral diseases.

An important nursing consideration when caring for a child with impetigo contagiosa is to: a. Apply topical corticosteroids to decrease inflammation. b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris. c. Carefully wash hands and maintain cleanliness when caring for an infected child. d. Examine child under a Wood lamp for possible spread of lesions.

ANS: C A Corticosteroids are not indicated in bacterial infections. B Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. C A major nursing consideration related to bacterial skin infections, such as impetigo contagiosa, is to prevent the spread of the infection and complications. This is done by thorough handwashing before and after contact with the affected child. D A Wood lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states, such as tinea capitis.

The primary clinical manifestation of scabies is: a. Edema b. Redness c. Pruritus d. Maceration

ANS: C A Edema is not observed in scabies. B Redness is not observed in scabies. C Scabies is caused by the scabies mite. The inflammatory response and intense itching occur after the host has become sensitized to the mite. This occurs approximately 30 to 60 days after initial contact. In the previously sensitized person, the response occurs within 48 hours. D Maceration is not observed in scabies.

What best describes a full-thickness (third-degree) burn? a. Erythema and pain b. Skin showing erythema followed by blister formation c. Destruction of all layers of skin evident with extension into subcutaneous tissue d. Destruction injury involving underlying structures such as muscle, fascia, and bone

ANS: C A Erythema and pain are characteristic of a first-degree burn or superficial burn. B Erythema with blister formation is characteristic of a second-degree or partial-thickness burn. C A third-degree or full-thickness burn is a serious injury that involves the entire epidermis and dermis and extends into the subcutaneous tissues. D A fourth-degree burn is a full-thickness burn that also involves underlying structures such as muscle, fascia, and bone.

A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a.Client with blood cultures pending b.Client who has thin, serous wound drainage c.Client with a white blood cell count of 23,000/mm3 d.Client whose wound has decreased in size

ANS: C A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.

The nurse is caring for a burn client who is receiving topical gentamicin sulfate (Garamycin). What laboratory value will the nurse plan to monitor? A. Blood glucose B. C-reactive protein C. Serum and urine creatinine D. Platelet count

ANS: C A. 2 Topical gentamicin sulfate does not affect blood sugar. B. C-reactive protein is used as a marker of inflammation. C. Topical gentamicin may have nephrotoxic effects, and the nurse should monitor serum and urine creatinine clearance before and during treatment. D. Topical gentamicin sulfate does not alter platelet counts.

In assessing the client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A. Acute Pain B. Potential for inadequate oxygenation C. Reduced self-image D. Potential for infection

ANS: C A. Acute Pain is relevant in the resuscitation phase of burn injury. B. Potential for inadequate oxygenation is relevant in the resuscitation phase of burn injury. C. In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. D. Potential for infection is relevant in the acute phase of burn injury.

Which assessment will the nurse prioritize for the client in the acute phase of burn injury? A. Bowel sounds B. Muscle strength C. Signs of infection D. Urine output

ANS: C A. Assessing bowel sounds is not the priority during the acute phase of burn injury. B. Assessing muscle strength is not the priority during the acute phase of burn injury. C. The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. D. Assessing urine output is not the priority during the acute phase of burn injury.

The client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A. Body temperature assessment B. Emotional support C. Fluid resuscitation D. Sterile dressing changes

ANS: C A. Assessment of body temperature is not the priority for this client. B. Although emotional support is important, this is not the priority during the resuscitation phase for this client. C. The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. D. Although sterile dressing changes are important, this is not the priority for this client.

Which clinical manifestation is indicative of wound healing for the client in the acute phase of burn injury? A. Pale, boggy, dry, or crusted granulation tissue B. Increasing wound drainage C. Scar tissue formation D. Sloughing of grafts

ANS: C A. Pale, boggy, dry, or crusted granulation tissue is indicative of infection. B. Increasing wound drainage is indicative of infection. C. Indicators of wound healing include the presence of granulation, re-epithelization, and scar tissue formation. D. Sloughing of grafts is indicative of infection.

The nurse is caring for the client with burns. Which question will the nurse ask the client and family to assess their coping strategies? A. "Do you support each other?" B. "How do you plan to manage this situation?" C. "How have you handled similar situations before?" D. "Would you like to see a counselor?"

ANS: C A. Yes or no questions are not very effective in extrapolating helpful information. B. The client and family in this situation probably are overwhelmed and may not know how they will manage. This question does not assess coping strategies. C. This question assesses whether the client's and the family's coping strategies may be effective. D. Asking the client and the family if they would like to see a counselor does not assess their coping strategies.

A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a."Do you spend a great deal of time in the sun?" b."Have you or any family members ever had skin cancer?" c."Which method of contraception are you using?" d."Do you drink alcoholic beverages?"

ANS: C Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin.

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a.Place a small pillow between bony surfaces. b.Elevate the head of the bed to 45 degrees. c.Limit fluids and proteins in the diet. d.Use a lift sheet to assist with re-positioning. e.Re-position the client who is in a chair every 2 hours. f.Keep the client's heels off the bed surfaces. g.Use a rubber ring to decrease sacral pressure when up in the chair.

ANS: A, D, F A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they should be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

Which nursing assessment is applicable to the care of a child with herpetic gingivostomatitis? a. Comparison of range of motion for the upper and lower extremities b. Urine output, mucous membranes, and skin turgor c. Growth pattern since birth d. Bowel elimination pattern

ANS: B A An oral herpetic infection does not affect joint function. B The child with herpetic gingivostomatitis is at risk for deficient fluid volume. Painful lesions on the mouth make drinking unpleasant and undesirable, with subsequent dehydration becoming a real danger. C Herpetic gingivostomatitis is not a chronic disorder that would affect the child's long-term growth pattern. D Although constipation could be caused by dehydration, it is more important to assess urine output, skin turgor, and mucous membranes to identify dehydration before constipation is a problem.

Ringworm, frequently found in schoolchildren, is caused by a(n): a. Virus b. Fungus c. Allergic reaction d. Bacterial infection

ANS: B A These are not the causative organisms for ringworm. B Ringworm is caused by a group of closely related filamentous fungi, which invade primarily the stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin. C Ringworm is not an allergic response. D These are not the causative organisms for ringworm.

The depth of a burn injury may be classified as: a. Localized or systemic b. Superficial, superficial partial thickness, deep partial thickness, or full thickness c. Electrical, chemical, or thermal d. Minor, moderate, or major

ANS: B A These terms refer to the effect of the burn injury. For example, is there a reaction in the area of the burn (localized) or throughout the body (systemic)? B The vocabulary to classify the depth of a burn is superficial, partial thickness, or full thickness. C These terms refer to the cause of the burn injury. D These terms refer to the severity of the burn injury.

What should the nurse teach an adolescent who is taking tretinoin (Retin-A) to treat acne? a. The medication should be taken with meals. b. Apply sunscreen before going outdoors. c. Wash with benzoyl peroxide before application. d. The effect of the medication should be evident within 1 week.

ANS: B A Tretinoin is a topical medication. Application is not affected by meals. B Tretinoin causes photosensitivity, and sunscreen should be applied before sun exposure. C If applied together, benzoyl peroxide and tretinoin have reduced effectiveness and a potentially irritant effect. D Optimal results from tretinoin are not achieved for 3 to 5 months.

The primary treatment for warts is: a. Vaccination b. Local destruction c. Corticosteroids d. Specific antibiotic therapy

ANS: B A Vaccination is prophylaxis for warts and is not a treatment. B Topical treatments include chemical cautery, which is especially useful for the treatment of warts. Local destructive therapy individualized according to location, type, and number. Surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies are used. C These are not effective in the treatment of warts. D These are not effective in the treatment of warts.

A nurse evaluates the following data in a client's chart: 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) Sotalol (Betapace) Vacuum-assisted wound closure (VAC) treatment to leg wound Based on this information, which action should the nurse take first? a.Assess the client's vital signs and initiate continuous telemetry monitoring. b.Contact the provider and express concerns related to the wound treatment prescribed. c.Consult the wound care nurse to apply the VAC device. d.Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.

ANS: B A client on anticoagulants is not a candidate for VAC because of the incidence of bleeding complications. The health care provider needs this information quickly to plan other therapy for the client's wound. The nurse should contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring is appropriate for a client who has a history of atrial fibrillation and should be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring.

Several clients have been brought to the emergency department (ED) after an office building fire. Which client is at greatest risk for inhalation injury? A. Middle-aged adult who is frantically explaining to the nurse what happened B. Young adult who suffered burn injuries in a closed space C. Adult with burns to the extremities D. Older adult with thick, tan-colored sputum

ANS: B A. Clients typically have some type of respiratory distress. However, the client is talking without difficulty, which shows that the client has minimal respiratory distress. B. The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. C. Extensive burns to the hands and face, not the extremities, would be a greater risk. D. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A. "The last tetanus injection was less than 5 years ago." B. "Burn wound conditions promote the growth of Clostridium tetani." C. "The wood in the fire had many nails, which penetrated the skin." D. "The injection was prescribed to prevent infection from Pseudomonas."

ANS: B A. Regardless of when the last tetanus injection is given, it is still given on admission to prevent Clostridium tetani. B. Burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid, 0.5 mL given IM, enhances acquired immunity to C. tetani. This agent is routinely given when the client is admitted to the hospital. C. This is not the primary reason the client received a tetanus toxoid injection. D. Tetanus toxoid injection does not prevent Pseudomonas infection.

A nurse assesses a client who has psoriasis. Which action should the nurse take first? a.Don gloves and an isolation gown. b.Shake the client's hand and introduce self. c.Assess for signs and symptoms of infections. d.Ask the client if she might be pregnant.

ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse should first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy should be completed after establishing a report with the client.

After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? a."I can help him shift his position every hour when he sits in the chair." b."If his tailbone is red and tender in the morning, I will massage it with baby oil." c."Applying lotion to his arms and legs every evening will decrease dryness." d."Drinking a nutritional supplement between meals will help maintain his weight."

ANS: B Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home

After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a."At the next family reunion, I'm going to ask my relatives if they have psoriasis." b."I have to make sure I keep my lesions covered, so I do not spread this to others." c."I expect that these patches will get smaller when I lie out in the sun." d."I should continue to use the cortisone ointment as the patches shrink and dry out."

ANS: B Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division.

A nurse evaluates the following data in a client's chart: 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL Albumin: 4.2 mg/dL Lymphocyte count: 2000/mm3 Sacral ulcer - 4 cm ´ 2 cm ´ 1.5 cm Based on this information, which action should the nurse take? a.Perform a neuromuscular assessment. b.Request a dietary consult. c.Initiate Contact Precautions. d.Assess the client's vital signs.

ANS: B The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse should request a dietary consult. The other interventions do not address the information provided.

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a.Beige freckles on the backs of both hands b.Irregular blue mole with white specks on the lower leg c.Large cluster of pustules in the right axilla d.Thick, reddened papules covered by white scales

ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.

A older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to check himself or herself? a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying."

ANS: C The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions

ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

ANS: C The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? (Select all that apply.): a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. e. Combs and brushes should be boiled in water for at least 10 minutes.

ANS: C, D, E Correct: An over-the-counter pediculicide, permethrin 1% (Nix, Elimite, Acticin), kills head lice and eggs with one application and has residual activity (i.e., it stays in the hair after treatment) for 10 days. Nix crème rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes. Incorrect: The hair should not be shampooed for 24 hours after the treatment. Even though the kill rate is high and there is residual action, retreatment should occur after 7 to 10 days. Combs and brushes should be boiled or soaked in antilice shampoo or hot water (greater than 60° C [140° F]) for at least 10 minutes. Advise parents to wash clothing (especially hats and jackets), bedding, and linens in hot water and dry at a hot dryer setting.

What procedure is contraindicated in the care of a child with a minor partial-thickness burn injury wound? a. Cleaning the affected area with mild soap and water b. Applying antimicrobial ointment to the burn wound c. Changing dressings daily d. Leaving all loose tissue or skin intact

ANS: D A Cleaning with mild soap and water are important to the healing process. B Antimicrobial ointment is used on the burn wound to fight infection. C Clean dressings are applied daily to prevent wound infection. When dressings are changed, the condition of the burn wound can be assessed. D All loose skin and tissue should be debrided, because it can become a breeding ground for infectious organisms.

The skin condition commonly known as "warts" is the result of an infection by which organism? a. Bacteria b. Fungus c. Parasite d. Virus

ANS: D A Infection with these organisms does not result in warts. B Infection with these organisms does not result in warts. C Infection with these organisms does not result in warts. D Human warts are caused by the human papillomavirus.

What should the parents of an infant with thrush (oral candidiasis) be taught about medication administration? a. Give nystatin suspension with a syringe without a needle. b. Apply nystatin cream to the affected area twice a day. c. Give nystatin before the infant is fed. d. Swab nystatin suspension onto the oral mucous membranes after feedings.

ANS: D A Medication may not reach the affected areas when it is squirted into the infant's mouth. Rubbing the suspension onto the gum ensures contact with the affected areas. B Nystatin cream is used for diaper rash caused by Candida. C To prolong contact with the affected areas, the medication should be administered after a feeding. D It is important to apply the nystatin suspension to the affected areas, which is best accomplished by rubbing it onto the gums and tongue, after feedings, every 6 hours, until 3 to 4 days after symptoms have disappeared.

When taking a history on a child with a possible diagnosis of cellulitis, what should be the priority nursing assessment to help establish a diagnosis? a. Any pain the child is experiencing b. Enlarged, mobile, and nontender lymph nodes c. Child's urinalysis results d. Recent infections or signs of infection

ANS: D A Pain is important, but the history of recent infections is more relevant to the diagnosis. B Lymph nodes may be enlarged (lymphadenitis), but they are not mobile and are nontender. Lymphangitis may be seen with red "streaking" of the surrounding area. C An abnormal urinalysis result is not usually associated with cellulitis. D Cellulitis may follow an upper respiratory infection, sinusitis, otitis media, or a tooth abscess. The affected area is red, hot, tender, and indurated.

The process of burn shock continues until what physiologic mechanism occurs? a. Heart rate returns to normal. b. Airway swelling decreases. c. Body temperature regulation returns to normal. d. Capillaries regain their seal.

ANS: D A The heart rate will be increased throughout the healing process because of increased metabolism. B Airway swelling subsides over a period of 2 to 5 days after injury. C Body temperature regulation will not be normal until healing is well under way. D Within minutes of the burn injury, the capillary seals are lost with a massive fluid leakage into the surrounding tissue, resulting in burn shock. The process of burn shock continues for approximately 24 to 48 hours, when capillary seals are restored.

Which statement made by a parent indicates an understanding about the management of a child with cellulitis? a. "I am supposed to continue the antibiotic until the redness and swelling disappear." b. "I have been putting ice on my son's arm to relieve the swelling." c. "I should call the doctor if the redness disappears." d. "I have been putting a warm soak on my son's arm every 4 hours."

ANS: D A The parent should not discontinue antibiotics when signs of infection disappear. To ensure complete healing, the parent should understand that the entire course of antibiotics should be given as prescribed. B A warm soak is indicated for the treatment of cellulitis. Ice will decrease circulation to the affected area and inhibit the healing process. C The disappearance of redness indicates healing and is not a reason to seek medical advice. D Warm soaks applied every 4 hours while the child is awake increase circulation to the infected area, relieve pain, and promote healing.

A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a.Draw blood for albumin, prealbumin, and total protein. b.Prepare for and assist with obtaining a wound culture. c.Place the client in bed and instruct the client to elevate the foot. d.Assess the right leg for pulses, skin color, and temperature.

ANS: D A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What will the nurse do first? A. Administer a diuretic. B. Provide a fluid bolus. C. Recalculate fluid replacement based on time of hospital arrival. D. Titrate fluid replacement.

ANS: D A. A common mistake in treatment is giving diuretics to increase urine output. Diuretics do not increase cardiac output. They actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. B. Fluid boluses are avoided because they increase capillary pressure and worsen edema. C. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital. D. The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids).

The burn client asks the nurse not to remove the loosened bits of skin and tissue during the dressing change, saying "The more skin you take off, the longer it will take me to heal." What is the nurse's best response? A. "Do you want some pain medication before I begin?" B. "The only things I am removing are blocks of bacteria growth, not skin." C. "Don't worry, I have worked the burn unit for years and know what I am doing." D. "This tissue is no longer living and as long as it is present, real healing cannot start."

ANS: D A. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity B. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity C. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity D. Clients often do not understand that removal of dead tissue must occur before healing can start; they view the débridement as making the situation worse. Helping them understand the rationale for the procedure may help them accept the process and alleviate their concern that débridement is inappropriate or harmful. Reference: p. 532, Psychosocial Integrity

The client is in the acute phase of burn injury. In which situation will the nurse decide to coordinate with the dietitian? A. Discouraging having food brought in from the client's favorite restaurant B. Providing more palatable choices for the client C. Helping the client lose weight D. Planning additions to the standard nutritional pattern

ANS: D A. It is fine for the client with a burn injury to have food brought in from the outside. B. The hospital kitchen can be consulted to see what other food options may be available to the client. C. It is not therapeutic for the client with burn injury to lose weight. D. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance.

The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feet does the nurse use as a basis to document a probable full-thickness injury? A. Most of the wounded area is red. B. The client reports that the area hurts when touched. C. The area does not blanch when firm pressure is applied. D. Thrombosed blood vessels are visible beneath the skin surface.

ANS: D A. Red areas can be associated with nearly any depth of burn injury. Reference: p. 515, Physiological Integrity B. The presence of pain is not a good indicator of burn depth. Although full-thickness injuries have much less pain than partial-thickness injuries, pain may still be present. Reference: p. 515, Physiological Integrity C. Deep partial-thickness injuries may or may not blanch with firm pressure. Reference: p. 515, Physiological Integrity D. The presence of thrombosed blood vessels beneath the skin surface is a strong indication of a full-thickness injury. Partial-thickness injuries can directly damage more superficial blood vessels but do not cause thrombosis of deeper vessels. Reference: p. 515, Physiological Integrity

When delegating care for clients on the burn unit, which client will the charge nurse assign to an RN who has floated to the burn unit from the pediatric unit? A. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B. Recently admitted client with a high-voltage electrical burn C. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D. Client receiving IV lactated Ringer's solution at 100 mL/hr

ANS: D A. This client requires specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. B. This client requires specialized knowledge about assessment and interventions in burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. C. This client requires specialized knowledge about interventions in burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries. D. An RN float nurse will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath.

A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a.Viral infection - Clindamycin (Cleocin) b.Bacterial infection - Acyclovir (Zovirax) c.Yeast infection - Linezolid (Zyvox) d.Fungal infection - Ketoconazole (Nizoral)

ANS: D Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.

A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education? a."Use lots of moisturizer several times a day to minimize dryness." b."Take a cold shower instead of soaking in the bathtub." c."Use antimicrobial soap to avoid infection of cracked skin." d."After you bathe, put lotion on before your skin is totally dry."

ANS: D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate a. Candida albicans. b. group A beta-hemolytic streptococci. c. Staphylococcus aureus. d. Streptococcus pyogenes.

ANS: D Streptococcus pyogenes is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

Where do the lesions of atopic dermatitis most commonly occur in the infant? (Select all that apply.): a. Cheeks b. Buttocks c. Extensor surfaces of arms and legs d. Back e. Trunk

ANS: A, C, E Correct: The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities. Incorrect: These lesions are not typically on the back or the buttocks.

A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a.Cool, moist compresses b.Topical corticosteroids c.Heating pad d.Tepid bath with cornstarch e.Back rub with baby oil

ANS: A, D For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse should implement cool, moist compresses and tepid baths with additives such as cornstarch. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

Parents of a child with lice infestation should be instructed carefully in the use of antilice products because of which potential side effect? a. Nephrotoxicity b. Neurotoxicity c. Ototoxicity d. Bone marrow depression

ANS: B A Antilice products are not known to be nephrotoxic. B Because of the danger of absorption through the skin and potential for neurotoxicity, antilice treatment must be used with caution. A child with many open lesions can absorb enough to cause seizures. C Antilice products are not ototoxic. D Products that treat lice are not known to cause bone marrow depression.

A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a."Do you have a bedpan at home?" b."How are you coping with providing this care?" c."What are you doing to prevent pediculosis?" d."Are you sharing a bed with your husband?"

ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wife's feelings and provide support for coping with changes. Asking about the client's toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregiver's support and coping mechanisms and ability to continue to care for her husband.

The nurse is caring for the client with burns to the face. Which statement by the client requires further evaluation by the nurse? A. "I am getting used to looking at myself." B. "I don't know what I will do when people stare at me." C. "I know that I will never look the way I used to, even after the scars heal." D. "My spouse does not stare at the scars as much as in the beginning."

ANS: B A. This statement indicates that the client is coping effectively. B. This statement indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. C. This statement indicates that the client is coping effectively. D. This statement indicates that the client is coping effectively.

The client is in the resuscitation phase of burn injury. Which route will the nurse use to administer pain medication to the client? A. Intramuscular B. Intravenous C. Sublingual D. Topical

ANS: B A. When administered to the client in the resuscitation phase of burn injury via the intramuscular route, drugs remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. B. During the resuscitation postburn phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. C. Because the skin is too damaged, the sublingual route is not the indicated route for administering drugs to the client in the resuscitation phase of burn injury. D. Because the skin is too damaged, the topical route is not the indicated route for administering drugs to the client in the resuscitation phase of burn injury.

The client with burns to the head, neck, and upper body from a house fire starts drooling uncontrollably about 8 hours after the injury. What is the nurse's best first action? A. Ensure that the client remains NPO. B. Notify the Rapid Response Team. C. Slow the IV infusion rate. D. Raise the head of the bed.

ANS: B The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the the head, neck, and upper body). The drooling indicates oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation now.

After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a.Low-fat diet with whole grains and cereals and vitamin supplements b.High-protein diet with vitamins and mineral supplements c.Vegetarian diet with nutritional supplements and fish oil capsules d.Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

ANS: B The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.

A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a."Wash your hands before touching the client." b."Wear gloves when bathing the client." c."Assess skin for breakdown during the bath." d."Apply lotion to lesions while the skin is wet." e."Use a damp cloth to scrub the lesions"

ANS: A, B All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the client's skin. The other statements are not appropriate for the care of open skin lesions.

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a. Obtaining a complete blood count (CBC) b. Protection from excessive heat c. Protection from excessive UV exposure d. Instructing the patient to take their multivitamin prior to treatment

ANS: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that they need further teaching? a. "I wear a hat and sit under the umbrella when not in the water." b. "I don't bother with sunscreen on overcast days." c. "I use a sunscreen with the highest SPF number." d. "I wear a UV shirt and limit exposure to the sun by covering up."

ANS: B The sun's rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

To assess the child with severe burns for adequate perfusion, the nurse monitors: a. Distal pulses b. Skin turgor c. Urine output d. Mucous membranes

ANS: C A Distal pulses may be affected by many variables. Urine output is the most reliable indicator of end-organ perfusion. B Skin turgor is often difficult to assess on burn patients because the skin is not intact. C Urine output reflects the adequacy of end-organ perfusion. D Mucous membranes do not reflect end-organ perfusion.

The nurse is evaluating the effectiveness of fluid resuscitation for the client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A. Blood urea nitrogen (BUN), 36 mg/dL B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

ANS: C A. A BUN of 36 mg/dL is above normal. B. A creatinine of 2.8 mg/dL is above normal. C. Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL or 0.5 mL/kg/hr. D. A urine specific gravity of 1.042 is above normal.

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a.A 44-year-old prescribed IV antibiotics for pneumonia b.A 26-year-old who is bedridden with a fractured leg c.A 65-year-old with hemi-paralysis and incontinence d.A 78-year-old requiring assistance to ambulate with a walker

ANS: C Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to a. bathe and dry the skin vigorously to stimulate circulation. b. keep the head of the bed elevated 30 degrees. c. limit intake of fluid and offer frequent snacks. d. turn the patient at least every 2 hours.

ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

The pediatric nurse understands that cellulitis is most often caused by: a. Herpes zoster b. Candida albicans c. Human papillomavirus d. Streptococcus or Staphylococcus organisms

ANS: D A Herpes zoster is the virus associated with varicella and shingles. B Candida albicans is associated with candidiasis or thrush. C Human papillomavirus is associated with various types of human warts. D Streptococcus, Staphylococcus, and Haemophilus influenzae are the organisms usually responsible for cellulitis