ATI_AQ_MED-SURG_Dermatological

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? A. Zoster vaccine B. Acyclovir C. Amoxicillin D. Infliximab

Acyclovir *The nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster

A nurse is assisting with the development of a program to educate clients about measure to reduce the risk of skin cancer. Which of the following instructions should the nurse include? A. Re-apply sunscreen every 4 hr during sun exposure B. Wear a sun visor instead of a hat when outside in the sun C. Avoid exposure to the midday sun D. Use a tanning booth instead of sunbathing outdoors

Avoid exposure to the midday sun *The nurse should instruct clients to avoid sun exposure to the sun between 1100 and 1500 when sun rays are the strongest

A nurse in a dermatology clinic is using the ABCDE method while screening several of a client's skin lesions for skin cancer. Which of the following findings should the nurse report to the provider? A. Symmetric shape B. Border regularity C. Color variation within a lesion D. Diameter >4 mm

Color variation within a lesion *The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. A stands for asymmetric shape. B stands for border irregularity. D stands for Diameter >6 mm. E stands for evolving or changing in any feature of the lesion

A nurse is reinforcing teaching with a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? A. Subcutaneous B. Epidermis C. Dermis D. Stratum corneum

Epidermis *Basal cell carcinoma originates from the epidermal layer of the skin. It is the most common form of cancer

A nurse is screening a client for skin cancer. When reinforcing teaching with the client about skin cancer risk, which of the following risk factors should the nurse include? A. Cigarette smoking B. Low-fiber diet C. Excessive exposure to ultraviolet light D. Human papillomavirus

Excessive exposure to ultraviolet light *Excessive exposure to ultraviolet (e.g. from sunlight or tanning beds), occupational exposure to chemical carcinogens, and chronic skin irritation are risk factors for skin cancer

A nurse is assisting with the admission of a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? A. IV B. I C. III D. II

II *With a stage II pressure ulcer, there is a partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer can become infected. The client might report pain, and there might be a small amount of drainage

A nurse in an urgent care clinic is caring for a client who has a snakebite on her arm. Which of the following actions should the nurse take? A. Immobilize the limb at the level of the heart B. Apply a tourniquet to the affected limb C. Use a sterile scapula to incise the wound D. Apply ice to the skin over the snakebite wound

Immobilize the limb at the level of the heart *The emergency management of a client who has a snakebite involves limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart

A nurse is caring for a client who has been applying silver sulfadiazine cream to a deep partial-thickness arm burn for the past 2 weeks. The nurse should monitor the client for which of the following adverse effects? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN

Leukopenia *Transient leukopenia is an adverse effect of silver sulfadiazine; therefore, the nurse should monitor the client for an allergic reaction that is causing a decrease in the client's WBC count

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses should the nurse make? A. Basal cell carcinomas B. Melanomas C. Actinic keratoses D. Squamous cell carcinomas

Melanomas *Melanomas are malignant neoplasms with atypical melanocytes in the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases to the bone, liver, lungs, spleen, the CNC, and lymph nodes

A nurse is caring for a client who has smoke inhalation and full-thickness burns covering 64% of her body. Which of the following nursing actions is the nurse's priority? A. Monitor intake and output B. Administer antibiotics C. Monitor respiratory status D. Encourage fluid and food intake

Monitor respiratory status *The priority action the nurse should take when using the ABC approach to client care is to monitor the client's respiratory status closely. Smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from the inflammatory response to heat can obstruct the airway. Endotracheal intubation might become necessary to maintain a patent airway

A nurse in a provider's office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions? A. Papules B. Macules C. Wheals D. Vesicles

Papules *A papule is a small, solid, elevated lesion with distinct borders. It is usually <10 mm in diameter. Warts and elevated moles are examples of papules

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? A. Cadaver skin B. Pig skin C. Amniotic membranes D. Beef collagen

Pig skin *Heterografts are obtained from an animal usually pig *Homographs are obtained from cadaver skin

A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first? A. Estimation of burn injury B. Respiratory rate C. Presence of bowel sounds D. Level of pain

Respiratory rate *ABC priority. Therefore the nurse's priority is to collect data about the client's respiratory status. A client who has burns to the face is at risk for pulmonary injury; the development of rapid, shallow respirations can indicate a respiratory emergency

A nurse is assisting with the care of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL

Sodium 132 mEq/L *The nurse should anticipate a client who is in the resuscitation phase of a burn injury to have a low sodium level because sodium is trapped in interstitual space

A nurse is contributing to the plan of care for a client who has been admitted for the treatment of a malignant melanoma of the upper leg without metastasis. The nurse should expect the provider to perform which of the following procedures? A. Curettage B. External radiation therapy C. Regional chemotherapy D. Surgical excision

Surgical excision *The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide, local excision followed by skin grafting

A nurse is collecting data from a client who is 3 days postoperative following abdominal surgery. The client's incision is slightly edematous, appears pink with crusting on the edges, and is draining serosanguinous fluid. Which of the following statements describes this incision? A. The incision is showing early signs of infection B. The incision is showing early signs of dehiscence C. The incision is showing signs of healing without complications D. The incision is showing signs of developing a fistula

The incision is showing signs of healing without complications *The nurse's findings are consistent with appropriate healing without complications

A nurse is observing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite

Third-degree frostbite *First-degree frostbite, the skin of the affected area is reddened and looks waxy. Second-degree, the skin of the affected area has large, fluid-filled blisters. Third-degree, the skin of the affected area has small blisters that are blood-filled, and the skin does not blanch. Fourth-degree, the skin of the affected area is frozen. Blisters do not appear. The client's muscles and bones are affected

A nurse is reinforcing discharge teaching with a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of malignancy of a mole? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color

Ulceration *Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of a lifetime follow-up evaluations and review the proper techniques for self-examining the skin every month

A nurse is reinforcing teaching with a client who has a large wound healing by secondary intention. The nurse should instruct the client that which of the following nutrients promotes wound healing? A. Vitamin B1 B. Calcium C. Vitamin C D. Potassium

Vitamin C *A diet high in protein and vitamin C is recommended because these nutrients promote wound healing

A nurse is reinforcing teaching with a client who has burn injuries to his trunk about what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be on a special shower table." B. "The water temperature will be very cool to ease my pain." C. "The nurse will use a firm-bristled brush to remove loose skin." D. "The nurse will use scissors to open small blisters."

"I will be on a special shower table." *Hydrotherapy involves a special shower table that facilitates examination and debridement of the wound. By using the showering technique as opposed to a tub bath, the water can be kept at a constant temperature, and there is a lower risk of wound infection

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? A. "May I go with my family to the visitor's lounge?" B. "I'll see my friends someday when I feel better." C. "My dad is coming to visit. Can you fix my fair for me?" D. "I told my cousins I'm in protective isolation."

"May I go with my family to the visitor's lounge?" *The client is asking to visit with her family in a public setting; therefore, this statement demonstrates a positive self-image

A nurse is reinforcing teaching with a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? A. "Move between the bed and the wheelchair once every 2 hours." B. "Make sure that your caregiver massages your skin daily." C. "Use a rubber ring when sitting in the wheelchair." D. "Shift your weight in the wheelchair every 15 minutes."

"Shift your weight in the wheelchair every 15 minutes." *This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure

A nurse is assisting with the development of an education session about malignant melanoma for a group of clients. The nurse should include that which if the following clients has an increased risk of developing malignant melanoma? A. A client who has brown eyes B. A client who has a light complexion C. A client who has black hair D. A client who is 20 years old

A client who has a light complexion *A light complexion and less pigmentation place a client at an increased risk of developing malignant melanoma

A nurse is caring for a client who has regular occupational exposure to sunlight and presents to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder B. Several flat, pigmented, circumcised areas of various sizes over the bridge of the nose C. A raise, circumscribed lesion on the face that contains yellow-white purulent material D. An irregularly shaped brown lesion with light blue areas on the neck

An irregularly shaped brown lesion with light blue areas on the neck *Malignant melanoma, the leading cause of skin cancer death, is a neoplasm of dermal or epidermal cells. Exposure to sunlight increases the risk, with fair-skinned people at the greatest risk. Malignant melanoma commonly starts in exposed skin areas like the back, scalp, face, and neck and metastasizes readily to other areas. Manifestations include a change in the color, size, or shape of a skin lesion and irregular borders in hues of tan, black, or blue

A nurse is caring for a client who has deep partial-and full-thickness burns and requires a topical antimicrobial drug. The goal of this medication therapy is to reduce which of the following outcomes? A. Bacterial growth B. Scarring C. Skin graft size D. Pain

Bacterial growth *Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help prevent bacterial from entering the body when a client has an impairment of the protective covering of the skin like burns. This medication creates a protective barrier, along with the dressing, between bacteria and the exposed body tissues to help prevent infection

A nurse is assisting with planning care for a client who has deep partial-thickness and full-thickness burns over 40% of his body surface. The client is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises B. Use clean technique to provide wound care C. Place the client on a low-protein diet D. Maintain the client on bed rest

Initiate range-of-motion exercises *The nurse should being performing active and passive range-of-motion exercises with the client to maintain mobility and prevent contractures

A community health nurse is reinforcing teaching about melanoma with a group of clients. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching? A. Solid color B. Symmetrical shape C. Less than 6 mm in diameter D. Irregular border

Irregular border *The nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit border irregularity. The nurse should reinforce teaching with clients about the appearance of melanoma lesions, including asymmetry of shape, border irregularity, color variation within a single lesion, diameter greater than 6 mm, and evolving or changing in any feature

A nurse is collecting data from a client who has an arm lesion. Which of the following characteristics is a clinical manifestation of malignant melanoma? A. Rough, dry, and scaly B. Firm nodule with crust C. Pearly papule with an ulcerated center D. Irregularly shaped with blue tones

Irregularly shaped with blue tones *Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on a client's upper back and lower legs

A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A. Partial-thickness burn B. Stage III pressure ulcer C. Surgical incision D. Dehisced sternal wound

Surgical incision *With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention

A nurse is collecting data from a client who sustained superficial partial-thickness and dee partial-thickness burns 72 hours ago. Which of the following findings should the nurse report to the provider? A. Edema in the affected extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1 (102.4F)

Temperature of 39.1 (102.4F) *An elevated temperature is an indication of infection, and the nurse should report the is finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wounds surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms

A nurse is reinforcing discharge teaching about foot care with a client who has diabetes mellitus. Which of the following instructions should the nurse include in the teaching? A. Wear nylon socks with shoes every day B. Trim toenails by rounding the edges of the nail C. Apply lotion between the toes after bathing D. Test water temperature with the wrist

Test water temperature with the wrist *The nurse should instruct the client to test water temperature with the wrist or a thermometer to detect if the water is too hot or too cold. Clients who have diabetes haver peripheral nerve damage, making it difficult to determine temperature and increasing the risk of burns