Tissue Integrity Prep U

C) DOCUMENT THAT THE STOMA APPEARS HEALTHY AND WELL PERFUSED A HEALTHY, VIABLE STOMA SHOULD BE SHINY AND PINK TO BRIGHT RED. THIS FINDING DOES NOT INDICATE THAT THE STOMA IS BLOCKED OR THAT SKIN INTEGRITY IS COMPROMISED

A NURSE IS ASSESSING A PATIENT'S STOMA ON POSTOPERATIVE DAY 3. THE NURSE NOTES THAT THE STOMA HAS A SHINY APPEARANCE AND A BRIGHT RED COLOR. HOW SHOULD THE NURSE BEST RESPOND TO THIS ASSESSMENT FINDING? A) IRRIGATE THE OSTOMY TO CLEAR A POSSIBLE OBSTRUCTION B) CONTACT THE PRIMARY CARE PROVIDER TO REPORT THIS FINDING C) DOCUMENT THAT THE STOMA APPEARS HEALTHY AND WELL PERFUSED D) DOCUMENT A NURSING DIAGNOSIS OF IMPAIRED

D)Gather new sterile supplies and start over WHEN FOLLOWING SURGICAL ASEPSIS, AREAS ARE CONSIDERED CONTAMINATED IF THEY ARE TOUCHED BY ANY OBJECT THAT IS NOT ALSO STERILE. ONE OF THE MOST IMPORTANT ASPECTS OF MEDICAL AND SURGICAL ASEPSIS IS THAT THE EFFECTIVENESS OF BOTH DEPENDS ON FAITHFUL AND CONSCIENTIOUS PRACTICE BY THOSE CARRYING THEM OUT.

A STUDENT NURSE IS PERFORMING A URINARY CATHETERIZATION FOR THE FIRST TIME AND INADVERTENTLY CONTAMINATES THE CATHETER BY TOUCHING THE BED LINENS. WHAT SHOULD THE NURSE DO TO MAINTAIN SURGICAL ASEPSIS FOR THIS PROCEDURE? A)Nothing, because the patient is on antibiotics. B)Complete the procedure and then report what happened. C)Apologize to the patient and complete the procedure. D)Gather new sterile supplies and start over

A)Scale A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't occur with psoriasis.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? A)Scale B)Crust C)Ulcer D)Scar

B)Irregular edges D)Larger than 1/4 inch in diameter E)Change in the mole The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply. A)Symmetrical shape B)Irregular edges C)Single color D)Larger than 1/4 inch in diameter E)Change in the mole

B)Senile lentigines Small, brown, pigmented, benign lesions, known as liver spots or senile lentigines, form on the hands and forearms of older people. Small, yellow or brown, raised lesions called senile keratoses may appear on the face and trunk and are precancerous and require close observation. Melanoma is diagnosed by biopsy and generally has irregular borders and is dark in color.

An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned that he has melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of? A)Senile keratoses B)Senile lentigines C)Melanoma D)Freckles

A)"Any injured cells are replaced with cells of the same type. Therefore, after healing, the wound will look like your surrounding skin." Tissue repair can take the form of regeneration, in which injured cells are replaced with cells of the same type, sometimes leaving no residual trace of previous injury. Replacement by connective (fibrous) tissue will lead to scar formation.

Following surgery for appendicitis, a teenaged client notes four small "stab" wounds on the abdomen. The client is obviously worried about body appearance. The nurse explains, "Your body will heal quickly and tissue repair will allow for regeneration of any cells needed." The client asks, "What does regeneration mean?" The nurse responds that tissue repair by regeneration means: A)"Any injured cells are replaced with cells of the same type. Therefore, after healing, the wound will look like your surrounding skin." B)"Your body will fill in the wound with connective tissue, making the scar area very strong." C)"Your body will develop a complex matrix of cells that will fill in the scar, giving it greater structure than before." D)"Your blood will send stem cells to the area to allow it to heal faster than normal."

D)angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal, but often has a reddish hue and does not pit. Urticaria (hives) is characterized as edematous skin elevations that vary in size, shape, and itch, which cause local discomfort. Contact dermatitis refers to inflammation of the skin caused by contact with an allergenic substance such as poison ivy. Pitting edema, the result of increased interstitial fluid, is associated with disorders such as congestive heart failure.

The nurse observes diffuse swelling involving the deeper skin layers in a client who has experienced an allergic reaction. The nurse would correctly document this finding as A)urticaria. B)contact dermatitis. C)pitting edema. D)angioneurotic edema.

C)Edema D)Anemia E)Diaphoresis Risk factors for pressure ulcer development include prolonged pressure on the tissue, sensory deficit or loss, edema, urinary or fecal incontinence, malnutrition, anemia, hypoproteinemia, and excessively moist skin.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply. A)Constipation B)Sensory overload C)Edema D)Anemia E)Diaphoresis

B)tea-colored urine Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia? A)temperature instability B)tea-colored urine C)seizures D)feeble sucking

D)Mucosal hemorrhages that have developed into crypt abscesses, which have in turn necrotized and ulcerated.

A 20-year-old woman has visited her family physician due to occasional bouts of bloody diarrhea over the past several weeks, a phenomenon that she experienced 2 years prior as well. Her physician has diagnosed her with ulcerative colitis based on her history and visualization of the affected region by colonoscopy and sigmoidoscopy. Which pathophysiologic phenomenon is most likely to underlie the client's health problem? A)Fissures and crevices developing in the mucosa that are seen as a characteristic "cobblestone" appearance. B)Erosion of the endothelial lining of the distal small intestine by a combination of genetic, autoimmune, and environmental factors. C)Compromise of the mucosal layer of the large intestinal surface by the effects of H. pylori. D)Mucosal hemorrhages that have developed into crypt abscesses, which have in turn necrotized and ulcerated.

D) LEAN MEATS AND LOW-FAT MILK

A NURSE IS CARING FOR AN ELDERLY CLIENT WITH A PRESSURE ULCER ON THE SACRUM. WHEN TEACHING THE CLIENT ABOUT DIETARY INTAKE, WHICH FOODS SHOULD THE NURSE EMPHASIZE? A) LEGUMES AND CHEESE B) WHOLE GRAIN PRODUCTS C) FRUITS AND VEGETABLES D) LEAN MEATS AND LOW-FAT MILK

B)rng or donut The nurse should not use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client's weight, and water beds distribute pressure over the entire surface.

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used? A)specialty mattress B)rng or donut C)gel flotation pad D)water bed

B)impetigo. Impetigo, which usually is caused by beta-hemolytic streptococci, is the most common bacterial skin infection.

A skin infection caused by beta-hemolytic streptococci common in children is: A)acne vulgaris. B)impetigo. C)scabies. D)herpes.

A) Pruritus Pruritus (itching) is one of the most common symptoms of patients with dermatologic disorders. Itch receptors are unmyelinated, penicillate (brush-like) nerve endings that are found exclusively in the skin, mucous membranes, and cornea.

Dry, rough, scaly skin with the presence of itching is best described as: A)Pruritus B)Shingles C)Candidiasis D)Seborrhea

B)Syphilis Syphilis is manifested by a painless chancres or ulcerated lesions. Psoriasis is exhibited by plaques with scales. Kaposi sarcoma are cutaneous lesions that are blue-red or dark brown in color. Urticaria is wheals or hives due to infection or allergic reactions.

Painless chancres or ulcerated lesions are associated with which systemic disease? A)Kaposi sarcoma B)Syphilis C)Psoriasis D)Urticaria

D)1 hour. The initial sign of pressure is erythema caused by reactive hyperemia, which normally resolves in less than 1 hour. All of the other time frames are incorrect.

The initial sign of skin pressure is erythema, which normally resolves in less than A)15 minutes. B)30 minutes. C)45 minutes. D)1 hour.

B) USING NORMAL SALINE SOLUTION TO CLEAN THE ULCER AND APPLYING A PROTECTIVE DRESSING AS NECESSARY THE NURSE MAY WASH THE AREA WITH NORMAL SALINE SOLUTION AND APPLY A PROTECTIVE DRESSING. THESE INTERVENTIONS WILL PROTECT THE AREA AND ARE WITHIN THE NURSE'S SCOPE OF PRACTICE. A NURSE MUST OBTAIN A PHYSICIAN'S ORDER TO USE A POVIDONE-IODINE WASH OR AN ANTIBIOTIC CREAM. MASSAGING WITH AN ASTRINGENT CAN FURTHER DAMAGE THE SKIN.

WHEN CARING FOR A CLIENT WITH A 3-CM STAGE I PRESSURE ULCER ON THE COCCYX, WHICH ACTION MAY THE NURSE INSTITUTE INDEPENDENTLY? A) USING A POVIDONE-IODINE WASH ON THE ULCERATION THREE TIMES PER DAY B) USING NORMAL SALINE SOLUTION TO CLEAN THE ULCER AND APPLYING A PROTECTIVE DRESSING AS NECESSARY C) APPLYING AN ANTIBIOTIC CREAM TO THE AREA THREE TIMES PER DAY D) MASSAGING THE AREA WITH AN ASTRINGENT EVERY 2 HOURS

B)Lack of vitamin C Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.

Which nutritional deficiency may delay wound healing? A)Lack of vitamin D B)Lack of vitamin C C)Lack of vitamin E D)Lack of calcium

A)"It is an elevated mass with irregular borders." A wheal is an elevated mass with irregular or transient borders. Hives are often described as "wheals."

Which statement is the nurse's best description of a wheal? A)"It is an elevated mass with irregular borders." B)"It is a pus-filled area." C)"It is a bleeding lesion." D)"It is a dry area that itches."

A)Vitiligo Vitiligo results in the development of white patches that may be localized or widespread. Hirsutism is the condition of excessive hair growth. Lichenification refers to a leathery thickening of the skin. Telangiectases refers to red marks on the skin caused by stretching of the superficial blood vessels.

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? A)Vitiligo B)Hirsutism C)Lichenification D)Telangiectases

C)Every 3 to 4 hours for sustained effectiveness. Lotions are frequently used to replenish lost skin oils or to relieve pruritus. They are usually applied directly to the skin, but a dressing soaked in the lotion can be placed on the affected area. Lotions must be applied every 3 or 4 hours for sustained therapeutic effect because if left in place for a long period, they may crust and cake on the skin.

A dermatologist recommends an over-the-counter suspension to relieve pruritus. The nurse advises the patient that the lotion should be applied: A)Overnight to enhance absorption. B)Hourly to prevent evaporation. C)Every 3 to 4 hours for sustained effectiveness. D)Twice a day to prevent crusting on the skin.

A)Red scaling rash on soles and between the toes Tinea pedis presents with red scaling rash on soles, and between the toes. Tinea capitis presents with patches of scaling in the scalp with central hair loss and the risk of kerion development (inflamed boggy mass filled with pustules). Tinea cruris presents with erythema, scaling, maceration in the inguinal creases and inner thighs.

A nurse is caring for a child with tinea pedis. Which assessment finding should the nurse expect? A)Red scaling rash on soles and between the toes B)Patches of scaling in the scalp with central hair loss C)Inflamed boggy mass filled with pustules D)Erythema, scaling, maceration in the inguinal creases and inner thighs

A)"I should not cover the area with plastic wrap after applying the cream." An occlusive dressing such as plastic wrap over the area should not be used with topical corticosteroids. High-potency preparations should not be used. There is no need to shake topical corticosteroids. Benzoyl peroxide requires shaking before use. Applying the medication at night and rinsing off in the morning is used for coal tar preparations.

A topical corticosteroid is prescribed for a child with contact dermatitis. Which statement by the mother would indicate the teaching was successful? A)"I should not cover the area with plastic wrap after applying the cream." B)"I should use the highest-potency steroid cream I can find." C)"I need to shake the preparation before using it." D)"I should apply the medicine at bedtime and rinse it off in the morning."

C)Tearing of a structure from its normal position

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? A)Tearing of the skin and tissue with some type of instrument; tissue not aligned B)Cutting with a sharp instrument with wound edges in close approximation with correct alignment C)Tearing of a structure from its normal position D)Puncture of the skin

D)concentration of immature blood vessels A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored.

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? A)bruising from the birth process B)an immature autoregulation of blood flow C)an allergic reaction to the soap used for the first bath D)concentration of immature blood vessels

C)Pruritus The nurse should be alert for pruritus and urticaria, which may indicate a mild anaphylactic reaction to the arteriogram dye. Decreased (not increased) alertness may occur as well as dyspnea (not hypoventilation). Unusually smooth skin isn't a sign of anaphylaxis.

A client is scheduled for a renal arteriogram. When the nurse checks the chart for allergies to shellfish or iodine, she finds no allergies recorded. The client is unable to provide the information. During the procedure, the nurse should be alert for which finding that may indicate an allergic reaction to the dye used during the arteriogram? A)Increased alertness B)Hypoventilation C)Pruritus D)Unusually smooth skin

A)Asks the client to open his or her mouth to facilitate inspection of the oral mucosa C)Instructs the client to brush the teeth with a soft toothbrush D)Consults with the healthcare provider about use of nystatin The description of the client's report is stomatitis following chemotherapy treatment. The nurse should assess the oral mucosa based on the client's report of pain and difficulty eating. The client is to use a soft toothbrush to minimize trauma to the mouth. Nystatin (Mycostatin) is a topical medication that may provide healing for the client's mouth. The client avoids alcohol-based mouthwashes as these are irritants. Flossing the teeth may cause additional trauma to the mouth

A client with cancer is receiving chemotherapy and reports to the nurse that his or her mouth is painful and has difficulty ingesting food. What actions should the nurse take? Select all that apply. A)Asks the client to open his or her mouth to facilitate inspection of the oral mucosa B)Rinses the client's mouth with alcohol-based mouthwash every 2 hours C)Instructs the client to brush the teeth with a soft toothbrush D)Consults with the healthcare provider about use of nystatin E)Teaches the client to floss the teeth once every 24 hours

A) BOUILLON, APPLE JUICE, AND GELATIN

AFTER REVIEWING THE PATIENT'S CHART, THE NURSE NOTES THAT THE PATIENT HAS BEEN ORDERED A CLEAR LIQUID DIET. WHICH MEAL TRAY WOULD THE PATIENT BE ALLOWED TO EAT? A) BOUILLON, APPLE JUICE, AND GELATIN B) FAT-FREE BROTH, GINGER ALE, AND CUSTARD C) CREAM OF WHEAT, CRANBERRY JUICE, AND MILK D) CLEAR BROTH, HOT TEA, AND YOGURT

B)Meticulous cleanliness Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? A)Continuous use of an indwelling catheter B)Meticulous cleanliness C)Avoidance of all lotions and lubricants D)Allowing the client to choose the position of comfort

A)Desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? A)Desiccation B)Maceration C)Necrosis D)Evisceration

C)Small, waxy nodule with pearly borders A small waxy nodule with pearly borders may indicate a basal cell carcinoma. This finding requires further investigation and treatment. Yellow, waxy deposits on the lower eyelids, bright red moles on the hands, and areas of dry, scaly skin are normal age-related changes to skin.

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation? A)Several areas of dry, scaly skin B)Yellow, waxy deposits on the lower eyelids C)Small, waxy nodule with pearly borders D)Bright red moles on the hands

A)SHE BACTERIAL INFECTION UNLIKE OTHER FORMS OF SHOCK, CLIENTS WITH SEPTIC SHOCK HAVE AN ELEVATED LEUKOCYTE COUNT AND INITIALLY MANIFEST FEVER ACCOMPANIED BY WARM, FLUSHED SKIN AND A RAPID, BOUNDING PULSE. THEREFORE, THE CLIENT WITH AN OVERWHELMING BACTERIAL INFECTION IS MOST LIKELY TO EXHIBIT THESE SYMPTOMS. BLOOD LOSS MAY PRECIPITATE HYPOVOLEMIC SHOCK. INJURY TO THE SPINAL CORD OR HEAD OR OVERDOSES OF OPIOIDS, OPIATES, TRANQUILIZERS, OR GENERAL ANESTHETICS CAN CAUSE NEUROGENIC SHOCK. ANAPHYLACTIC SHOCK IS A SEVERE ALLERGIC REACTION THAT FOLLOWS EXPOSURE TO A SUBSTANCE TO WHICH A PERSON IS EXTREMELY SENSITIVE.

AN 87-YEAR-OLD CLIENT WAS ADMITTED TO YOUR HOSPITAL UNIT WITH AN ELEVATED LEUKOCYTE COUNT AND A FEVER ACCOMPANIED BY WARM, FLUSHED SKIN. WHICH DO HER SYMPTOMS SUGGEST? A)SHE HAS A BACTERIAL INFECTION B) SHE LOST BLOOD FROM FREQUENTLY USING NSAIDS C) SHE HAS HAD AN OVERDOSE OF OPIOIDS D) SHE HAS HAD A SEVERE ALLERGIC REACTION TO A BEE STING

B) COLONOSCOPY RECOMMENDATIONS FOR SCREENING FOR COLORECTAL CANCER INCLUDE SCREENING COLONOSCOPIES EVERY 10 YEARS. FECAL OCCULT BLOOD TESTS SHOULD BE COMPLETED ANNUALLY IN PEOPLE OVER AGE 50. PSA TESTS FOR PROSTATE-SPECIFIC ANTIGEN IS USED AS A SCREENING TOOL FOR PROSTATE CANCER. A PAP TEST IS A SCREENING TOOL FOR CERVICAL CANCER.

THE NURSE IS CONDUCTING A COMMUNITY EDUCATION PROGRAM USING THE AMERICAN CANCER SOCIETY'S COLORECTAL SCREENING AND PREVENTION GUIDELINES. THE NURSE DETERMINES THAT THE PARTICIPANTS UNDERSTAND THE TEACHING WHEN THEY IDENTIFY THAT PEOPLE OVER THE AGE OF 50 SHOULD HAVE WHICH OF THE FOLLOWING SCREENING TESTS EVERY 10 YEARS? A) FECAL OCCULT BLOOD TEST B) COLONOSCOPY C) PROSTATE-SPECIFIC ANTIGEN (PSA) D) PAPANICOLAOU (PAP)

D)Repairing the skin barrier Moisturizing agents are the cornerstone of treatment for dry skin. These agents exert their effects by repairing the skin barrier, increasing the water content of the skin, reducing transepidermal water loss, and restoring the lipid barrier's ability to attract, hold, and redistribute water.

The first-line treatment for dry skin is moisturizing agents. How do these agents work? A)Decreasing pruritis B)Penetrating the lipid barrier of the skin C)Increasing transepidermal water loss D)Repairing the skin barrier

A)"Avoid irritating fabrics such as wool." B)"Wearing breathable fabrics such as cotton is recommended." E)"Avoid use of perfumes." Skin affected with atopic dermatitis is sensitive. Care to avoid irritants and triggers should be avoided. Fabrics such as wool and synthetics can be irritating. Cotton is recommended. Moisturizing the skin is beneficial. Using unscented lotion and petroleum jelly can be used. Limit exposure of the skin to perfumes and dyes in skin care and bathing products.

The nurse is discussing dermatitis with the parents of an affected child. When addressing nonpharmacological options for managing the condition what information can be included? Select all that apply. A)"Avoid irritating fabrics such as wool." B)"Wearing breathable fabrics such as cotton is recommended." C)"Apply moisturizers throughout the day." D)"Vigorously towel dry to increase blood flow to affected areas." E)"Avoid use of perfumes."

A)Keloid The hypertrophied, elevated, irregular scar would be documented as a keloid. Lichenification refers to thickening and roughening of the skin or accentuated skin markings that may be due to repeated rubbing, irritation, or scratching. A nodule refers to an elevated, palpable solid mass that extends into the dermis. Cicatrix is another term used to denote a scar.

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following? A)Keloid B)Lichenification C)Nodule D)Cicatrix

D. CARRIER

A CLIENT WITH GONORRHEA IS THE? A. PATHOGEN B. VIRULENCE C. SPECIFICITY D. CARRIER

A) MAY HAVE A LATEX ALLERGY. MOST CONDOMS ARE MADE OF LATEX. THE CLIENT WHO EXPERIENCES ITCHING, SWELLING, HIVES, OR OTHER SYMPTOMS AFTER CONTACT WITH A CONDOM MAY HAVE A LATEX ALLERGY.

THE NURSE IS CONDUCTING A HEALTH HISTORY OF A PREOPERATIVE CLIENT. THE CLIENT SHARES THAT SHE EXPERIENCED VAGINAL ITCHING AND BURNING AND LABIAL SWELLING AFTER HER PARTNER TRIED A NEW BRAND OF CONDOMS. THE NURSE SUSPECTS THAT THE CLIENT: A) MAY HAVE A LATEX ALLERGY. B) MAY HAVE A SEXUALLY TRANSMITTED DISEASE. C) NEEDS TO CHANGE HER POSITION DURING INTERCOURSE. D) IS SUSCEPTIBLE TO THE LUBRICANT.

C) "I WILL AVOID USING SOAP AND WATER ON THE AFFECTED AREA AND WILL APPLY AN EMOLLIENT CREAM ON THIS AREA FREQUENTLY."

TO TREAT A CHILD'S ATOPIC DERMATITIS, A PHYSICIAN ORDERS A TOPICAL APPLICATION OF HYDROCORTISONE CREAM TWICE DAILY. AFTER MEDICATION INSTRUCTION BY THE NURSE, WHICH STATEMENT BY THE PARENT INDICATES EFFECTIVE TEACHING? A) I WILL SPREAD A THICK COAT OF HYDROCORTISONE CREAM ON THE AFFECTED AREA AND WILL WASH THIS AREA ONCE A WEEK." B) "I WILL GENTLY SCRAPE THE SKIN BEFORE APPLYING THE CREAM TO PROMOTE ABSORPTION." C) "I WILL AVOID USING SOAP AND WATER ON THE AFFECTED AREA AND WILL APPLY AN EMOLLIENT CREAM ON THIS AREA FREQUENTLY." D) "I WILL APPLY A MOISTURIZING CREAM SPARINGLY AND WILL WASH THE AFFECTED AREA FREQUENTLY."

A)Hyperbilirubinemia Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to an increased hemolysis. Complications of this process include hyperbilirubinemia.

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication? A)Hyperbilirubinemia B)Respiratory distress syndrome C)Transient tachypnea D)Polycythemia

A)Topical mupirocin ointment D)Cool compresses to assist in removing crusts on vesicles E)Regular hygiene measures

The nurse is caring for a child with a skin disorder. The child presented with papules that progressed to vesicles with a honey-colored exudate. What treatment would the nurse expect to be ordered to treat this disorder? Select all that apply. A)Topical mupirocin ointment B)Warm compresses after washing with soap and water several times a day C)Oral cephalexin D)Cool compresses to assist in removing crusts on vesicles E)Regular hygiene measures

A)Exudate containing white blood cells, protein, and tissue debris A purulent or suppurative exudate contains pus, which is composed of degraded white blood cells, proteins, and tissue debris. Fibrinous exudates contain large amounts of fibrinogen. Serous exudates are watery fluids low in protein. Hemorrhagic exudates occur when there is severe tissue injury that causes damage to blood vessels or when there is significant leakage of red cells

The nurse is reviewing assessment documentation of a client's wound and notes "purulent drainage." The nurse would interpret this as: A)Exudate containing white blood cells, protein, and tissue debris B)Exudate containing large amounts of fibrinogen C)Exudate that is watery fluid, low in protein D)Exudate that resulted from leakage of red cells

B)"The largest organ of the body helps regulate body temperature." The skin is the largest organ of the body. The skin helps regulate the body temperature by heating and cooling. The sebaceous and sweat glands are not fully functional until middle childhood. The major role of the skin is to protect the organs and structures of the body against bacteria, chemicals, and injury. Excretion in the form of perspiration is also a function of the skin glands, called the sweat glands. Sebaceous glands in the skin secrete oils to lubricate the skin and hair. The integumentary system is in place at birth, but the system is immature. A function of the respiratory system is to distribute oxygen to body cells.

The nurse is reviewing the integumentary system during a presentation to a group of nurses. Which statement made by the nurse is the most accurate regarding the integumentary system? A)"The sebaceous and sweat glands are fully functional in the infant." B)"The largest organ of the body helps regulate body temperature." C)"The integumentary system is not in place until after the child is born and then takes many years to mature." D)"One role of the integumentary system is to distribute oxygen to the body cells."

A)"Eosinophils are a type of white blood cell that are often elevated with atopic dermatitis. These are part of the CBC and helps in making the diagnosis." Atopic dermatitis is a type of allergic skin disorder, not a bacterial infection, in which the eosinophil count is often elevated. This is one test that will help in diagnosing the disorder. This explanation addresses the parents' question.

The parents of a child diagnoses with atopic dermatitis ask the nurse, "My child has a skin disorder. I don't understand why a complete blood count (CBC) was ordered?" What is the appropriate response by the nurse? A)"Eosinophils are a type of white blood cell that are often elevated with atopic dermatitis. These are part of the CBC and helps in making the diagnosis." B)"The complete blood count is a routine test used anytime there is an abnormal condition in the body." C)"This test will help in determining the type of bacteria that is causing this infection." D)"This is just another tool to help rule out any other disorders that can be causing this skin disorder. There will be other lab tests ordered as well."

C) FOLLOW THE DIETARY AND FLUID RESTRICTIONS AND BOWEL PREPARATION PROCEDURES FOR A PATIENT DUE TO UNDERGO A PROCTOSIGMOIDOSCOPY, IT IS ESSENTIAL THAT THE PATIENT FOLLOWS THE DIETARY AND FLUID RESTRICTIONS AND BOWEL PREPARATION PROCEDURES IF THE EXAMINATION INVOLVES THE LOWER GI STRUCTURES. FOR THE PATIENT UNDERGOING AN ESOPHAGOGASTRODUODENOSCOPY (EGD), IT IS NECESSARY FOR THE PATIENT TO SPRAY OR GARGLE WITH A LOCAL ANESTHETIC. THE PATIENT IS NOT ADVISED TO CONSUME THREE QUARTS OF WATER AND IS NOT ADVISED TO VOID BEFORE THE TEST. THESE INTERVENTIONS MAY BE ESSENTIAL FOR TESTS THAT INVOLVE ULTRASONOGRAPHIC PROCEDURES.

WHICH OF THE FOLLOWING SHOULD BE INCLUDED AS PART OF THE PREPROCEDURE TEACHING FOR A PATIENT SCHEDULED FOR A PROCTOSIGMOIDOSCOPY INVOLVING THE LOWER GI STRUCTURES? A) CONSUME AT LEAST THREE QUARTS OF WATER 30 MINUTES BEFORE THE TEST B) DO NOT VOID FOR AT LEAST 30 MINUTES BEFORE THE TEST C) FOLLOW THE DIETARY AND FLUID RESTRICTIONS AND BOWEL PREPARATION PROCEDURES D) SPRAY OR GARGLE WITH A LOCAL ANESTHETIC

D) I NEED TO TREAT THIS INFECTION SO IT DOESN'T SPREAD INTO MY PELVIS BECAUSE I WANT TO HAVE CHILDREN SOME DAY." CHLAMYDIA IS A COMMON CAUSE OF PELVIC INFLAMMATORY DISEASE AND INFERTILITY. IT DOESN'T AFFECT THE KIDNEYS OR CAUSE BIRTH DEFECTS. IT CAN CAUSE CONJUNCTIVITIS AND RESPIRATORY INFECTION IN NEONATES EXPOSED TO INFECTED CERVICOVAGINAL SECRETIONS DURING DELIVERY. USE OF A DIAPHRAGM ISN'T A RISK FACTOR.

WHICH STATEMENT MADE BY A CLIENT WITH A CHLAMYDIAL INFECTION INDICATES UNDERSTANDING OF THE POTENTIAL COMPLICATIONS? A) "I'M GLAD I'M NOT PREGNANT; I'D HATE TO HAVE A MALFORMED BABY FROM THIS DISEASE." B) "I HOPE THIS MEDICINE WORKS BEFORE THIS DISEASE GETS INTO MY URINE AND DESTROYS MY KIDNEYS." C) "IF I HAD KNOWN A DIAPHRAGM WOULD PUT ME AT RISK FOR THIS, I WOULD HAVE TAKEN BIRTH CONTROL PILLS." D) I NEED TO TREAT THIS INFECTION SO IT DOESN'T SPREAD INTO MY PELVIS BECAUSE I WANT TO HAVE CHILDREN SOME DAY."