Pressure Ulcers & Prevention
The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?
A . Non-blanchable redness
B. A shallow open injury
C. Visible subcutaneous fat
D. Exposed bone with eschar
A. non-blanchable redness
Which of the following information regarding the transmission of lice would the nurse identify as a myth?
A. Lice can be spread by sharing of hats, caps, and combs.
B. Lice can jump from one individual to another.
C. Lice need to be removed from the hair with a fine comb.
D. Lice can be seen without magnification.
ANS: B
The nurse is correct to identify that lice cannot jump from one individual to another. Direct contact is needed for transmission. The other options are correct.
A client who plays football for a local high school is seeing the health care provider for treatment of athlete's foot. What does the nurse anticipate the health care provider to order?
A. Antibiotic
B. Antifungal
C. Antiviral
D. Antineoplastic
B. Antifungal
A nurse assessing the wound healing of a client documents that the wound is well approximated and forms a clean, straight line with little loss of tissue. This wound healed by:
A. Primary intention.
B. Secondary intention.
C. Tertiary intention.
D. Dehiscence.
A. Primary intention
Which is the primary preventable cause of skin cancer?
A. Fair skin
B. Excess melanin
C. Exposure to UV radiation
D. Skin disease
ANS: C
Skin cancer is caused by exposure to UV radiation, both artificial and in sunlight. Fair-skinned individuals are more susceptible because they do not have as many melanin-producing cells within their skin. Skin diseases do not cause cancer.
An older adult client, who is bedridden, is admitted to the unit because of a pressure injury. During assessment, the nurse finds that the ulcer extends into the dermis. At what stage should the nurse document this injury?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B. Stage II
A client is being treated for acne vulgaris. What contributes to follicular irritation?
A. overproduction of sebum
B. chocolate
C. stress
D. potato chips
A. The overproduction of sebum provides an ideal environment for bacterial growth within the irritated follicle. The follicle becomes further distended and irritated, causing a raised papule in the skin.
A nurse is caring for a client who has a prescription for diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse make?
A. "Gradually decrease the dose once tolerance to the effect is reached."
B. "Distribute the doses evenly throughout the day."
C. "Take the daily dose at bedtime."
D. "Take the medication with meals."
C. "Take the daily dose at bedtime."
Taking the dose at bedtime will allow the client to obtain the benefit of maximum relief of symptoms and rest without itching.
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The skin on the knees is intact, but they have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?
A. Contusion
B. Abrasion
C. Puncture
D. Avulsion
A. Contusion
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?
A. "Your wound will heal slowly as granulation tissue forms and fills the wound."
B. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal."
C. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."
D. "As soon as the infection clears, your surgeon will staple the wound closed."
A. "Your wound will heal slowly as granulation tissue forms and fills the wound."
A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan?
A. Keep the ulcer bed dry.
B. Clean the wound bed with hydrogen peroxide.
C. Provide the client a diet high in vitamin C.
D. Reposition the client at least every 4 hr.
C. Provide the client a diet high in vitamin C.
Which term describes a fungal infection of the body?
A. Tinea capitis
B. Tinea corporis
C. Tinea cruris
D. Tinea pedis
B. Tinea corporis
Which client is most likely to benefit from treatment with topical nystatin?
A. a client with candidiasis growing in skin folds
B. a client whose acne has not responded to topical antibiotics
C. a toddler diagnosed with impetigo
D. a school-aged child with pruritis secondary to chicken pox infection
A. a client with candidiasis growing in skin folds
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?
A. The wound will take up to 3 weeks to heal.
B. Pain management will be a challenge.
C. Skin grafting will be necessary.
D. Ligaments, tendons, muscles, and bone are not involved.
ANS: C
Rationale: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.
A nurse is aware of the varied therapeutic applications for hot and cold application. Which clients may benefit the most from the application of heat?
A. a client whose oral temperature is 38.6° C (101.5° F)
B. a client whose injured knee is visibly swollen
C. a client who is experiencing epistaxis (nosebleed)
D. a client who is experiencing back spasms
D. a client who is experiencing back spasms
A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?
A. Massage the client’s bony prominences.
B. Keep the head of the bed elevated.
C. Reposition the client at least every 2 hr.
D. Keep the client’s skin moist.
C. Reposition the client at least every 2 hr.
The nurse is caring for a client with a new tattoo. Which nursing diagnosis is of highest priority?
A. Altered Skin Integrity
B. Infection Risk
C. Acute Pain
D. Altered Tissue Perfusion
ANS: B
Rationale: The trauma created by a tattoo is similar to a minor burn, thus, skin integrity, pain, and tissue perfusion are not the highest priority. Infection risk is the highest priority due to the injection of ink in the dermis. The priority of care is preventing infection.
The health care provider prescribes methotrexate for a 28-year-old woman with severe psoriasis. When obtaining a health history from the patient, the most important information for the nurse to communicate to the health care provider is that the patient has
a. a history of infectious mononucleosis as a teenager.
b. a family history of age-related macular degeneration of the retina.
c. been trying to get pregnant
d. been using large doses of vitamins and health foods to treat the psoriasis.
Correct Answer: C
Rationale: Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
A. 9%
B. 18%
C. 27%
D. 36%
ANS: D
Rationale: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area. None of the other answer choices correctly applies the Rule of Nines.
A client's wound is a thin, watery, pink-tinged substance. The nurse correctly describes the drainage as:
A. Sanguineous
B. Serosanguineous
C. Serous
D. Purulent
B. Serosanguineous
Which of the following are primary risk factors for pressure ulcers? Select all that apply.
A. Low-protein diet
B. Insomnia
C. Lengthy surgical procedures
D. Fever
E. Sleeping on a waterbed
A. C. & D.
The nurse teaches the client who demonstrates herpes zoster (shingles) that
A. once a client has had shingles, they will not have it a second time.
B. a person who has had chickenpox can contract it again upon exposure to a person with shingles.
C. the infection results from reactivation of the chickenpox virus.
D. no known medications affect the course of shingles.
C. It is assumed that herpes zoster represents a reactivation of the latent varicella (chickenpox) virus and reflects lowered immunity. It is believed that the varicella zoster virus lies dormant inside nerve cells near the brain and spinal cord and is reactivated with weakened immune systems and cancers. A person who has had chickenpox is immune and therefore not at risk of infection after exposure to clients with herpes zoster. Some evidence shows that infection is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.
When planning care for a client with herpes zoster, what medication, if administered within the first 24 hours of the initial eruption, can arrest this virus?
A. Deltasone (Prednisone)
B. Vancomycin
C. Triamcinolone cream (Kenalog)
D. Acyclovir (Zovirax)
D. Acyclovir (Zovirax)
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
A. removing dead or infected tissue to promote wound healing
B. stimulating the wound bed to promote the growth of granulation tissue
C. removing purulent drainage from the wound bed in order to accurately assess it
D. removing excess drainage and wet tissue to prevent maceration of surrounding skin
A. removing dead or infected tissue to promote wound healing. Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
C. Include intact skin at the wound edges in the culture.
D. Swab an area of skin away from the wound to identify normal flora.
A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.