Test 1 ch 43

Question 1

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 1

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

Question 2

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 2

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.

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

ANS: D

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.

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

ANS: A
In a burn injury, usually the greatest fluid loss occurs within the first 12 hours.

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

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.

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

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.

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

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.

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

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..

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

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.

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

ANS: B
Stage 2 pressure injuries appear as a shallow open injury, usually shiny or dry, with a red-pink wound bed without slough. Stage 1 involves intact skin with non-blanchable redness. A stage 3 pressure injury involves full-thickness tissue loss and sometimes subcutaneous fat is visible. At stage 4, there is a full thickness tissue loss with exposed bone, tendon, cartilage or muscle.

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

ANS: A
Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber dressings are used for wounds with copious exudate. Transparent film is not absorbent.

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

ANS: C
As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. Burn shock occurs from hypovolemia in the first 72 hours of a burn injury. Seizures are not associated with the burn injury. Raising the foot of the bed would not be of value in this situation.

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

ANS: B
Persons using coal tar derivatives should avoid exposure to sunlight for 72 hours after use. The product stains clothes and bathroom fixtures. There is no need to drink additional fluids, bathe with astringent soaps or reduce calcium rich foods.

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

ANS: D
Tinea corporis is known as ringworm of the body. It occurs on parts of the body with little or no hair. Tinea pedis is a fungal infection of the feet. Tinea capitus is a fungal infection of the scalp. Tinea cruris is a fungal infection of the groin area.

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

ANS: B
In dermatitis venenata (poison oak or ivy), the patient should wash the affected part immediately after contact with the offending allergen. Applying baking soda is not effective. Cool compresses and air exposure are not the initial intervention.

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 wound debridement?
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

ANS: B
Débridement is the removal of damaged tissue and cellular debris from a wound or burn to prevent infection and to promote healing. Debridement does not increase the effectiveness of the skin graft, promote wound suppuration or movement.

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

ANS: C
Signs and symptoms of inhalation injury include singed nasal hairs. Breathing difficulties may take several hours to occur.

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

ANS: C
Any change in color, size, or texture and any bleeding or pruritus of a nevus deserves investigation. A malignant melanoma is a cancerous neoplasm in which pigment cells or melanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue.

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

ANS: C

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

ANS: A

Question 27

The nurse will provide which instruction regarding reducing the risk factors for melanoma?
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

ANS: A
Encourage the patient to protect skin from the sun by wearing protective clothing, including a hat with 4-in brim, applying sunscreen all over the body, and avoiding the midday sun from 10 a.m. to 4 p.m. Having all nevi removed is impractical. Watching for changes in moles does not reduce risk factors; it allows for early detection. Sun lamps are just as damaging as the sun.

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

ANS: A
Balanced rest, activity, and diet will support medication management. It is not necessary to increase activity to promote mobility. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium.

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

ANS: A
The entire amount of antibiotic medication should be completed even if the symptoms have abated to ensure the eradication of the infectious agent. Cellulitis can return if untreated or undertreated. Washing wounds with soap and water can prevent many infections, but this is not related to the discussion of antibiotics. Cellulitis can spread, however this is not related to the discussion of antibiotics.

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

ANS: C
Persons with genital herpes should be assessed for HIV because the therapy for herpes is suppressive; persons with HIV are not candidates for suppressant therapy.Hepatitis B, syphilis and cirrhosis are not associated with genital herpes.

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

ANS: C

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

ANS: C
A layer in the epidermis contains highly specialized cells called melanocytes.

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

ANS: C
The primary concern is to stop the burning process, arrest skin damage, provide an open airway, control any bleeding, prevent infection by covering with a clean cloth, and obtain medical help by transporting to the nearest hospital.

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

ANS: A
The priority of care should proceed from the establishment of an airway, initiation of fluid therapy, insertion of Foley and NG tube, administration of analgesics, and tetanus prophylaxis.