50 terms

Week 2 review Set 2

Set 2 of 2
A nurse is caring for a light-skinned pt w/COPD. When assessing the pts nail beds, the n notices
that they are a dusky-blue color. This is indicative of which of the following?
When the pt shows the nurse skin-color areas that are changed, flat, and nonpalpable, the nurse
recognizes that the pt is demonstrating:
Macule or patch
A nurse discussing male-pattern baldness w/ a pt would be correct in teaching the pt that this type
of baldness is caused by which of the following hormones:
The nurse assesses the pts nails and notes clubbing to the fingertips. The nurse recognizes this as a
nail disorder common in pts who have:
Hypoxia, by straightening of the normal angle and softening of the nail base
When assessing hydration status in an elderly pt, the n would monitor which of the following skin
When assessing the skin of a middle-age man, the nurse notices a blue0red plaque on the patient's
chest. This cutaneous skin manifestation is indicative of which of the following systemic diseases?
Psoriasis or actinic keratosis
The nurse is documenting that the patient has bruising on the lateral aspect of the right arm after a
fall. Of the following terms, which term will the nurse use to describe bruising on the skin in her
The nurse if conducting an elderly female patient's assessment and notes the patient has a malepattern
hair distribution. This is likely due to which of the following?
increased level of testosterone, could be due to a hormone imbalance
The nurse working in an ambulatory care center notes that an elderly patient has bright red moles
on the skin. Benign changes in elderly skin that appear as bright red moles are termed:
Cherry angiomas
When assessing the skin of a patient with Addison's disease, the nurse would expect which of the
following skin manifestations?
Brown-tan skin caused by cortisol deficiency stimulating increased melanin production. they will have a bronzed appearance termed "external tan" and most apparent around nipples, perineum, genitalia, and pressure points
The nurse follows which of the following guidelines when providing skin care and protection for
bathing a patient with pruritus.
Tepid water, shake off excess water and blot in between skin folds with a towel. do not vigorously rub pt. apply lubrication to skin with an emollient to trap moisture
A nurse who is caring for a patient's wound that is chronic but not infected should apply which of
the following principles of wound care.
leave a covering for 48-72 hours. (acute wounds 24 hours)
The nurse is providing care for a patient who has a sacral pressure ulcer with a wet to dry dressing.
Which guideline is appropriate for a wet-to-dry dressing?
Prevent additional damage, do not let dressing touch outside of the wound
The nurse is caring for a patient with diagnosis of pemphigus. An appropriate nursing intervention
would consist of which of the following.
Treat with corticosteroids. watch for fluid volume deficit and electrolyte imbalance. Relieve pain. use cool, wet dressings or bath. use powder on the bed liberally so pt won't stick.
A patient has been diagnosed with squamous cell carcinoma. The nurse knows that the primary goal
of treatment in this type of cancer is which of the following?
Surgical incision: CUT IT OUT
A child is being seen in the dermatology clinic has been diagnosed with scabies. The mother asks
why the child's itching is worse at night. The nurse's explanation for this occurrence is based on which
of the following:
Mites are more active at night so there's more itching
It is important for the nurse explaining various causes of irritant contact dermatitis to include
which of the following as a potential cause of this skin disorder to prevent repeated cases?
Avoid heat, soap, rubbing, fabric softener, dryer sheets, topical meds, lotions or ointments
The nurse creating a teaching plan for a patient with psoriasis should include which of the
Can be aggravated by stress, trauma, and seasonal and hormonal changes. doesn't need a lot of washing. use warm water not hot and avoid picking and scratching, keep nails short.
A patient receiving topical corticosteroids is concerned that his skin is becoming thin. The nurse
would be correct in giving the following explanation regarding the adverse effects of corticosteroids?
Effects can be reversed, just stop using the med
A nurse caring for a patient who has sustained second -degree burns on his left leg. A skin graft has
been used to cover the area of the burn. Nursing management of the skin graft site includes which of
the following?
Protection from infection, dressings, keep soft and pliable with cream, protection from extreme temp, external trauma, and sunlight
A patient who has sustained second degree facial burns and a facial fracture is undergoing
reconstructive surgery. The nursing dx for this patient is disturbed body image related to disfigurement.
An appropriate nursing intervention related to this diagnosis would include which of the following:
assist pt by helping recognize uniqueness, small gestures, refer for self esteem support.
Because skin irritation and itching can interfere with normal sleep, the nurse teaches the patient
with pruritic skin disorders to:
wear cotton clothing, keep room cool and use humidifier, keep nails trimmed.
When assessing the health of a patient diagnosed with toxic epidermal necrolysis (TEN), the nurse
would be alert to which of the following precipitating factors:
Triggered by reaction to medications, antibiotics, sulfonimides, antiseizure agents, and NSAID's
A patient has been brought to the dermatology clinic after a mole excision on the back of his neck.
A keloid has formed in this area. The nurse knows that the tx plan for this patient may consist of which
of the following interventions:
Surgical excision, intra-lesional corticosteroid therapy, radiation
The nurse is teaching a patient diagnosed with basal cell carcinoma. The most common cause of
basal cell carcinoma is:
Exposure to the sun
A nurse planning care for a patient with psoriasis would include which of the following diagnoses?
Page 1697 under nursing interventions.
deficient knowledge, impaired skin integrity, disturbed body image
Which of the following general guidelines should the nurse incorporate into health education for
parents of school-age children regarding scabies?
do not exchange clothes, clean all bedding, mites are more active at night, do not take hot showers
While assessing a patient with suspected skin cancer, the nurse observes an elevated blue-black
lesion on the patient's ear. The nurse knows that this is indicative of which of the following types of
skin cancer?
nodular melanoma
Which of the following principles applies when the nurse instructs the patient to examine his or her
skin for melanoma?
do this in a systematic manner
When planning care for a patient with herpes zoster, the nurse is aware that which of the following
medications, administered within first 24 hours of the initial eruption, can arrest herpes zoster?
antiviral agents, acyclovir
During the emergent/resuscitative phase of burn injury, the nurse should closely monitor which of
the following blood values?
Hct and ABG's
The nurse considers that the most time-consuming elements of burn care in a patient with a burn
injury after the emergent phase is:
wound care
According to the rules of nines, a pt who is affected by burns to the anterior and posterior trunk
would demonstrate what would demonstrate what % of body burn?
The nursing care priorities for a pt with a burn injury include wound care, nutritional support, and
prevention of complications such as infection. Based upon these care priorities, the patient is most
likely in which of the following phases of burn care?
Acute phase
A nurse is caring for a pt in the emergent/resuscitative phase of burn injury. Upon analysis of the pt
lab studies, the nurse will expect the results to indicate:
hyperkalemia, hyponatremia, metabolic acidosis, elevated Hct
The nurse assisting with hydrotherapy recognizes that this wound cleansing measure should be
limited to:
if the pt is ambulatory
Biobrane was applied to a patient's partial-thickness burn injury. Two weeks later, the nurse notices
that the Biobrane is separating from the burn wound. The appropriate nursing intervention when this
separation occurs is to:
trim it. as the biobrane gradually separates the wound is healing.
The nurse preparing a care plan for a patient who has sustained a deep partial-thickness burn injury
will give the highest priority to which of the following nursing diagnoses?
airway, infection, hydration, pain, anxiety
A serious Gastrointestinal disturbance that may frequently occur in a patient who has suffered a
major burn is :
paralytic ileus, curling ulcer, abdominal compartment syndrome
A patient received burns to his entire back and left arm. Using the rule of nines, the nurse can
calculate that he has sustained burns on what percentage of his body?
A 33 year old female teacher is admitted with second-degree burns over 50% of her body. The
third day post burn, she develops tachypnea and hoarseness with speech. What is the most likely cause
of these symptoms?
smoke inhalation, leading to pulmonary edema
The nurse is caring for a patient in the acute phase of burn care. While performing an assessment
during this phase of burn care, the nurses recognized that airway obstruction related to upper airway
edema may occur up to:
48-72 hours
Patients who have sustained a severe burn injury and have an impaired intestinal mucosal barrier
are at an increased risk for infection. The implementation of which of the following interventions will
assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?
early enteral feedings
The nurse preparing the patient for mechanical debridement informs the patient that this will
surgical scissors, scalpels, forceps
The nurse caring for a patient with burns on his legs. Which nursing intervention will help to
prevent contractures?
passive and active ROM
The nurse receives a phone call from a frantic father who has observed his 4-year-old child tip a pot
of boiling water onto her chest. The father has called an ambulance and the pediatrician's office while
he waits. The nurse instructs the father to:
Cool the burn briefly (1st 30 sec.) remove restrictive objects, cover the wound
The trauma nurse monitoring a patient who has just arrived after a burn injury sustained in a fire is
aware that the major cause of death in most burn patients is:
smoke inhalation
A patient presenting to the emergency room from the site of a chemical fire has a burn that involves
the epidermis, dermis, and the muscle and bone of the right arm. The patient verbalizes no pain in the
right arm and the skin appears charred. Based upon the assessment findings, what is the depth of the
burn on the patient's right arm?
full thickness
In planning the care for a patient with a burn in the emergency room, the nurse recognizes that the
patient is likely to experience a local and systemic response to the burn when the burn exceeds a total
body surface area (TBSA) of:
greater than 20%
A patient is burned on the face and the left forearm in a house fire. What percentage of burn does
the patient have?