A
A nurse is caring for a client whose skin cancer will soon be removed by excision.
Which of the following actions should the nurse perform?
A. Teach the client about early signs of secondary blistering diseases.
B. Teach the client about self-care after treatment.
C. Assess the client's risk for recurrent malignancy.
D. Assess the client for adverse effects of radiotherapy.
ANS: B
Rationale: Because many skin cancers are removed by excision, clients are usually
treated in outpatient surgical units. The role of the nurse is to teach the client about
prevention of skin cancer and about self-care after treatment. Assessing the client's risk
for recurrent malignancy is primarily the role of the health care provider. Blistering
diseases do not result from cancer or subsequent excision. Excision is not accompanied
by radiotherapy.
A client has just undergone surgery for malignant melanoma. Which of the following
nursing actions should be prioritized?
A. Maintain the client on bed rest for the first 24 hours postoperative.
B. Apply distraction techniques to relieve pain.
C. Provide soft or liquid diet that is high in protein to assist with healing.
D. Anticipate the need for, and administer, appropriate analgesic medications.
ANS: D
Rationale: Nursing interventions after surgery for a malignant melanoma center on
promoting comfort, because wide excision surgery may be necessary. Anticipating the
need for and administering appropriate analgesic medications are important. Distraction
techniques may be appropriate for some clients, but these are not a substitute for
analgesia. Bed rest and a modified diet are not necessary.
A nurse educator is teaching a group of nurses about Kaposi sarcoma. What would
the educator identify as characteristics of endemic Kaposi sarcoma? Select all that apply.
A. Affects people predominantly in the eastern half of Africa
B. Affects men more than women
C. Does not affect children
D. Cannot infiltrate
E. Can progress to lymphadenopathic forms
ANS: A, B, E
Rationale: Endemic (African) Kaposi sarcoma affects people predominantly in the eastern
half of Africa, near the equator. Men are affected more often than women, and children
can be affected as well. The disease may resemble classic KS or it may infiltrate and
progress to lymphadenopathic forms.
A 35-year-old kidney transplant client comes to the clinic exhibiting new skin lesions.
The diagnosis is Kaposi sarcoma. The nurse caring for this client recognizes that this is
what type of Kaposi sarcoma?
A. Classic
B. AIDS related
C. Iatrogenic
D. Endemic
ANS: C
Rationale: Iatrogenic/organ transplant--associated Kaposi sarcoma occurs in transplant
recipients and people with AIDS. This form of KS is characterized by local skin lesions and
disseminated visceral and mucocutaneous diseases. Classic Kaposi sarcoma occurs
predominantly in men of Mediterranean or Jewish ancestry between 40 and 70 years of
age. Endemic KS affects people predominantly in the eastern half of Africa. AIDS-related
KS is seen in people with AIDS.
30. A 65-year-old man presents at the clinic reporting nodules on both legs. The man tells
the nurse that his son, who is in medical school, encouraged him to seek prompt care and
told him that the nodules are related to the fact that he is Jewish. What health problem
should the nurse suspect?
A. Stasis ulcers
B. Bullous pemphigoid
C. Psoriasis
D. Classic Kaposi sarcoma
ANS: D
Rationale: Classic Kaposi sarcoma occurs predominantly in men of Mediterranean or
Jewish ancestry between 40 and 70 years of age. Most clients have nodules or plaques on
the lower extremities that rarely metastasize beyond this area. Classic KS is chronic,
relatively benign, and rarely fatal. Stasis ulcers do not create nodules. Bullous
pemphigoid is characterized by blistering. Psoriasis characteristically presents with
silvery plaques.
A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware
that the client is likely seeking treatment for which of the following?
A. Wrinkles near the lips and eyes
B. Removal of acne scars
C. Vascular lesions on the cheeks
D. Real or perceived misshaping of the eyes
ANS: A
Rationale: Chemical face peeling is especially useful for wrinkles at the upper and lower
lip, forehead, and periorbital areas. Chemical face peeling does not remove acne scars,
remove vascular lesions, or reshape the eyes.
A client comes to the dermatology clinic requesting the removal of epidermal nevi on
the client’s right cheek. The nurse knows that the procedure especially useful in treating
such lesions is what?
A. Skin graft
B. Laser treatment
C. Chemical face peeling
D. Free flap
ANS: B
Rationale: Lasers are useful in treating cutaneous vascular lesions such as epidermal
nevi. Skin grafts, chemical face peels, and free flaps would not be used to remove this
lesion.
A 30-year-old client has just returned from the operating room after having a "flap"
done following a motorcycle accident. The client's spouse asks the nurse about the major
complications following this type of surgery. What would be the nurse's best response?
A. "The major complication is when the client develops chronic pain."
B. "The major complication is when the client loses sensation in the flap."
C. "The major complication is when the pedicle tears loose and the flap dies."
D. "The major complication is when the blood supply fails and the tissue in the flap
dies."
ANS: D
Rationale: The major complication of a flap is necrosis of the pedicle or base as a result
of failure of the blood supply. This is more likely than tearing of the pedicle and chronic
pain and is more serious than loss of sensation.
34. A public health nurse is participating in a health promotion campaign that has the
goal of improving outcomes related to skin cancer in the community. What action has the
greatest potential to achieve this goal?
A. Educating participants about the relationship between general health and the
risk of skin cancer
B. Educating participants about treatment options for skin cancer
C. Educating participants about the early signs and symptoms of skin cancer
D. Educating participants about the health risks associated with smoking and
assisting with smoking cessation
ANS: C
Rationale: The best hope of decreasing the incidence of skin cancer lies in educating
clients about the early signs. There is a relationship between general health and skin
cancer, but teaching individuals to identify the early signs and symptoms is more likely to
benefit overall outcomes related to skin cancer. Teaching about treatment options is not
likely to have a major effect on outcomes of the disease. Smoking is not among the major
risk factors for skin cancer.
35. An older adult resident of a long-term care facility has been experiencing generalized
pruritus that has become more severe in recent weeks. What intervention should the
nurse add to this resident's plan of care?
A. Avoid the application of skin emollients
B. Apply antibiotic ointment, as prescribed, following baths
C. Avoid using hot water during the client's baths
D. Administer acetaminophen four times daily as prescribed
ANS: C
Rationale: If baths have been prescribed, the client is reminded to use tepid (not hot)
water and to shake off the excess water and blot between intertriginous areas (body
folds) with a towel. Skin emollients should be applied to reduce pruritus. Acetaminophen
and antibiotics do not reduce pruritus.
A client has a diagnosis of seborrhea and has been referred to the dermatology clinic,
where the nurse contributes to care. When planning this client's care, the nurse should
include what nursing diagnosis?
A. Risk for deficient fluid volume related to excess sebum synthesis
B. Ineffective thermoregulation related to occlusion of sebaceous glands
C. Disturbed body image related to excess sebum production
D. Ineffective tissue perfusion related to occlusion of sebaceous glands
ANS: C
Rationale: Seborrhea causes highly visible manifestations that are likely to have a
negative effect on the client's body image. Seborrhea does not normally affect fluid
balance, thermoregulation, or tissue perfusion.
A nurse is working with a family whose 5-year-old child has been diagnosed with
impetigo. What educational intervention should the nurse include in this family's care?
A. Ensuring that the family knows that impetigo is not contagious
B. Teaching about the safe and effective use of topical corticosteroids
C. Teaching about the importance of maintaining high standards of hygiene
D. Ensuring that the family knows how to safely burst the child's vesicles
Rationale: Impetigo is associated with unhygienic conditions; educational interventions
to address this are appropriate. The disease is contagious, thus vesicles should not be
manually burst. Because of the bacterial etiology, corticosteroids are ineffective.
The nurse is caring for a client who developed a pressure injury as a result of
decreased mobility. The nurse on the previous shift has provided client teaching about
pressure injuries and healing promotion. The nurse determines that the client has
understood the teaching by observing the client:
A. perform range-of-motion exercises.
B. avoid placing body weight on the healing site.
C. elevate body parts that are susceptible to edema.
D. demonstrate the technique for massaging the wound site.
ANS: B
Rationale: The major goals of pressure injury treatment may include relief of pressure,
improved mobility, improved sensory perception, improved tissue perfusion, improved
nutritional status, minimized friction and shear forces, dry surfaces in contact with skin,
and healing of pressure ulcer, if present. The other options do not demonstrate the
achievement of the goal of the client teaching.
39. An older adult client, who is bedridden, is admitted to the unit because of a pressure
injury that can no longer be treated in a community setting. During assessment, the
nurse finds that the ulcer extends into the muscle and bone. At what stage should the
nurse document this injury?
A. I
B. II
C. III
D. IV
ANS: D
Rationale: Stage III and IV pressure injuries are characterized by extensive tissue
damage. In addition to the interventions listed for stage I, these advanced draining,
necrotic pressure injuries must be cleaned (débrided) to create an area that will heal.
Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that
extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and
infection may develop. Stage I is an area of erythema that does not blanch with pressure.
Stage II involves a break in the skin that may drain.