chapter 43

Question 1

A resident of an assisted living center reports having sharp pain on one side of the body,
with patches of “blisters”. The nurse notices vesicles on one side of the thorax, which follow
a peripheral nerve pathway. Suspecting herpes zoster, the nurse immediately contacts the
health care provider. Which is the reason for the prompt notification?
a. Early recognition is essential to treat the disorder.
b. Prompt notification prevents sexual transmission.
c. Oral ulcers could prevent intake of adequate fluids.
d. Early administration of the varicella vaccine is needed.

Answer 1

a. Early recognition is essential to treat the disorder.

Question 2

Which action will the nurse take when administering a therapeutic bath to a patient who has
severe pruritus from contact dermatitis?
a. Use Burow’s solution to help promote healing.
b. Rub the skin briskly to decrease pruritus.
c. Limit bathing to three times a week.
d. Ensure that bath area is at least 85 degrees and dehumidified.

Answer 2

a. Use Burow’s solution to help promote healing.

Question 3

Several residents in a long term care facility have been diagnosed with herpes zoster. Which
resident will require the closest observation for development of complications?
a. A resident who is sexually active
b. A resident recovering from a hip fracture
c. A resident with dementia who requires assistance eating.
d. A resident who is undergoing chemotherapy for breast cancer

Answer 3

d. A resident who is undergoing chemotherapy for breast cancer

Question 4

A child has been sent to the school nurse with pruritus and honey-colored crusts on the
lower lip and chin. The nurse believes these lesions most likely are caused by which
condition?:
a. chickenpox.
b. impetigo.
c. shingles.
d. herpes simplex type I.

Answer 4

b. impetigo.

Question 5

A school nurse assesses a child who has an erythematous circular patch of vesicles on her
scalp with alopecia and report spain and pruritus. For which reason will the nurse use a
Woods lamp?
a. To dry out the lesions.
b. To reduce the pruritus.
c. To kill the fungus.
d. To cause fluorescence of the infected hairs.

Answer 5

d. To cause fluorescence of the infected hairs.

Question 6

A patient, age 46, reports to the health care provider’s office with urticaria with elevated
lesions that are white in the center with a pale red border on hands and arms. He says, “It
itches like crazy.” Which type of lesion would the nurse include in the documentation?
a. Macules
b. Plaques
c. Wheals
d. Vesicles

Answer 6

c. Wheals

Question 7

The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What
does the S in this guide indicate?
a. Severity of the symptoms
b. Site of the lesions
c. Symptomatology of the lesions
d. Surface area of the lesions

Answer 7

a. Severity of the symptoms

Question 8

Which instruction will the nurse give the patient taking isotretinoin to treat acne?
a. Do not take acetaminophen when using this medication.
b. This medication may cause dry skin or eczema to develop
c. Wear heavy makeup to cover up the acne until this medication takes effect
d. Stay away from school or your friends until this medication begins to take effect.

Answer 8

b. This medication may cause dry skin or eczema to develop

Question 9

A 30-year-old African American had surgery 6 months ago and the incision site is now
raised, indurated, and shiny. This is most likely which type of tissue growth?
a. Angioma
b. Keloid
c. Melanoma
d. Nevus

Answer 9

b. Keloid

Question 10

A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface
area. When would the greatest fluid loss resulting from the burns occur?
a. Within 12 hours after burn trauma
b. 24 to 36 hours after burn trauma
c. 36 to 48 hours after burn trauma
d. 48 to 72 hours after burn trauma

Answer 10

a. Within 12 hours after burn trauma

Question 11

Which is the greatest concern during the emergent phase of a burn injury?
a. joint contractures
b. Fluid overload
c. hypovolemic shock.
d. adrenal failure.

Answer 11

c. hypovolemic shock.

Question 12

A nurse arrives at an accident scene where the victim has just received an electrical burn.
Which is the nurse’s primary concern?
a. The extent and depth of the burn
b. The sites of entry and exit
c. The likelihood of cardiac arrest
d. Control of bleeding

Answer 12

c. The likelihood of cardiac arrest

Question 13

A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72
hours, the nurse will have to observe for which most common cause of burn-relateddeaths?
a. shock.
b. respiratory arrest.
c. hemorrhage.
d. infection.

Answer 13

d. infection.

Question 14

Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood.
Which condition is most likely?
a. Curling ulcer
b. Paralytic ileus
c. Ruptured colon
d. Gastritis

Answer 14

a. Curling ulcer

Question 15

When providing the open method of treatment for a patient who is 52 years old with burns
to the lower extremities, which does the nurse expect to see included in the nursing plan?
a. Change the dressing using good medical asepsis.
b. Provide an analgesic immediately after the dressing change.
c. Perform circulation checks every 2 to 4 hours.
d. Keep the room temperature at 85°F (29.4°C) to prevent chilling.

Answer 15

d. Keep the room temperature at 85°F (29.4°C) to prevent chilling.

Question 16

The nurse has staged a pressure injury that has a shallow crater with a dry pink wound bed
in which way?
a. stage 1.
b. stage 2.
c. stage 3.
d. stage 4.

Answer 16

b. stage 2.

Question 17

Which will the nurse dressing a necrotic pressure injury with a minimal exudate most likely
use?
a. Hydrocolloid dressing
b. Alginate dressing
c. Hydrofiber dressing
d. Transparent film

Answer 17

a. Hydrocolloid dressing

Question 18

The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has
partial-thickness burns to 24% of the body surface area and begins to excrete large amounts
of urine. Which action should the nurse take?
a. Increase the IV rate and monitor for burn shock.
b. Monitor for signs of seizure activity.
c. Assess for signs of fluid overload.
d. Raise the foot of the bed and apply blankets.

Answer 18

c. Assess for signs of fluid overload.

Question 19

A patient with severe eczema is starting a coal tar derivative treatment. Which will the nurse
include in the teaching plan for the patient relative to this treatment?
a. Drink at least 1000 mL of fluid daily.
b. Avoid exposure to sunlight for 72 hours after use.
c. Bathe with an astringent soap.
d. Reduce intake of high calcium foods.

Answer 19

b. Avoid exposure to sunlight for 72 hours after use.

Question 20

Which will the nurse examine when assessing a patient for tinea corporis?
a. Soles of the feet
b. Scalp
c. Groin
d. Abdomen

Answer 20

d. Abdomen

Question 21

Which is the initial intervention for relief of the pruritus of dermatitis venenata?
a. Apply baking soda to lesions.
b. Wash area with copious amounts of water.
c. Apply cool compresses continuously.
d. Expose area to air.

Answer 21

b. Wash area with copious amounts of water.

Question 22

A patient who has sustained a burn injury will undergo wound debridement. The nurse
includes which explanation when explaining the purpose of burn wounddebridement?
a. To increase the effectiveness of the skin graft.
b. Prevention of infection and promote healing.
c. Promoting suppuration of the wound.
d. Promoting movement in the affected area.

Answer 22

b. Prevention of infection and promote healing.

Question 23

A patient has been admitted to the hospital with burns to the upper chest. The nurse notes
singed nasal hairs. The nurse needs to assess this patient frequently for whichcondition?
a. Decreased activity
b. Bradycardia
c. Respiratory complications
d. Hypertension

Answer 23

c. Respiratory complications

Question 24

Which may indicate a malignant melanoma in a nevus on a patient’s arm?
a. Even coloring of the mole
b. Decrease in size of the mole
c. Irregular border of the mole
d. Symmetry of the mole

Answer 24

c. Irregular border of the mole

Question 25

A nurse can assess cyanosis in a dark-skinned patient by assessing the color of which body
part?
a. abdomen
b. sclera.
c. lips and mucous membranes.
d. soles of the feet.

Answer 25

c. lips and mucous membranes.

Question 26

A patient developed a severe contact dermatitis of the hands, arms, and lower legs after
spending an afternoon picking strawberries. The patient states that the itching is severe and
cannot keep from scratching. Which instruction will be helpful in managing thepruritus?
a. Use cool, wet dressings and baths to promote vasoconstriction.
b. Trim the fingernails short to prevent skin damage from scratching.
c. Expose the areas to the sun to promote drying and healing of the lesions.
d. Wear cotton gloves and cover all other affected areas with clothing to prevent
environmental irritation.

Answer 26

a. Use cool, wet dressings and baths to promote vasoconstriction.

Question 27

The nurse will provide which instruction regarding reducing the risk factors formelanoma?
a. Avoid exposure to the sun and use protective measures when exposure occurs.
b. Have all nevi removed.
c. Watch for changes in moles, especially on the back.
d. Use a sun lamp for tanning.

Answer 27

a. Avoid exposure to the sun and use protective measures when exposure occurs.

Question 28

Which patient instruction will the nurse reinforce relative to the management of systemic
lupus erythematosus (SLE)?
a. Maintain a balance between rest and activity.
b. Increase activity to promote mobility.
c. Increase exposure to the sun to increase vitamin D absorption.
d. Increase sodium consumption.

Answer 28

a. Maintain a balance between rest and activity.

Question 29

Which patient statement indicates that more teaching is needed regarding antibiotic therapy
for the treatment of cellulitis?
a. “My skin is cleared up. I don’t think I need the medication anymore.”
b. “Cellulitis can come back at any time.”
c. “If I had washed that scratch with soap and water, I probably would not have
gotten cellulitis.”
d. “Cellulitis is contagious.”

Answer 29

a. “My skin is cleared up. I don’t think I need the medication anymore.”

Question 30

Which will a patient be assessed for upon the diagnosis of genital herpes?
a. Hepatitis B
b. Syphilis
c. Human immunodeficiency virus (HIV).
d. Cirrhosis

Answer 30

c. Human immunodeficiency virus (HIV).

Question 31

The school nurse recognizes the signs of scabies when a child displays which symptom?
a. small fluid-filled blisters that sting when scratched.
b. dry scaly patches in body creases that itch.
c. wavy threadlike lines on the body and pruritus.
d. cluster of papular lesions with pruritus.

Answer 31

c. wavy threadlike lines on the body and pruritus.

Question 32

Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where
can the melanocytes be found?
a. Dermis
b. Superficial fascia
c. Epidermis
d. Loose connective tissue

Answer 32

c. Epidermis

Question 33

The nurse arrives to the scene of a house fire. A victim is running out of the house, with
flames on the arms. Which is the nurse’s first action?
a. Transport victim to hospital.
b. Cover victim with clean cloth or sheet.
c. Stop, drop, and roll.
d. Remove all nonadherent clothing and jewelry.

Answer 33

c. Stop, drop, and roll.

Question 34

What is the last intervention for a hospitalized severely burned victim during the emergent
phase?
a. Tetanus prophylaxis.
b. Insert Foley catheter.
c. Insert nasogastric tube.
d. Establish airway.
e. Administer analgesics.
f. Initiate fluid therapy.

Answer 34

a. Tetanus prophylaxis.

Question 35

The most deadly skin cancer is

Answer 35

melanoma

Question 36

The most deadly skin cancer is

Answer 36

sebaceous

Question 37

The nurse assisting with data collection of a burned patient upon arrival in the emergency
room observes that the entire right arm (anterior and posterior), right anterior leg, chest, and
abdomen are covered with reddened skin and blisters. Using the Rule of Nines, the nurse
estimates the percentage of burn to be ?
%

Answer 37

36%