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21 Cards in this Set
- Front
- Back
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A nurse is collecting data from a client who has an arm lesion. Which of the following characteristics is a clinical manifestation of a malignant melanoma? |
a. Rough, dry, and scaly b. Firm nodule with crust c. Pearly papule with an ulcerated center d. Irregularly shaped with blue tones
Answer
a. Rough, dry, and scaly This finding is a clinical manifestation of actinic keratosis. b. Firm nodule with crust This finding is a clinical manifestation of squamous cell carcinoma. c. Pearly papule with an ulcerated center This finding is a clinical manifestation of basal cell carcinoma. d. Irregularly shaped with blue tones CORRECT. Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client’s upper back and lower legs. |
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A nurse is contributing to the plan of care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should expect the provider to perform which of the following procedures? |
a. Curettage
b. External radiation therapy
c. Regional chemotherapy
d. Surgical excision
Answer
a. Curettage
Curettage is used for small lesions that are not melanomas.
b. External radiation therapy
Melanoma is resistant to radiation therapy. However, radiation along with corticosteroids might be helpful to clients who have metastatic disease.
c. Regional chemotherapy
Regional chemotherapy is the treatment for localized tumors and superficial basal cell carcinomas without metastasis.
d. Surgical excision
CORRECT. The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide local excision, followed by skin grafting. |
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A nurse is collecting data from a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? |
a. Edema in the affected extremities b. Severe pain at the burn sites c. Urine output of 30 mL/hr d. Temperature of 39.1° C (102.4° F)
Answer
a. Edema in the affected extremities Significant edema is expected when fluid shifts after a burn injury. b. Severe pain at the burn sites Superficial partial-thickness and deep partial-thickness burns are painful throughout burn therapy. c. Urine output of 30 mL/hr A urinary output of 30 mL/hr is within the expected reference range. A decrease in urine output is expected with edema and fluid shifts on or about the fourth day following a major burn injury. d. Temperature of 39.1° C (102.4° F)
CORRECT. An elevated temperature is an indication of infection and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms. |
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A nurse is reinforcing teaching with a client who has burn injuries to his trunk about what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? |
a. "I will be on a special shower table." b. "The water temperature will be very cool to ease my pain." c. "The nurse will use a firm-bristled brush to remove loose skin." d. "The nurse will use scissors to open small blisters."
Answer
a. "I will be on a special shower table."
CORRECT. Hydrotherapy is a special shower table that facilitates examination and debridement of the wound. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature and there is a lower risk of wound infection. b. "The water temperature will be very cool to ease my pain." The nurse should use warm water during the hydrotherapy treatment to help the client maintain adequate body temperature. c. "The nurse will use a firm-bristled brush to remove loose skin." The nurse should use soft washcloths or gauze to gently scrub and debride the wounds. d. "The nurse will use scissors to open small blisters." The nurse should leave small blisters intact; however, she will open large blisters. |
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A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? |
a. Partial-thickness burn b. Stage III pressure ulcer c. Surgical incision d. Dehisced sternal wound
Answer
a. Partial-thickness burn A partial-thickness burn will heal by spontaneous re-epithelialization. Since it involves the uppermost layers of the dermis, scarring can be minimal or extensive depending on the depth of the burn. b. Stage III pressure ulcer A stage III pressure ulcer will heal by secondary intention. c. Surgical incision
CORRECT. With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention. d. Dehisced sternal wound A dehisced sternal wound can either close by secondary or tertiary intention. |
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A nurse is reinforcing teaching with a client who has a large wound healing by secondary intention. The nurse should instruct the client that which of the following nutrients promotes wound healing? |
a. Vitamin B1 b. Calcium c. Vitamin C d. Potassium
Answer
a. Vitamin B1 Vitamin B1 promotes functioning of the nervous system; however, it does not specifically promote wound healing. b. Calcium Calcium aids in blood clotting and muscle contraction; however, it does not specifically promote wound healing. c. Vitamin C
CORRECT. A diet high in protein and vitamin C is recommended because these nutrients promote wound healing. d. Potassium Potassium is necessary for muscle activity and fluid balance; however, it does not specifically promote wound healing. |
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A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses should the nurse make? |
a. Basal cell carcinomas b. Melanomas c. Actinic keratoses d. Squamous cell carcinomas
Answer
a. Basal cell carcinomas Basal cell carcinomas are the most common type of skin cancer and rarely metastasize. They arise from the basal cell layer of the epidermis or the hair follicles and generally appear on sun-exposed areas of the body. b. Melanomas
CORRECT. Melanomas are malignant neoplasms with atypical melanocytes in both the epidermis, the dermis, and sometimes the subcutaneous cells. It is the most lethal type of skin cancer, often causing metastases in the bone, liver, lungs, spleen, the CNS, and lymph nodes. c. Actinic keratoses Actinic keratoses are premalignant. They can evolve to squamous cell carcinomas; however, they are not the most lethal type of skin cancer. d. Squamous cell carcinomas Squamous cell carcinomas arise from the epidermis and are potentially metastatic; however, they are not the most lethal type of skin cancer. |
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A nurse is assisting with the admission of a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client’s sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? |
a. IV
b. I
c. III
d. II
Answer
a. IV
With a stage IV pressure ulcer, the client has full-thickness tissue loss, with destruction, tissue necrosis, and visible damage to muscle, bone, or supporting structures. Sinus tracts, deep pockets of infection, tunneling, and undermining can also occur.
b. I
With a stage I pressure ulcer, the skin is intact with an area of persistent, nonblanchable redness, usually over a bony prominence, that might feel warm or cool when touched. The tissue is swollen and congested, and the client might report discomfort at the site. With darker skin tones, the ulcer can appear blue or purple and different from other skin areas.
c. III
With a stage III pressure ulcer, there is full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer might extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
d. II
CORRECT. With a stage II pressure ulcer, there is partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer can become infected. The client might report pain, and there might be a small amount of drainage. |
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A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? |
a. "May I go with my family to the visitor’s lounge?" b. "I’ll see my friends one day when I feel better." c. "My dad is coming to visit. Can you fix my hair for me?" d. "I told my cousins I’m in protective isolation."
Answer
a. "May I go with my family to the visitor’s lounge?" CORRECT. The client is asking to visit with her family in a public setting; therefore, this statement demonstrates a positive self-image. b. "I’ll see my friends one day when I feel better." This statement indicates that the client does not feel comfortable being seen by her peer group. Since interaction with the peer group is important to an adolescent, the client's statement shows that she has not accepted the alterations in her face and hands. c. "My dad is coming to visit. Can you fix my hair for me?" Asking for assistance with her appearance indicates the client has not yet accepted or adapted to her changed body image. Encouraging the client’s participation in self-care activities is one suggested nursing intervention because the independence fosters self-worth and self-image. d. "I told my cousins I’m in protective isolation." This statement indicates that the client does not feel comfortable being seen by her extended family. This statement demonstrates an attempt to escape from interpersonal contact and indicates that the client has not accepted the alterations in her face and hands. |
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A nurse is assisting with the development of an education session about malignant melanoma for a group of clients. The nurse should include that which of the following clients has an increased risk for developing malignant melanoma? |
a. A client who has brown eyes b. A client who has a light complexion c. A client who has black hair d. A client who is 20 years of age
Answer
a. A client who has brown eyes Blue eyes, rather than brown eyes, place a client at risk for developing malignant melanoma. b. A client who has a light complexion
CORRECT. A light complexion and less pigmentation place a client at an increased risk for developing malignant melanoma. c. A client who has black hair Clients who have red or blonde hair are at risk for developing malignant melanoma. d. A client who is 20 years of age Clients who are 60 years of age and older are at an increased risk for developing malignant melanoma. |
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A nurse is reinforcing teaching with a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? |
a. "Move between the bed and the wheelchair once every 2 hours." b. "Make sure that your caregiver massages your skin daily." c. "Use a rubber ring when sitting in the wheelchair."
d. "Shift your weight in the wheelchair every 15 minutes."
Answer
a. "Move between the bed and the wheelchair once every 2 hours." The nurse should instruct wheelchair-bound clients at risk for pressure ulcer formation to change position at least once every hour. b. "Make sure that your caregiver massages your skin daily." The nurse should instruct the client and his caregiver to avoid massaging the skin, especially over bony prominences, because it can further traumatize fragile tissues. c. "Use a rubber ring when sitting in the wheelchair." The nurse should instruct the client and his caregiver to avoid using a rubber ring for sitting because it reduces circulation to the client’s skin. d. "Shift your weight in the wheelchair every 15 minutes."
CORRECT. This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure.
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A nurse is assisting with the development of a program to educate clients about measures to reduce the risk of skin cancer. Which of the following instructions should the nurse include? |
a. Re-apply sunscreen every 4 hr during sun exposure. b. Wear a sun visor instead of a hat when outside in the sun. c. Avoid exposure to the midday sun. d. Use a tanning booth instead of sunbathing outdoors. Answer a. Re-apply sunscreen every 4 hr during sun exposure. The nurse should instruct clients to re-apply a broad-spectrum sunscreen every 2 hr during sun exposure. b. Wear a sun visor instead of a hat when outside in the sun. The nurse should instruct clients to wear a wide-brimmed hat because it provides broader protection from the sun than a sun visor. c. Avoid exposure to the midday sun. CORRECT. The nurse should instruct clients to avoid skin exposure to the sun between 1100 and 1500 because sun rays are the strongest during that time. d. Use a tanning booth instead of sunbathing outdoors. The nurse should instruct clients to avoid sunbathing using any method, which includes tanning outdoors, using tanning beds or booths, sunlamps, and tanning pills. |
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A nurse is assisting with the care of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? |
a. Hemoglobin 10 g/dL b. Sodium 132 mEq/L c. Albumin 3.6 g/dL d. Potassium 4.0 mEq/dL
Answer
a. Hemoglobin 10 g/dL This laboratory value is below the expected reference range. The nurse should anticipate an elevated hemoglobin level during the resuscitation phase due to loss of fluid volume. b. Sodium 132 mEq/L
CORRECT. The nurse should anticipate a client who is in the resuscitation phase of a burn injury to have a low sodium level because sodium is trapped in interstitial space. c. Albumin 3.6 g/dL This laboratory finding is within the expected reference range. The nurse should anticipate a low albumin level during the resuscitation phase. d. Potassium 4.0 mEq/dL This laboratory finding is within the expected reference range. The nurse should anticipate an elevated potassium level during the resuscitation phase. |
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A nurse in an urgent care clinic is caring for a client who has a snakebite on her arm. Which of the following actions should the nurse take? |
a. Immobilize the limb at the level of the heart. b. Apply a tourniquet to the affected limb. c. Use a sterile scapula to incise the wound. d. Apply ice to the skin over the snakebite wound.
Answer
a. Immobilize the limb at the level of the heart.
CORRECT. The emergency management of a client who has a snakebite focuses on limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart. b. Apply a tourniquet to the affected limb. The nurse should not apply a tourniquet to the affected limb because this action is ineffective and can worsen the client’s outcome. c. Use a sterile scapula to incise the wound. The nurse should not use a sterile scapula to incise the wound because this action is ineffective and can worsen the client’s outcome. d. Apply ice to the skin over the snakebite wound. The nurse should not apply ice to the skin over the wound because this action is ineffective and can worsen the client’s outcome. |
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A nurse is observing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? |
a. First-degree frostbite b. Second-degree frostbite c. Third-degree frostbite d. Fourth-degree frostbite
Answer
a. First-degree frostbite When a client has first-degree frostbite, the skin of the affected area is reddened and looks waxy. b. Second-degree frostbite When a client has second-degree frostbite, the skin of the affected area has large, fluid-filled blisters. c. Third-degree frostbite
CORRECT. When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled and the skin does not blanch. d. Fourth-degree frostbite When a client has fourth-degree frostbite, the skin of the affected area is frozen. Blisters do not appear. The client’s muscles and bones are affected. |
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A nurse in a provider’s office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which of the following skin lesions? |
a. Papules
b. Macules
c. Wheals
d. Vesicles
Answer
a. Papules CORRECT. A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Warts and elevated moles are examples of papules. b. Macules A macule is flat, variably shaped, discolored, and small, typically smaller than 10 mm in diameter. A macule is a change in the color of the skin. Freckles and the rash associated with rubella are types of macules. c. Wheals Wheals, also known as hives, are transient, elevated, irregularly shaped lesions caused by localized edema. Wheals are a common manifestation of an allergic reaction. d. Vesicles A vesicle is a circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise with herpes simplex, poison ivy, and chickenpox. |
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A nurse in a provider’s office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? |
a. Zoster vaccine b. Acyclovir c. Amoxicillin d. Infliximab
Answer
a. Zoster vaccine The nurse should anticipate a prescription for the zoster vaccine for an older adult client to prevent herpes zoster. b. Acyclovir
CORRECT. The nurse should anticipate a prescription for acyclovir, an antiviral medication, because it inhibits replication of the virus that causes herpes zoster. c. Amoxicillin The nurse should anticipate a prescription for amoxicillin for a client who has a bacterial infection. d. Infliximab The nurse should anticipate a prescription for infliximab for a client who has Crohn’s disease. |
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A nurse is caring for a client who has been applying silver sulfadiazine cream to a deep partial-thickness arm burn for the past 2 weeks. The nurse should monitor the client for which of the following adverse effects? |
a. Hyponatremia
b. Leukopenia
c. Hyperchloremia
d. Elevated BUN
Answer
a. Hyponatremia
Hyponatremia is an adverse effect of thiazide diuretics.
b. Leukopenia
Transient leukopenia is an adverse effect of silver sulfadiazine; therefore, the nurse should monitor the client for an allergic reaction causing a decrease in the client's WBC count.
c. Hyperchloremia
Hyperchloremia is an adverse effect of mafenide acetate solution.
d. Elevated BUN
Impaired kidney function is an adverse effect of gentamicin. |
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A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? |
a. Partial-thickness burn A partial-thickness burn will heal by spontaneous re-epithelialization. Since it involves the uppermost layers of the dermis, scarring can be minimal or extensive depending on the depth of the burn. b. Stage III pressure ulcer A stage III pressure ulcer will heal by secondary intention. c. Surgical incision With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention. d. Dehisced sternal wound A dehisced sternal wound can either close by secondary or tertiary intention. |
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A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client’s questions about the dressing, the nurse explains that it is obtained from which of the following sources? |
a. Cadaver skin b. Pig skin c. Amniotic membranes d. Beef collagen
Answer
a. Cadaver skin Homographs are obtained from cadaver skin. b. Pig skin
CORRECT. Heterografts are obtained from an animal, usually a pig. c. Amniotic membranes Human amniotic membranes are used to treat burns; however, they are not heterograft dressings. d. Beef collagen Artificial skin made from beef collagen is used to treat burns; however, it is not a heterograft dressing. |
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A nurse is reinforcing discharge teaching with a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of malignancy of a mole? |
a. Ulceration
b. Blanching of surrounding skin
c. Dimpling
d. Fading of color
Answer
a. Ulceration Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month. b. Blanching of surrounding skin Redness or swelling of the skin around a mole, rather than blanching, is an indication of potential malignancy. c. Dimpling Dimpling is not an indication of a mole’s potential malignancy. d. Fading of color Darkening of a mole, rather than fading, is associated with potential malignancy. |
