Adaptive Quizzing - Integumentary System
43. Which action would the nurse take when preparing to change a client's dressing using surgical asepsis? Keep the area free of microorganisms. Protect self from microorganisms in the wound. Confine the microorganisms to the surgical incision site. Limit the number of opportunistic microorganisms to a minimum.
A
12. A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. Which response by the nurse is therapeutic? a. "Why did you sign the consent?" b. "Tell me why you want to refuse the procedure." c. "You are obviously afraid about something concerning the procedure." d. "Although the procedure is very important, I understand why you changed your mind."
B
123. The nurse notices an isolated erythematous pustule with hair growing from the enter of the lesion in the buttock of a client. Which diagnosis can the nurse anticipate being documented in the client's electronic medical record? Cellulitis Folliculitis Candidiasis Dermatophytosis
B
14. A client reports facial lesions that are surrounded by redness and cause itching. On assessment, the lesions are found to be thick with a honey-colored crust and surrounded by erythema. Which infection is suspected by the primary health care provider? a. Shingles b. Impetigo c. Folliculitis d. Verruca vulgaris
B
16. The nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client asks what to do about itchy, dry skin. Which response by the nurse is appropriate? a. "Wear plenty of warm clothes to keep moisture in the skin." b. "Use a moisturizer on the skin daily to help reduce itching." c. "Take hot tub baths only twice a week to reduce drying of the skin." d. "Expose the skin to the air to help reduce the sensation of itching."
B
22. Which term would the nurse use to document a 1 cm elevated solid lesion noted on a client's skin? a. Papule b. Nodule c. Vesicle d. Pustule
B
36. The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury? a. Hypokalemia and hyponatremia b. Hyperkalemia and hyponatremia c. Hypokalemia and hypernatremia d. Hyperkalemia and hypernatremia
B
38. Which characteristic mental change occurs with delirium and differentiates it from dementia? Select all that apply. One, some, or all responses may be correct. a. Daytime sleepiness b. Rapid-onset confusion c. Lasts over several years d. Progressive deterioration e. Apathetic thought process
B
35. Which description is common to zosteriform-type lesions? a. Wide distribution b. Diffuse distribution c. Bilateral distribution d. Band-like distribution
D
98. A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. Which condition will the nurse assess the client for during the return visit to the radiology department? Ataxia Hypoxia Arthralgia Dysphagia
D
33. Which condition presents as chalk white patches on the skin? a. Vitiligo b. Jaundice c. Cyanosis d. Erythema
A
118. Which type of allergic condition of the skin manifests in the client as delated hypersensitivity? Urticaria A medication reaction Atopic dermatitis Contact dermatitis
D
124. While assessing the skin of a client, the nurse observes weeping papules, fissuring, and lichenification on the client's foot. The nurse would anticipate teaching the client about which disorder? Medication eruption Atopic dermatitis Contact dermatitis Nonspecific eczematous dermatitis
D
10. Which information would the nurse include in a community education session on decreasing the risk for musculoskeletal injuries? Select all that apply. One, some, or all responses may be correct. a. Use of seatbelts b. Obeying speed limits c. Wearing safety equipment d. Avoiding impaired vehicle use e. Refraining from distracted driving
A, B, C, D, E
94. Which teaching point would the nurse provide to help an aging client prevent skin complications related to decreased sebum gland production? "Use soap with a high fat content." "Do not squeeze your nasal pores." "Lower the water heater temperature." "Avoid frequent bathing with hot water."
B
20. A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? a. Client with shock b. Client with anemia c. Client with epilepsy d. Client with peripheral vascular disease
C
101. Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct. Lopsided smile Unilateral vision Incoherent speech Unable to raise right arm Symptoms started 2 hours ago
A, B, C, D, E
56. Which medication would be prescribed for the client to treat severe nodulocystic acne? Imiquimod Isotretinoin Clindamycin Corticosteroids
B
116. Which clinical finding is associated with a skin assessment of decreased thickness and excessive dryness of the epidermis? Skin tears Skin cancer Skin fragility Skin hyperplasia
C
3. The client reports crumbly, discolored, and thickened toenails. What could be the possible reason for this condition? a. Allergy b. Insect bite c. Fungal infection d. Bacterial infection
C
122. The nurse is caring for a client admitted for removal of basal cell carcinoma and reconstruction of the nose. Which contributing factor would the nurse question the client about when collecting a health history? Dietary patterns Familial tendencies Amount of tobacco use Ultraviolet radiation exposure
D
55. Which side effects are related to oral psoralen in phototherapy? Select all that apply. One, some, or all responses may be correct. Atrophy Sunburn Mucositis Ocular damage Persistent pruritus
B, E
115. Which findings are expected when assessing the skin of an older adult? Select all that apply. One, some, or all responses may be correct. Scaly skin Tenting of skin Transparent skin Increased wrinkles Pigmented lesions
B, C, D, E
24. While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent which complication? a. Renal calculi b. Disorientation c. Pressure injuries d. Urinary infection
C
6. Which description is associated with a hematoma? a. The occurrence of redness in patches of variable size and shape b. The thickening of the skin with accentuated normal skin markings c. The visible swelling due to extravasation of blood of sufficient size d. The pinpoint, discrete deposits of blood in the extravascular tissues
C
64. The nurse observes elevated superficial lesions filled with purulent fluid on a client's skin. Which type of lesion would the nurse document on the health record? a. Wheal b. Plaque c. Pustule d. Vesicle
C
102. Which nursing action would be included in the plan of care to promote the nutritional status of a client during the acute phase of treatment after extensive burns? Provide a diet high in sodium. Limit caloric intake to decrease the work of the body. Reduce protein intake to avoid overtaxing the kidneys. Administer the prescribed intravenous fluid with the added vitamin C.
D
69. Which benign tumor forms on the surface of the client's epithelium? a. Fibroma b. Adenoma c. Papilloma d. Chondroma
C
31. Which is the most important topic to include in teaching to promote the comfort of a client with a pruritic skin disease? a. Sleep b. Exercise c. Elimination d. Hand hygiene
A
105. The nurse is caring for a client who returns from surgery with a drain that is attached to a portable wound drainage system exiting from the surgical site. Which principle underlying the function of a portable drainage system will the nurse consider when planning care for this client? Gravity Osmosis Active transport Negative pressure
D
106. When teaching an older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding? "I should gently pat my skin." "I should use mild, heavily fatted soap." "I should wash my skin with tepid, rather than hot water." "I should apply powders or talc on a perineum wound."
D
11. Which finding could be described as visibly dilated, superficial, and cutaneous small blood vessels found on the face and thighs? a. Tenting b. Angioma c. Varicosity d. Telangiectasia
D
110. The nurse is caring for a client who is scheduled to have a pigskin graft applied to a burned area. About which type of graft will the nurse educate the client? Isograft Allograft Homograft Heterograft
D
112. Which disorder would the nurse suspect in the client who has blue nail beds? Thrombocytopenia Polycythemia vera Iron-deficiency anemia Cardiopulmonary disease
D
90. A client reporting hair loss describes using straightening combs. Which condition would the nurse suspect? a. Vitiligo b. Nevus of Ota c. Pseudofolliculitis d. Traction alopecia
D
96. A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which response by the nurse would be the best explanation to give to the client? "Bed rest will decrease catabolism to promote healing at the site of injury." "Bed rest will lower your metabolic rate in an attempt to help reduce the fever." "Bed rest will reduce the energy demands on your body in the presence of infection." "Bed rest limits muscle contractions that may force bacteria into the bloodstream."
D
52. Which condition is likely in a client who has an interruption of venous return? Tenting Varicosity Petechiae Ecchymosis
B
59. The nurse is providing care for a client who has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action would the nurse take postoperatively? Maintain intermittent low suction to limit trauma. Cleanse the area around the insertion site to prevent skin breakdown. Attach the tube to a negative-pressure drainage system to promote drainage. Reposition the client frequently to increase the flow of bile through the tube.
B
57. Which point would the nurse include in a teaching plan to help manage pain during dressing changes if a client has burns over 18% of body surface? Deep breathing exercises Progressive muscle relaxation Active range-of-motion exercises Important elements of wound care
A
80. A client newly diagnosed with scleroderma states, "Where did I get this from?" How would the nurse reply? a. "The exact cause is unknown, but it is thought to be a result of autoimmunity." b. "The exact cause is unknown, but it is thought to be a result of ocular motility." c. "The exact cause is unknown, but it is thought to be a result of increased amino acid metabolism." d. "The exact cause is unknown, but it is thought to be a result of defective sebaceous gland formation."
A
82. Which body part would be examined to assess for jaundice in a dark-skinned client? a. Hard palate b. Conjunctivae c. Palms and soles d. Sclera adjacent to conjunctiva
A
83. Which action would be the nurse's first priority when receiving a client with major burns? a. Assessing airway patency b. Checking the client from head to toe c. Administering oxygen as needed d. Elevating the extremities if no fractures are noticed
A
2. Which changes with a client's hair would be responsible developing white hair at the age of 23? a. Decreased oils b. Decreased density c. Decreased estrogen levels d. Decreased melanocytes
D
46. Which lesions are considered primary lesions? Scales Ulcers Fissures Erosions
D
9. A dark-skinned client has a gray-colored tongue and lips. Which complication does the nurse suspect? a. Cyanosis b. Jaundice c. Bleeding d. Inflammation
A
27. Which skin color alteration may be observed in a client diagnosed with methemoglobinemia? a. Red b. Blue c. White d. Yellow-orange
B
92. While providing care for an obese client who underwent an open cholecystectomy, the nurse identifies a separation in the surgical incision. Which complication is the client experiencing? Adhesions Dehiscence Evisceration Contractions
B
29. Which information about skin care would the nurse include in the teaching plan for a client who is receiving radiation therapy? a. "Cover the area with a sterile gauze bandage." b. "Put warm compresses on the site once a day." c. "Limit lying on the back and unaffected side when sleeping." d. "Avoid applying lotions and powders over the area."
D
45. Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound? Electrical stimulation Topical growth factors Hyperbaric oxygen therapy Negative pressure wound therapy
D
68. Which finding would indicate that a client needs to be evaluated by the health care provider for Alzheimer disease (AD)? Select all that apply. One, some, or all responses may be correct. a. Forgets home address b. Has difficulty multitasking c. Unable to find food in freezer d. Neglects balancing checkbook e. Wears pajama bottoms to store
A
7. Which color would the nurse anticipate when assessing a client's skin tears? a. Red b. Gray c. Black d. Yellow
A
95. The primary health care provider advises the client to apply 0.9% spinosad topical suspension to scalp and hair. Which causative organism would the nurse anticipate for the client's condition? Tick Lice Mite Bees
B
1. Which skin damage is caused by chronic exposure to ultraviolet rays? Select all that apply. One, some, or all responses may be correct. a. Dryness b. Photoaging c. Vascular lesions d. Wrinkling of skin e. Benign neoplasm
B photoaging D Wrinkling of skin The skin damages that happen from chronic exposure to ultraviolet rays are photoaging and skin wrinkling. Dryness, vascular lesions, and benign neoplasm are changes related to aging.
15. Which gastrointestinal (GI) change may be found in the client with burn injuries? a. Abdominal distention b. Increased peristalsis c. Activation of GI motility d. Increased blood flow to the GI area
A
18. A client with a skin infection reports an itching sensation associated with pain at the site of infection. The assessment finding shows erythematous blisters and interdigital scaling and maceration. The nurse would expect to teach the client about which condition? a. Tinea pedis b. Tinea cruris c. Tinea corporis d. Tinea unguium
A
47. The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? Decreased rate of glomerular filtration Excessive blood loss through the burned tissues Plasma proteins moving out of the intravascular compartment Sodium retention occurring as a result of the aldosterone mechanism
C
5. A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? a. "Bathing will not be permitted." b. "Dressings will be changed daily." c. "Personal protective equipment will be worn by staff." d. "Room temperature will be kept below 72ºF [22.2ºC]."
C
91. Which type of burn injury should be followed up by scheduling the client for an electrocardiogram (ECG)? Flame burn Chemical burn Electrical burn Radiation burn
C
114. While assessing the skin of a light-skinned client, the nurse concludes that the client has ecchymosis. Which skin color variation would confirm this diagnosis? Gray color Dark red color Deep brown color White color
B
13. Which is a serious side effect of x-rays? a. Vesicles b. Papular c. Desquamation d. Plaque-like lesions
C
49. Which information would the nurse consider when planning care for a client with scabies? Scabies is highly contagious. It is caused by a fungus. Chronic with exacerbations are classic symptoms. There is a correlation with other allergies.
A
42. Which organism infestation is diagnosed with the help of the mineral oil test? Lice Ticks Mites Fungus
C
58. Which integumentary change is associated with delayed wound healing in a client? Decreased cell division Decreased epidermal thickness Decreased immune system cells Increased epidermal permeability
A
62. A client has bright-red erythematosus macules and papules on the skin. The nurse would expect to teach the client about which condition? a. Medication eruption b. Atopic dermatitis c. Contact dermatitis d. Nonspecific eczematous dermatitis
A
25. Which changes to the client's skin are caused by the atrophy of eccrine sweat glands? a. Ecchymosis b. Dry skin c. Wrinkles d. Skin shearing
B
117. Which physiological activity is associated with the "proliferative phase" of normal wound healing? White blood cells migrate into the wound. Epithelial cells grow over the granulation tissue. Scar tissue gradually becomes thinner and pale. Vasodilation occurs with increased capillary permeability.
B
103. An older adult client with postherpetic neuralgia reports deep tissue pain. Which skin infection does the nurse expect to observe in the client's electronic medical record? Cellulitis Candidiasis Herpes zoster Herpes simplex
C
111. Which skin color change would the nurse expect to see if a client with dark skin develops cyanosis? Gray Purple Dark red Purple-to-brownish
A
104. A client is scheduled for skin cancer surgery and has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent? Ambivalent feelings are present and acknowledged. A sedative type of medication has been given recently. A complete history and physical has not been performed and recorded. A discussion of alternatives with two primary health care providers has not occurred.
B
26. Which assessment finding is associated with chronic eczema? a. Localized edema b. Rough, thick skin c. Decreased skin turgor d. Increased skin temperature
B
119. When teaching a client with pruritus about person care interventions, which client statement indicates understanding of the interventions? "I will trim my fingernails regularly." "I will apply moisturizing before my bath." "I will avoid filing the edges of fingernails into oval shapes." "I will use baby powder or talc in my groin areas."
A
121. Which type of burn or injury may cause a client to have a cervical spine injury? Electrical burns Chemical burns Inhalation injury Cold thermal injury
A
108. Which skin lesion presents as a firm, edematous, irregularly shaped lesion on a client who reports an insect bite? Wheal Plaque Vesicle Pustule
A
37. Which risk would the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn? a. The risk of septicemia and its potential complications from treatment b. The risk of psychosocial adjustment and resuming previous roles c. The risk of oral mucous membrane injury and its associated risks d. The of insufficient community resources and emotional support
A
4. Which function of the dermis is accurate? a. Provides cells for wound healing b. Assists in retention of body heat c. Acts as mechanical shock absorber d. Inhibits proliferation of microorganisms
A
40. Which medication can cause chemical burns? a. Anthralin b. Prednisone c. Tazarotene d. Calcipotriene
A
71. Which information would the nurse include in a teaching plan for a client whose burns are being treated with the exposure (open) method? a. Aseptic techniques are required. b. Plants, but not flowers, are allowed. c. Equipment will be shared with others. d. Dressings will be changed every 3 days.
A
88. A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which nursing intervention would be included in the plan of care when providing wound care for this client? a. Use a consistent approach to care and encourage participation. b. Prepare equipment while doing the procedure and explain the treatment to the client. c. Rinse the burn area with 105ºF (40.6ºC) water to prevent loss of body temperature. d. Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done.
A
97. A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges are curling up and asks the nurse about it. Which is the best response by the nurse? "May I take a look at it?" "It's time for another graft." "Is there any sign of redness?" "It is supposed to curl up at the edges."
A
109. The nurse is caring for a client with severe burns 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? Milk Tea Orange juice Tomato juice
B
39. Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? a. Atrophy of the sweat glands b. Decreased subcutaneous fat c. Stiffening of the collagen fibers d. Degeneration of the elastic fibers
B
70. The nurse is providing postoperative care for a client and assess that the skin around the client's T-tube is war and excoriated. Which intervention would the nurse implement? a. Reinforce the dressing when it is wet. b. Use a skin barrier around the tube's exit site. c. Cleanse around the site with an antiseptic solution. d. Change the type of adhesive tape on the dressing.
B
107. Which intervention relieves integumentary itching, promoting comfort of the client exposed to poison ivy? Saline rinse Cold therapy Heat therapy Wet compress
D
120. A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up? "I will leave the skin markings intact." "I will protect the skin from sources of heat." "I will wear soft clothing over the upper body." "I will use an oatmeal-based lotion after each treatment."
D
125. Which finding would the nurse identify as normal inflammation versus an infection when assessing a client's wound that was sutured 72 hours ago? Client report of increasing pain A temperature of 101.6ºF (38.6ºC) Small amounts of purulent drainage A slight red border around the wound
D
19. A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which directions will the nurse include in the teaching plan? a. Trimming toenails so that they are short and rounded b. Checking bathwater temperature by putting the toes in first c. Using alcohol to rub hands, feet, legs, and arms at least two times a day d. Seeking professional treatment for any minor injuries to the extremities
D
48. A client who has been bitten by a raccoon states, "Where I live, there seems to be raccoons and wild animals everywhere." Which information would the nurse consider about rabies when planning care for this client? Rabies is a bacterial infection characterized by encephalopathy and opisthotonos. Rabies is an acute bacterial septicemia that results in convulsions and a morbid fear of water. Rabies is a nonspecific immune response to organisms deposited under the skin by an animal bite. Rabies is an acute viral infection, characterized by convulsions and difficulty swallowing.
D
78. The nurse teaches a client about strategies to reduce burn injuries. Which statement made by the client indicates the need for further teaching? a. "I should never smoke in bed." b. "I should never use gasoline to start a fire." c. "I should never leave hot oil unattended while cooking." d. "I should never leave burning candles near open curtains unattended."
D
85. Which role does vitamin C have in wound healing? a. It aids in the process of epithelialization. b. Vitamin C helps in the synthesis of immune factors. c. It increases the metabolic energy required for inflammation. d. Vitamin C is required for collagen production by fibroblasts.
D
73. A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. Which is the nurse's best response? a. "This type of schedule gives noncancerous cells time to recover." b. "The department only operates from Monday through Friday." c. "Your energy level will be increased greatly by a 5-day schedule." d. "Side effects are eliminated when treatment is administered for 5 rather than 7 days."
A
113. A client has thin, dark red vertical lines about 1 to 3 mm long in the nails. Which diseases are associated with this physiologic alteration in the client? Select all that apply. One, some, or all responses may be correct. Psoriasis Trichinosis Cardiac failure Diabetes mellitus Bacterial endocarditis
B, E
87. A client with vesiculopustular lesions with honey-colored crusts on the face visits a primary health care provider. Which bacterial condition is suspected? a. Cellulitis b. Impetigo c. Carbuncle d. Erysipelas
B
89. A state's Nurse Practice Act does not allow a RN to suture wounds. The primary health care provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action would the nurse take? a. Refuse to suture wounds. b. Follow the primary health care provider's instructions. c. Agree to suture wounds in the primary health care provider's presence. d. Report the situation to the state board of nursing (Canada: Provincial/Territorial RN Association).
A
93. A client is burned on the anterior part of both legs, from the knees to the feet. Which percentage of total body surface area (TBSA) burned would the nurse document in the client's hospital record, using the rule of nines? 9% 18% 27% 36%
A
99. A person on the beach sustains a deep partial-thickness sunburn. Which first-aid measure would the nurse recommend before the client seeks health care? Cool, moist towels Dry, sterile dressings Analgesic sunburn spray Vitamin A and D ointment
A
100. The nurse examines the wound of a client and notes greenish-blue pus. Which organism does the nurse suspect? Colonization with Proteus Colonization with Pseudomonas Colonization with Staphylococcus Colonization with aerobic coliform and Bacteroides
B
17. A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which dietary adjustment would the nurse recommend? a. Increase low-sodium milk intake. b. Provide high-protein drinks. c. Increase foods that are low in potassium. d. Provide 10% more calories in the form of fats.
B
28. Which predisposing condition may be present in a client with pitting edema? a. Shock b. Kidney disease c. Hypothyroidism d. Severe dehydration
B
30. A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall? a. Partial-thickness burns require grafting before they can heal. b. Partial-thickness burns are often painful, reddened, and have blisters. c. Partial-thickness burns cause destruction of both the epidermis and dermis. d. Partial-thickness burns often take months of extensive treatment before healing.
B
34. Which type of asepsis is the nurse using when he or she washes his or her hands before changing a client's postoperative dressing? a. Wound asepsis b. Medical asepsis c. Surgical asepsis d. Concurrent asepsis
B
66. Which skin lesion is found in clients with acne? a. Wheal b. Plaque c. Vesicle d. Pustule
D
74. Which lesion may alter skin turgor? a. Cysts b. Patches c. Macules d. Lichenification.
D
75. Which technology will be used for the treatment of electrical burns? a. Skin substitutes b. Electrical stimulation c. Topical growth factors d. Hyperbaric oxygen therapy
D
81. A primary health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. The application of local heat transferring temperature to the body is which principle? a. Radiation b. Insulation c. Convection d. Conduction
D
84. A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection. Which rationale explains the nurse's comments? a. Poor personal hygiene is the cause. b. Inadequate dietary intake is the cause. c. The client's developmental level is the cause. d. A procedure performed at the hospital is the cause.
D
63. Which client conditions does the nurse associate with bluish-colored mucous membranes? Select all that apply. One, some, or all responses may be correct. a. Edema b. Diabetes mellitus c. Hemochromatosis d. Methemoglobinemia e. Cardiopulmonary disease
D, E
21. Which fungal infection is commonly referred to as athlete's foot? a. Tinea pedis b. Tinea cruris c. Tinea corporis d. Tinea unguium
A
44. A client who has been in a coma for 2 months is being maintained on bed rest. At which angle will the nurse place the head of the bed to prevent the effects of shearing force? 30 degrees 45 degrees 60 degrees 90 degrees
A
53. Which example is associated with third spacing in a burn injury? Blister formation Edema formation Fluid mobilization Fluid accumulation
A
65. While assessing the skin of a client, the nurse notices an elevated, solid lesion measuring 4 mm × 4 mm in size. Which type of lesion does the client have? a. Papule b. Vesicle c. Pustule d. Macule
A
67. Which variations in nail color would indicate that a client has trauma to the nail beds? a. Red color b. Blue color c. White color d. Yellow-brown color
A
72. Which condition would be associated with nonpitting edema over the tibia? a. Endocrine imbalance b. Inflammatory response c. Fluid and electrolyte imbalance d. Venous and cardiac insufficiency
A
76. Which type of debridement would the health care provider schedule for a client who requires removal of large amounts of nonviable tissue, quickly? a. Surgical debridement b. Autolytic debridement c. Enzymatic debridement d. Mechanical debridement
A
86. Which percentage will the nurse calculate for total body surface area (TBSA) burned for an adult client who has burns to the genitalia? a. 1% b. 4.5% c. 9% d. 18%
A
41. Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. Monitoring vital signs Cutting off the clothing Inserting a urinary catheter Removing the client's jewelry Establishing an intravenous line
A, B, C, D, E
32. Which functions are related to the subcutaneous layer of skin? Select all that apply. One, some, or all responses may be correct. a. It provides insulation. b. It acts as an energy reservoir. c. It prevents systemic dehydration. d. It provides cells for wound healing. e. It acts as a mechanical shock absorber.
A, B, E
50. Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply. One, some, or all responses may be correct. Burns Skin cancer Osteomyelitis Diabetic ulcers Myocardial infarction
A, C, D
79. Which information may be obtained by palpation. Select all that apply. One, some, or all responses may be correct. a. Turgor b. Bruises c. Texture d. Lesions e. Moisture content f. Petechiae
A, C, D, E
77. Which dressing technique promotes autolysis in the spontaneous separation of necrotic tissue? a. Continuous wet gauze b. Moisture-retentive covering c. Topical enzyme preparations d. Wet-to-dry damp saline moistened gauze
B
23. A client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information would the nurse include in the teaching plan? a. "Rinse the mouth 3 times a day with lemon juice and water." b. "Brush the teeth once daily and use dental floss after each meal." c. "Clean the mouth with a soft toothbrush or a gentle spray." d. "Gently clean the mouth with commercial mouthwash."
C
8. A client sustained minor skin injuries after an accident. Which event occurs close to the time of injury? a. Thinning of the scar tissue b. Formation of granulation tissue c. Migration of leukocytes to the site of injury d. Arrival of fibroblasts to the site of infection
C
60. Which factors put a client at risk for bacterial infections? Select all that apply. One, some, or all responses may be correct. Dry skin Underweight Atopic dermatitis Diabetes mellitus Systemic antibiotics
C, D, E
51. The nurse is teaching campfire safety to a group of community members and includes information about what to do if a person catches on fire. The nurse teaches the most effective method for putting out the flames. Which information from the group members indicates successful learning? Wrap hand with towel and slap at the flames. Instruct the victim to roll on the ground. Pour cold liquid over the flames. Remove the victim's burning clothes.
B
54. Which change in the epidermis causes increased risk of sunburn? Decreased cell division Decreased melanocyte activity Decreased vitamin D production Decreased immune system cells
B
61. The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? a. Fluid volume b. Skin integrity c. Physical mobility d. Urinary elimination
B
