Test 1 ch 43 Flashcards
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.
ANS: A
Pruritus is responsible for most of the discomfort. Wet dressings and using Burow’s solution help promote the healing process. Rubbing the skin would increase pruritis. Give daily baths with an application to cleanse the skin. A cool environment with increased humidity decreases the pruritus
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.
ANS: A
Early recognition of herpes zoster (shingles) will allow administration of antiviral agents, prevention of secondary infections and pain relief. Acyclovir, when given within 72 hours of the onset of symptoms, reduces pain and the duration of the outbreak. Herpes zoster is not transmitted sexually. Oral lesions are associated with Herpes simplex 1. Varicella vaccine will not be effective against this current outbreak.
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
ANS: D
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.
ANS: B
Impetigo is seen at all ages but is particularly common in children. The crust is honey-colored and easily removed and is associated with pruritus. The disease is highly contagious and spreads by contact. Chickenpox and shingles are characterized by vesicles and are not honey-colored. Herpes simplex type I is also known as “cold sores” or “fever blisters”. Lesions are generally located around and in the mouth.
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.
ANS: D
Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a brilliant blue green. The Woods lamp does not dry out lesions, reduce pruritus or kill fungus.
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
ANS: C
Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border. Macules are small, flat blemishes flush with the skin surface. Plaques are elevated, firm, rough lesions with a flat topped surface. A vesicle is a circumscribed elevation of skin filled with serous fluid.
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
ANS: A
The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present). In this mnemonic, S does not stand for site, symptomology or surface area of the lesion.
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.
ANS: B
Isotretinoin may cause dry skin or eczema to develop. There is no reason to avoid acetaminophen when using this medication. Heavy makeup is not advised. The nurse should provide emotional support to the patient with acne so the patient can continue their lifestyle.
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
ANS: B
Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in Whites. An angiomas resembles a birthmark. A melanoma is a serious form of skin cancer. A nevus is commonly referred to as a mole.
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
ANS: A
In a burn injury, usually the greatest fluid loss occurs within the first 12 hours.
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.
ANS: C
Hypovolemic shock is frequently lethal in the emergent period of a severe burn because of the transfer of fluids into the interstitial tissue from the circulating volume. Joint contractures and fluid overload occur during later phases of the burn injury. Adrenal failure is not associated with the emergent period of a severe burn.
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
ANS: C
Most electrical burns result in cardiac arrest, and the patient will require CPR or acute cardiac monitoring. After the patient’s respiratory and cardiac systems are stable, the nurse will assess the extent and depth of the burn, and the sites of entry and exit. Bleeding is not common with an electric burn.
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.
ANS: D
Infection is the most common complication and cause of death after the first 72 hours. Shock, due to hypovolemia is most common during the emergent phase of the burn injury. Respiratory arrest and hemorrhage are not common causes of death.
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
ANS: A
Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body. The first sign is usually vomiting of bright red blood. Paralytic ileus involves the small intestine becoming immobile, characterized by absent bowel sounds. A ruptured colon would cause internal bleeding, and possibly rectal bleeding. Gastritis would not cause bright red bleeding..
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.
ANS: D
Chilling may be controlled by keeping the room temperature at 85°F (29.4°C). The open method of burn injury treatment does not involve dressings; the wound is left undressed. Strict surgical protocol is observed and analgesia should be given before the treatment. Circulation is not restricted if the wound area is left open.
