Porth (2020) 5th nur 317 Flashcards
Chapter 52
A 20-year-old female tells the nurse she is concerned about getting a good suntan before going on a vacation. The best response by the nurse would be:
Use a self-tanning product that produces the appearance of a tan without sun exposure.
Use natural sunlight without sunscreen to acquire a tan.
Attend a tanning salon several times per week to tan evenly prior to travel.
Use tanning pills with canthaxanthin, which is found in carrots, to help tan.
Use a self-tanning product that produces the appearance of a tan without sun exposure.
Rationale:The use of self-tanning products that do not require sun exposure is the safest way to add tan-like color to skin. Tanning in a salon promotes UV damage. The use of tanning pills is not recommended because of their association with liver damage. Natural sunlight exposure promotes UV damage.
A 16-year-old male is concerned about the acne that has developed on his face and asks the nurse what caused it to develop. The best response would be:
“If you keep your hands off your face when sitting, it will completely clear.”
“Your acne has developed because of increased hormone levels in your body.”
“You have acne because you eat a lot of fatty, oily foods.”
“You are not scrubbing your face hard enough to prevent the acne from occurring.”
“Your acne has developed because of increased hormone levels in your body.”
Rationale:Acne typically occurs in the teen years related to increased androgen hormones, which increase the activity of the sebaceous cells. Food has not been found to cause acne as once thought. Scrubbing the face may actually increase the acne.
Which statements are true concerning cellulitis? Select all that apply.
Cellulitis is a deep infection.
Cellulitis is treated with antifungal agents.
Cellulitis is accompanied by fever.
Cellulitis is caused by a streptococcus or a staphylococcus infection.
Cellulitis is complicated by fungus.
Cellulitis is a deep infection., Cellulitis is accompanied by fever., Cellulitis is caused by a streptococcus or a staphylococcus infection.
Rationale:Cellulitis is a deeper infection caused by streptococcus and staphylococcus infection. It is not a fungal infection or typically complicated by fungus. It is often accompanied by fever, erythema, heat, and pain.
Which statements regarding skin tags are true? Select all that apply.
They can be as large as a pea.
They vary in color.
They are common among adults.
They are considered precancerous.
They can be removed by electrodesiccation.
They can be as large as a pea., They vary in color., They are common among adults., They can be removed by electrodesiccation.
Rationale:Skin tags are soft, brown or flesh-colored papules commonly seen in 25% of adults. They occur on any skin surface but most frequently the neck, axilla, and intertriginous areas. They range in size from a pinhead to the size of a pea. Skin tags have the normal texture of the skin. They are benign and can be removed with scissors or electrodesiccation for cosmetic purposes.
A client has just received the diagnosis of malignant melanoma, stage 3B. He asks the nurse what this means. The nurse should respond by relaying which information? Select all that apply.
Malignant melanoma is a very rapid growing, aggressive cancer.
This cancer usually extends wide and deep but rarely metastasizes.
Your cancer has grown into the deep tissues and quite likely into lymph nodes.
This cancer is mainly contained to the head and neck area.
Malignant melanoma is a very rapid growing, aggressive cancer., Your cancer has grown into the deep tissues and quite likely into lymph nodes.
Rationale:Although melanoma represents a small subset of skin cancers, it is the most deadly. It is a rapidly progressing, metastatic form of cancer. Malignant melanomas differ in size and shape. Usually, they are slightly raised and black or brown. Borders are irregular and surfaces are uneven. Most appear to arise from preexisting nevi or new mole-like growths. There may be surrounding erythema, inflammation, and tenderness. Because most melanomas initially metastasize to regional lymph nodes, additional information may be obtained through lymph node biopsy. Consistent with other cancerous tumors, melanoma is commonly staged using the TNM (tumor, lymph node, and metastasis) staging system. Basal cell cancer usually extends wide and deep but rarely metastasizes and are most frequently seen on the head and neck, most often occurring on skin that has hair.
A nurse is caring for four clients. Select the client most at risk for the development of a pressure ulcer.
A 22-year-old female who is in traction after a motor vehicle accident
A 72-year-old undernourished female who recently underwent thigh surgery
An 80-year-old male who requires a walker for ambulation but who is otherwise healthy
A 40-year-old male paraplegic who has strong upper body strength
A 72-year-old undernourished female who recently underwent thigh surgery
Rationale:Populations at risk for pressure ulcers include persons with quadriplegia and older adults with restricted activity and hip fractures in a critical care setting. An undernourished postsurgical client is at risk for ulcer development.
Which statements regarding hemangiomas of infancy are true? Select all that apply.
They are generally benign
Boys are more likely to present with hemangiomas
They generally appear at the time of birth
Hemagniomas are red in color
They are small lesions
:They are generally benign,
Hemagniomas are red in color,
They are small lesions
Rationale:Hemangiomas of infancy are small, red lesions that are noticed shortly after birth. Hemangiomas of infancy are generally benign vascular tumors. A small proportion of these lesions are present at birth, and the remainder develop within a few weeks after birth. Girls are three times more likely to have hemangiomas than boys.
Which childhood diseases that present with a rash can be protected against via vaccines? Select all that apply.
Scarlet fever
Rubella
Rubeola
Roseloa infantum
Varicella
Rubella, Rubeola, Varicella
Rationale:Vaccines are only available to protect against rubella, rubeola, and varicella.
4-year-old male child has several small pustules with honey-colored crusted drainage on his face but in no other location. The child is diagnosed with impetigo. The most appropriate treatment would be:
Oral antibiotics
Topical mupirocin and limiting exposure, as it is transmitted easily
Because it is only located on the face, it does not need to be treated.
Oral antifungal, such as griseofulvin
Topical mupirocin and limiting exposure, as it is transmitted easily
Rationale:The condition should be treated with topical mupirocin with limited exposure due to risk of transmission with direct contact. Oral antibiotics would not be the first-line treatment as it is isolated in one area. Antifungals would not be effective for a bacterial infection. Due to the risk of further transmission to self and others, impetigo is treated with either topical or systemic antibiotics (decision based on location of impetigo).
Which characteristics of a cherry angioma should be considered suspicious?
Observed on the trunk
Sudden collection of several papules
Purple color
Appearance before age 40
Sudden collection of several papules
Rationale:Cherry angiomas are smooth, cherry red or purple, dome-shaped papules that occur in nearly all people older than 30 years of age. They usually are found on the trunk and are generally benign unless there is a sudden appearance of many cherry angiomas.
A client presents with an exacerbation of psoriasis. The most important question for the nurse to ask the client would be:
“Have you traveled to a foreign country in the last 14 days?”
“Have you been under an excessive amount of stress at home or at work?”
“Have you recently been sexually active?”
“Have you been eating large amounts of oily foods?”
“Have you been under an excessive amount of stress at home or at work?”
Rationale:Environmental stimuli may trigger the release of cytokines and growth factors from keratinocytes and other cells, with ensuing immune and inflammatory responses that lead to the full development of psoriatic lesions. Psoriatic lesions can be induced in susceptible individuals by trauma, a process known as the Köbner phenomenon. Precipitating factors for an exacerbation of psoriasis include increased stress, infection, trauma, and the use of certain medications. Types of food ingested, sexual activity, and travel to foreign countries have not been linked to psoriasis.
A nurse comes upon a automobile accident where smoke and flames are coming from the car’s engine. What would be the nurse’s first priority in this situation?
Go in search of people to help
Assess the airway of people in the car
Stop the fire or remove the person from the vehicle
Give water to the people in the vehicle
Stop the fire or remove the person from the vehicle
Rationale:Regardless of the type of burn, it is first priority to stop the fire and provide a safe environment for the people affected. The heat source should be removed, and flames should be doused with water or smothered with a blanket. The people should be removed from the vehicle, especially if the fire cannot be contained. After moving them to a safe distance, their airways should be assessed next. If cellular phone is working, the nurse should call 911 and report the findings. That way, help will be on the way.
A client has a burn that involves the entire epidermis and various degrees of the dermis. It is painful, moist, and blistered. The nurse recognizes the burn as:
Third-degree full thickness
Second-degree full thickness
Second-degree partial thickness
First-degree partial thickness
Second-degree partial thickness
Rationale:Second-degree partial-thickness burns involve the epidermis and parts of the dermis. First-degree partial-thickness burns involve only the outer layers of the epidermis. Third-degree full-thickness burns extend into the subcutaneous tissue and may involve bone and muscle. Second-degree full-thickness burns involve the entire epidermis and dermis.
Which factor is most protective against squamous cell carcinomas?
Male gender
Lack of family history
Dark skin color
Under 50 years of age
Dark skin color
Rationale:Dark-skinned people are rarely affected. Males are twice as likely as females to have squamous cell carcinoma. Age and history are not protective, as the increase in the incidence of squamous cell carcinomas is consistent with increased exposure to ultraviolet radiation.
Upon assessment, it is noted that a client has a dark yellowish brown tint to the great toenail. The client reports no injury and that “it’s been like that for years.” The nurse recognizes this as which type of fungal infection?
Tinea capitis
Tinea corporis
Tinea unguium
Tinea pedis
Tinea unguium
Rationale:Tinea unguium is a dermatophyte infection of the nails. Tinea capitis is a fungal infection of the scalp and hair shaft. Tinea pedis is the most common fungal dermatosis, primarily affecting the spaces between the toes, the soles, or sides of the feet. Tinea corporis involves the body.
Which term is used to denote the pigmentation disorder in which the skin suddenly develops white patches on the face and arms?
Melasma
Albinism
Vitiligo
Paleness
Vitiligo
Rationale:The condition described above that comes on suddenly is vitiligo. Albinism is present from birth, and melasma involves dark spots on the skin. Paleness is a term used to denote minimal skin color.
What would be the best response to the mother of two teens who have been diagnosed with scabies?
“Scabies usually occurs when hygiene practices need improvement.”
“One of your children probably had direct contact with an infected person.”
“One of the parents is likely an unaffected carrier.”
“Scabies occurs with increased sexual activity.”
“One of your children probably had direct contact with an infected person.”
Rationale:Scabies is spread through direct person-to-person contact; the teens could have contacted with someone who has scabies. Scabies does not occur only with sexual contact. This condition does not involve unaffected carriers. Poor hygiene is not the trigger for this condition
A woman has just delivered a child with a hemangioma on his right cheek area. The mother asks, “What is that thing on his face?” The nurse will respond with discussing which facts about hemangiomas? Select all that apply.
“These hemangiomas may grow larger early on followed by a period where the growth is reversed.”
“If this birth mark develops ulceration, we will need to keep a close eye on it to prevent any infections.”
“We will keep a close watch on your infant’s vision since hemangiomas can develop malformation of the eye that could develop into glaucoma.”
“Most of these hemangiomas will remain with the infant for the rest of his life. However, they are not cancerous.”
“This is a vascular birthmark that can be located in anatomic regions; it is associated with other anomalies.”
“These hemangiomas may grow larger early on followed by a period where the growth is reversed.”,
“If this birth mark develops ulceration, we will need to keep a close eye on it to prevent any infections.”,
“This is a vascular birthmark that can be located in anatomic regions; it is associated with other anomalies.”
Rationale:Hemangiomas of infancy (formerly called strawberry hemangiomas) are small, red lesions that are noticed shortly after birth. Hemangiomas of infancy are generally benign vascular tumors produced by proliferation of endothelial cells. They are seen in approximately 10% of children in the first year of life. Hemangiomas of infancy typically undergo an early period of proliferation during which they enlarge, followed by a period of slow involution during which the growth is reversed until complete resolution. A small percentage of hemangiomas develop complications. Ulceration, the most frequent complication, can be painful and carries the risk of infection, hemorrhage, and scarring. Port-wine stains usually are confined to the skin but may be associated with vascular malformations of the eye, resulting primarily in glaucoma.
A client is admitted to the hospital with first- and second-degree burns. Which assessment findings are associated with first-degree burns? Select all that apply.
Wet
Red or pink
Painful
Full-thickness burn
Red or pink, Painful
Rationale:First-degree burns (superficial partial thickness burns) involve only the outer layers of the epidermis. They are red or pink, dry, and painful.
