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When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?
Correct Answer: A. Ineffective airway clearance related to edema of the respiratory passages
When caring for a client with upper torso burns, the nurse’s primary goal is to maintain respiratory integrity. Therefore, option A should take the highest priority. Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum.
- Option B: This nursing diagnosis isn’t appropriate because burns aren’t a disease. Note circulation, motion, and sensation of digits frequently. Edema may compromise circulation to extremities, potentiating tissue necrosis and the development of contractures.
- Option C: Disturbed sleep pattern may be appropriate, but don’t command a higher priority than the ineffective airway clearance because they don’t immediately reflect life-threatening problems. Initially, the patient may use denial and repression to reduce and filter information that might be overwhelming. Some patients display a calm manner and alert mental status, representing a dissociation from reality, which is also a protective mechanism.
- Option D: Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies.
In a female client with burns on the legs, which nursing intervention helps prevent contractures?
- A. Applying knee splints.
- B. Elevating the foot of the bed.
- C. Hyperextending the client’s palms.
- D. Performing shoulder range-of-motion exercises.
Correct Answer: A. Applying knee splints.
Applying knee splints prevents leg contractures by holding the joints in a position of function. Maintain proper body alignment with supports or splints, especially for burns over joints. Promotes functional positioning of extremities and prevents contractures, which are more likely over joints.
- Option B: Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function. Medicate for pain before activity or exercise. Reduces muscle and tissue stiffness and tension, enabling the patient to be more active and facilitating participation.
- Option C: Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Incorporate ADLs with physical therapy, hydrotherapy, and nursing care. Combining activities produces improved results by enhancing the effects of each.
- Option D: Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs. Perform ROM exercises consistently, initially passive, then active. Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium from the bone.
A male client comes to the physician’s office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which instruction would best prevent skin damage?
- A. “Minimize sun exposure from 1 to 4 p.m. when the sun is strongest.”
- B. “Use sunscreen with a sun protection factor of 6 or higher.”
- C. “Apply sunscreen even on overcast days.”
- D. “When at the beach, sit in the shade to prevent sunburn.”
Correct Answer: C. “Apply sunscreen even on overcast days.”
Sunscreen should be applied even on overcast days, because the sun’s rays are as damaging then as on sunny days. Apply sunscreen to dry skin 15 minutes before going outside. Use at least 1 oz (2 tablespoons or enough to fill a shot glass) to cover the exposed areas of the body. Don’t overlook often-forgotten places like the scalp, the back of the neck, the tops of the feet, and the ears. Reapply the sunscreen every 2 hours and after swimming, sweating, or towel-drying. Use a lip balm with an SPF of at least 15 too.
- Option A: The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. Wear protective clothing such as loose shirts with long sleeves, long pants, a wide-brimmed hat, and shoes. Keep in mind that clothes don’t protect the skin completely from the sun’s rays, so wear sunscreen too.
- Option B: The nurse should recommend sunscreen with a sun protection factor of at least 15. Choose a sunscreen with a sun-protection factor (SPF) of 15 or more that’s waterproof or water-resistant. Never seek out the sun to get a tan. Like sunburn, a suntan damages the skin.
- Option D: Sitting in the shade when at the beach doesn’t guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun’s rays onto the skin. Head indoors right away if the skin starts to ache or tingle.
A female client is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. [Question taken from Nurseslabs.com] Using the Rule of Nines, what is the total body surface area that has been burned?
Correct Answer: D. 36%
The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client’s burns cover 36% of the body surface area.
- Option A: The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by trauma and emergency medicine providers to assess the total body surface area (TBSA) involved in burn patients. Measurement of the initial burn surface area is important in estimating fluid resuscitation requirements since patients with severe burns will have massive fluid losses due to the removal of the skin barrier.
- Option B: The Rule of Nines estimation of body surface area burned is based on assigning percentages to different body areas. The entire head is estimated as 9% (4.5% for anterior and posterior). The entire trunk is estimated at 36% and can be further broken down into 18% for anterior components and 18% for the back. The anterior aspect of the trunk can further be divided into chest (9%) and abdomen (9%).
- Option C: The upper extremities total 18% and thus 9% for each upper extremity. Each upper extremity can further be divided into anterior (4.5%) and posterior (4.5%). The lower extremities are estimated at 36%, 18% for each lower extremity. Again this can be further divided into 9% for the anterior and 9% for the posterior aspect. The groin is estimated at 1%.
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Which nursing intervention can help a client maintain healthy skin?
- A. Keep the client well hydrated.
- B. Avoid bathing the client with mild soap.
- C. Remove adhesive tape quickly from the skin.
- D. Recommend wearing tight-fitting clothes in hot weather.
Correct Answer: A. Keep the client well hydrated.
Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body’s first line of defense. The role of water within the stratum corneum is pivotal to the maintenance of normal skin integrity and turnover. Water allows for the increased flexibility of the tissues and is a crucial component of the enzymatic reactions responsible for cleavage of the corneodesmosome connections between corneocytes during the desquamation process.
- Option B: To help a client maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. Dry skin has many causes including frequent hand washing, exposure to harsh chemicals, low ambient humidity, as well as medical conditions like atopic dermatitis, ichthyosis, and psoriasis.
- Option C: The nurse shouldn’t remove adhesive tape quickly because this action can strip or scrape the skin. Conversely, when the water content is too low, hydrolytic enzymes needed for this reaction are unable to function. The water content of the stratum corneum ranges from 10% to 30% in healthy skin, as compared to 75% to 85% water content of stratum basale. This gradient is a key feature in its function as a barrier.
- Option D: The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation. Below a critical water concentration, the corneodesmosome connections remain intact, which results in a build-up of corneocytes and the appearance of dry, flaky skin.
A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
- A. Scale
- B. Crust
- C. Ulcer
- D. Scar
Correct Answer: A. Scale
A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don’t accompany psoriasis. Psoriasis is a chronic proliferative and inflammatory condition of the skin. It is characterized by erythematous plaques covered with silvery scales particularly over the extensor surfaces, scalp, and lumbosacral region.
- Option B: Impetigo is a common infection of the superficial layers of the epidermis that is highly contagious and most commonly caused by gram-positive bacteria. It most commonly presents as erythematous plaques with a yellow crust and may be itchy or painful. The lesions are highly contagious and spread easily.
- Option C: Decubitus ulcers are skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body. They should receive prompt treatment; otherwise, complications associated with these injuries can be fatal. The cornerstone of treatment is to reduce the pressure exerted at the site of the lesion.
- Option D: Hypertrophic scarring represents an undesirable variant in the wound healing process. In hypertrophic scars, excess connective tissue is deposited in the area of the original tissue wound. Hypertrophic scarring presents as an area of increased induration and often dyspigmentation over the site of a wound, especially in areas of increased wound tension.
A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?
- A. Related to potential interactions between the topical corticosteroid and other prescribed drugs
- B. Related to vasodilatory effects of the topical corticosteroid
- C. Related to percutaneous absorption of the topical corticosteroid
- D. Related to topical corticosteroid application to the face, neck, and intertriginous sites
Correct Answer: C. Related to percutaneous absorption of the topical corticosteroid
A potent topical corticosteroid may increase the client’s risk for injury because it may be absorbed percutaneously, causing the same adverse effects as systemic corticosteroids. Corticosteroids are better absorbed and more permeable in regions of thin epidermis, such as the eyelid, compared to thicker regions of epidermis, such as the sole. The penetration difference between the two varies by 300 fold. The penetration increases two- to ten-fold in diseased states, such as inflammation and desquamation.
- Option A: Topical corticosteroids aren’t involved in significant drug interactions. Patients need to be monitored carefully as unsupervised use of these medications can result in local and systemic adverse effects. The duration of treatment should not be greater than 2 to 4 weeks, regardless of potency. High-potency steroids should not be administered for longer than 2 weeks, and after this period, should be tapered to avoid adverse effects.
- Option B: These preparations cause vasoconstriction, not vasodilation. The anti-inflammatory effect of topical corticosteroids consists of vasoconstriction, inhibition of the release of phospholipase A2, and a direct inhibitory effect on DNA and inflammatory transcription factors. Vasoconstriction of the blood vessels within the upper dermis decreases the number of inflammatory mediators being delivered to the region applied.
- Option D: A potent topical corticosteroid rarely is prescribed for use on the face, neck, or intertriginous sites because the application in these areas may lead to increased adverse effects. The adverse effects of topical corticosteroids can be divided into local and systemic effects. Local adverse effects occur with prolonged treatment and are based on the topical steroid potency, vehicle, and application site. The most common local effects include atrophy, striae, rosacea, perioral dermatitis, acne, and purpura.
A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?
- A. During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.
- B. Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days.
- C. Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms.
- D. A client with genital herpes lesions can have sexual contact but must use a condom.
Correct Answer: A. During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.
Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature delivery. Both primary and recurrent HSV infections in pregnant women can lead to intrauterine transmission and resultant congenital HSV infection. More women than men have been reported to be infected, and as expected, the prevalence increases with an increasing number of sexual partners.
- Option B: Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Genital symptoms are commonly seen in the outpatient primary care setting, despite many going without a clear diagnosis. HSV-2, in particular, may present as a primary infection with painful genital ulcers, sores, crusts, tender lymphadenopathy, and dysuria.
- Option C: Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. It is commonly subclinical, and the only manifestation may be mild, self-limiting blepharoconjunctivitis, marked by inflammatory vesicles or ulcers and can include lesions in the corneal epithelium. Mild fever, malaise, or upper respiratory tract infection may also be present.
- Option D: A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease. There is no cure for HSV-2, early identification of symptoms, and prompt institution of pharmacotherapy can lead to early suppression of viral replication. Abstinence during known viral shedding can decrease the risk of transmission to a seronegative partner.
A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to this drug?
- A. Aplastic anemia
- B. Ototoxicity
- C. Cardiac arrhythmias
- D. Seizures
Correct Answer: B. Ototoxicity
The most significant adverse reactions to gentamicin and other aminoglycosides are ototoxicity (indicated by vertigo, tinnitus, and hearing loss) and nephrotoxicity (indicated by urinary cells or casts, oliguria, proteinuria, and reduced creatinine clearance). These adverse reactions are most common in elderly and dehydrated clients, those with renal impairment, and those receiving concomitant therapy with another potentially ototoxic or nephrotoxic drug. Gentamicin isn’t associated with aplastic anemia, cardiac arrhythmias, or seizures.
- Option A: Aplastic anemia is not associated with gentamicin. The gentamicin is prone to accumulate in the renal proximal tubular cells and can cause damage. Hence, mild proteinuria and reduction of the glomerular filtration rate are potential consequences of gentamicin use, achieving 14% of gentamicin users in a review
- Option C: Cardiac arrhythmias are not an adverse effect of Gentamicin. Characteristically, gentamicin reaches high concentrations in the renal cortex and the inner ear. The latter may be injured, leading to auditory and, especially, vestibular dysfunction. The first manifestation of cochlear damage is often high-pitched tinnitus, which may last a few weeks after the gentamicin is interrupted.
- Option D: Seizures are not an adverse effect of Gentamicin. The neuromuscular blockade, although a rare event, is a serious adverse effect of virtually all aminoglycosides. The known risk factors are concurrent conditions (e.g., myasthenia gravis) or medications (e.g., vecuronium) that interfere with the neuromuscular junction.
A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?
- A. “Apply one applicator of terconazole intravaginally at bedtime for 7 days.”
- B. “Apply one applicator of tioconazole intravaginally at bedtime for 7 days.”
- C. “Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days.”
- D. “Apply sulconazole nitrate twice daily by massaging it gently into the lesions.”
Correct Answer: C. “Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days.”
A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times a day for 7 days. The benefits of acyclovir include its low side effect profile, which allows it to be tolerated for long periods. Suppressive treatment with acyclovir can prevent or delay up to 80% of recurrences, thus reducing shedding by greater than 90%.
- Option A: Terconazole is used to treat vulvovaginal candidiasis. There are also prescription therapies: nystatin 100000-unit vaginal tablet for 14 nights, terconazole 80 mg one suppository vaginally for 3 nights, terconazole 0.8% cream vaginally for 3 nights, butoconazole 2% cream one applicator vaginally once (do not use during the first trimester of pregnancy).
- Option B: Tioconazole is used to treat vulvovaginal candidiasis. For vaginal candidiasis, several over the counter options are available: clotrimazole 1% cream vaginally for 7 to 14 nights, clotrimazole 2% cream vaginally for 3 nights, miconazole 2% cream vaginally for 7 nights, miconazole 4% cream vaginally for 3 nights, miconazole 100 mg suppository vaginally for 3 nights, tioconazole 6.5% ointment vaginally once.
- Option D: Sulconazole nitrate is used to treat tinea versicolor. Topical medications are considered the first-line therapy for pityriasis versicolor. Topical treatments are divided into nonspecific antifungal agents (sulfur plus salicylic acid, selenium sulfide 2.5%, and zinc-pyrithione) that primarily remove dead tissue and prevent further invasion, and specific antifungal drugs, that have fungicidal or fungistatic effects.
Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?
- A. With a circular motion, to enhance absorption.
- B. With an upward motion, to increase blood supply to the affected area.
- C. In long, even, outward, and downward strokes in the direction of hair growth.
- D. In long, even, outward, and upward strokes in the direction opposite hair growth.
Correct Answer: C. In long, even, outward, and downward strokes in the direction of hair growth
When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation. One fingertip unit (FTU) is equal to 0.5 grams. The suggested dose of FTU is dependent upon the body region being treated. Topical corticosteroids are recommended for once to twice daily use.
- Option A: Topical corticosteroids are administered topically; however, successful administration depends upon obtaining an accurate diagnosis, choosing the correct drug, selecting the appropriate vehicle and potency, and the frequency of application.
- Option B: The vehicle is the carrier of the drug. The vehicle selection depends on the region affected and the type of lesion present. It also functions to hydrate the skin and increase absorption. Creams are less potent than ointment but cosmetically more appealing since they leave no residue; the drying, non-occlusive nature leads to their administration for acute exudative inflammation and dermatitis within the intertriginous areas.
- Option D: Corticosteroids are better absorbed and more permeable in regions of thin epidermis, such as the eyelid, compared to thicker regions of epidermis, such as the sole. The penetration difference between the two varies by 300 fold. The penetration increases two- to ten-fold in diseased states, such as inflammation and desquamation.
Nurse Mary is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it’s meant to protect?
- A. Polyurethane foam mattress
- B. Ring or donut
- C. Gel flotation pad
- D. Waterbed
Correct Answer: B. Ring or donut
Rings or donuts aren’t to be used because they restrict circulation. Selection of a device may depend on factors such as mobility of the individual, the results of skin assessment, the level of and site at risk, weight, staff availability and skill plus the general health and condition of the individual. It is also important that any device is able to be cleaned and decontaminated effectively. It is accepted that these devices should be used in conjunction with other preventative strategies such as repositioning.
- Option A: Foam mattresses evenly distribute pressure. All studies showed a clinical benefit of higher specification foam mattresses (cubed foam mattress, soft foam mattress, pressure redistributing foam mattress), in reducing the incidence of pressure ulcers when compared to standard hospital mattresses.
- Option C: Gel pads redistribute with the client’s weight. A gel-filled pad and a pressure-reducing cushion (designed to improve tissue tolerance in sitting by providing more surface area and reducing peak pressure) were clinically beneficial compared to foam cushions for reducing the incidence of pressure ulcers in people who use a wheelchair.
- Option D: The water bed also distributes pressure over the entire surface. Both a bead-filled mattress and a water-filled mattress showed a clinical benefit for reducing the incidence of pressure ulcers when compared to standard hospital mattresses (type not specified).
Nurse Harry documents the presence of a scab on a client’s deep wound. The nurse identifies this as which phase of wound healing?
- A. Inflammatory
- B. Migratory
- C. Proliferative
- D. Maturation
Correct Answer: B. Migratory
The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells, synthesis of scar tissue by fibroblasts, and development of new cells that grow across the wound. Wound healing is a natural physiological reaction to tissue injury. However, wound healing is not a simple phenomenon but involves a complex interplay between numerous cell types, cytokines, mediators, and the vascular system.
- Option A: In the inflammatory phase, a blood clot forms, epidermis thickens, and an inflammatory reaction occurs in the subcutaneous tissue. The inflammatory phase is characterized by hemostasis, chemotaxis, and increased vascular permeability which limits further damage, closes the wound, removes cellular debris and bacteria, and fosters cellular migration. The duration of the inflammatory stage usually lasts several days.
- Option C: During the proliferative phase, the actions of the migratory phase continue and intensify, and granulation tissue fills the wound. The proliferative phase is characterized by the formation of granulation tissue, reepithelialization, and neovascularization. This phase can last several weeks.
- Option D: In the maturation phase, cells and vessels return to normal and the scab sloughs off. The maturation and remodeling phase is where the wound achieves maximum strength as it matures.
In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?
- A. A urine output consistently above 100 ml/hour.
- B. A weight gain of 4 lb (2 kg) in 24 hours.
- C. Body temperature readings all within normal limits.
- D. An electrocardiogram (ECG) showing no arrhythmias.
Correct Answer: A. A urine output consistently above 100 ml/hour
In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Monitor urinary output and specific gravity. Observe urine color and Hematest as indicated. Generally, fluid replacement should be titrated to ensure average urinary output of 30–50 mL/hr (in the adult).
- Option B: The expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Urine can appear red to black (with massive muscle destruction) because of the presence of blood and release of myoglobin. If gross myoglobinuria is present, minimum urinary output should be 75–100 mL/hr to reduce risk of tubular damage and renal failure.
- Option C: Weight gain from fluid resuscitation isn’t a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Fluid replacement formulas partly depend on admission weight and subsequent changes. A 15%–20% weight gain can be anticipated in the first 72 hr during fluid replacement, with return to pre-burn weight approximately 10 days after burn.
- Option D: Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators. Monitor vital signs, central venous pressure (CVP). Note capillary refill and strength of peripheral pulses. Serves as a guide to fluid replacement needs and assesses cardiovascular response.
A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause:
- A. Palpitations
- B. Dizziness
- C. Diarrhea
- D. Metallic taste
Correct Answer: C. Diarrhea
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Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting. It isn’t associated with palpitations, dizziness, or a metallic taste. Acyclovir is an antiviral agent that incorporates itself into viral DNA preventing further synthesis. It inhibits DNA synthesis and viral replication after it is converted to acyclovir triphosphate by viral and cellular enzymes. Patients also may experience nausea, vomiting, diarrhea, headache when taken orally.
- Option A: Less commonly, patients experience inflammation or phlebitis at the infusion site, nausea, vomiting, transaminitis, and rash (including Steven-Johnson syndrome) when taken intravenously. Rotating infusion sites and decreasing final infusion concentration less than 10 mg/mL can help prevent inflammation/phlebitis at the infusion site.
- Option B: Least commonly, patients experience abdominal pain, aggression/confusion, agitation, alopecia, anaphylaxis, anemia, angioedema, anorexia, ataxia, coma, disseminated intravascular coagulation (DIC), dizziness, and fatigue.
- Option D: Acute kidney injury (AKI) is the most significant side effect of parenteral acyclovir administration. The incidence of AKI is comparable to other nephrotoxic medications such as aminoglycosides. Patients with CKD are at higher risk.
A female client sees a dermatologist for a skin problem. Later, the nurse reviews the client’s chart and notes that the chief complaint was intertrigo. This term refers to which condition?
- A. Spontaneously occurring wheals.
- B. A fungus that enters the skin’s surface, causing infection.
- C. Inflammation of a hair follicle.
- D. Irritation of opposing skin surfaces caused by friction.
Correct Answer: D. Irritation of opposing skin surfaces caused by friction.
Intertrigo refers to irritation of opposing skin surfaces caused by friction. Intertrigo is a superficial inflammatory skin condition of the skin’s flexural surfaces, prompted or irritated by warm temperatures, friction, moisture, maceration, and poor ventilation. Characteristically, the lesions are erythematous patches of various intensity with secondary lesions appearing as the condition progresses or is manipulated.
- Option A: Spontaneously occurring wheals occur in hives. Contact urticaria (CU) is a transient wheal and flare reaction that occurs within 10 to 60 minutes at the site of contact of the offending agent and completely resolves within 24 hours. The risk for developing CU increases when there is an interruption of the stratum corneum due to filaggrin gene mutations or skin irritants.
- Option B: A fungus that enters the skin surface and causes infection is a dermatophyte. The dermatophyte’s ability to attach to the keratinized tissue of skin forms the basis for the dermatophytosis (superficial fungal skin infections). The dermatophytes causing tinea corporis belong to genera Trichophyton, Epidermophyton, and Microsporum.
- Option C: Inflammation of a hair follicle is called folliculitis. Folliculitis is a common, generally benign, skin condition in which the hair follicle becomes infected/inflamed and forms a pustule or erythematous papule of overlying hair-covered skin. While this is a non-life threatening condition and in most cases is self-limited, it can present challenges for immunocompromised patients and in some cases progress to more severe diseases.
A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
- A. Turn him frequently.
- B. Perform passive range-of-motion (ROM) exercises.
- C. Reduce the client’s fluid intake.
- D. Encourage the client to use a footboard.
Correct Answer: A. Turn him frequently.
The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation.
- Option B: During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers. ROM exercise helps in reducing muscle stiffness and spasticity. It can also help prevent contractures.
- Option C: Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. Offer solid foods and liquids at different times. Prevents the patient from swallowing food before it is thoroughly chewed. In general, liquids should be offered only after the patient has finished eating foods.
- Option D: A footboard prevents plantar flexion and foot drop by maintaining the foot in a dorsiflexed position. Discontinue use of footboard, when appropriate. Continued use (after change from flaccid to spastic paralysis) can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion.
A male client visits the physician’s office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribe:
- A. An I.V. corticosteroid
- B. An I.V. antibiotic
- C. An oral antibiotic
- D. A topical agent
Correct Answer: D. A topical agent
Although many drugs are used to treat skin disorders, topical agents — not I.V. or oral agents — are the mainstay of treatment. Topical corticosteroids play a major role in the treatment of many dermatologic conditions. They are FDA-approved and indicated for the use of inflammatory and pruritic presentations of dermatologic conditions.
- Option B: The active ingredient, or drug, in a topical preparation is mixed with an inactive ingredient (called the vehicle). The vehicle determines the consistency of the product (for example, thick and greasy or light and watery) and whether the active ingredient remains on the surface or penetrates the skin.
- Option C: Topical drugs (drugs applied directly to the skin) are a mainstay of treating skin disorders. Systemic drugs are taken by mouth or given by injection and are distributed throughout the body. Rarely, when a high concentration of a drug is needed at the affected area, a doctor injects the drug just under the skin (intradermal injection).
- Option D: In addition, many preparations are available in different strengths (concentrations). Choice of vehicle depends on where the drug will be applied, how it will look, and how convenient it is to apply and leave on. Creams, the most commonly used preparations, are emulsions of oil in water, meaning they are primarily water with an oil component. (An ointment is the opposite, some water mixed mostly with oil.) Creams are easy to apply and appear to vanish when rubbed into the skin. They are relatively nonirritating.
While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate response from the nurse is:
- A. “All family members will need to be treated.”
- B. “If someone develops symptoms, tell him to see a physician right away.”
- C. “Just be careful not to share linens and towels with family members.”
- D. “After you’re treated, family members won’t be at risk for contracting scabies.”
Correct Answer: A. “All family members will need to be treated.”
When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he’s symptomatic or not. Scabies is a contagious skin condition caused by the mite Sarcoptes scabiei which burrows into the skin and causes severe itching. Scabies is transmitted by direct skin-to-skin contact or indirectly by contact with contaminated material (fomites).
- Option B: Skin-to-skin contact transmits the infectious organism therefore, family members and skin contact relationships create the highest risk. Scabies was declared a neglected skin disease by the World Health Organization (WHO) in 2009 and is a significant health concern in many developing countries.
- Option C: Towels and linens should be washed in hot water. The classic form of scabies may have a population of mites on an individual that range between 10 to 15 organisms. It typically takes ten minutes of skin-to-skin contact for mites to transmit to another human host, in cases of classic scabies. Transmission of the disease can also occur by fomite transmission via clothing or bed sheets.
- Option D: Scabies can be transmitted from one person to another before symptoms develop. Infested individuals require identification and prompt treatment because a misdiagnosis can lead to outbreaks, morbidity, and an increased economic burden. Adult female mites dig burrow tunnels 1 to 10 millimeters long within the superficial layers of the epidermis and lay 2 to 3 eggs daily. The mites die 30 to 60 days later, and the eggs hatch after approximately 2 to 3 weeks. It merits mentioning that not all treatment options can penetrate the eggs stored within the skin.
When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care?
- A. Placing mitts on the client’s hands.
- B. Administering systemic antibiotics as prescribed.
- C. Applying topical antibiotics as prescribed.
- D. Continuing to administer antibiotics for 21 days as prescribed.
Correct Answer: B. Administering systemic antibiotics as prescribed.
Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication. Systemic antibiotics should be prescribed for all cases of bullous impetigo and cases of non-bullous impetigo with more than five lesions, deep tissue involvement, systemic signs of infection, lymphadenopathy or lesions in the oral cavity.
- Option A: The client’s nails should be kept trimmed to avoid scratching; however, mitts aren’t necessary. Children with impetigo should maintain good personal hygiene and avoid other children during the active outbreak. It is important to wash hands, linens, clothes and affected areas that may have come into contact with infected fluids.
- Option C: Topical antibiotics are less effective than systemic antibiotics in treating impetigo. Topical antibiotics alone or in conjunction with systemic antibiotics are used to treat impetigo. Antibiotic coverage should cover both S aureus and S pyogenes (i.e. GABHS). While untreated impetigo is often self-limiting, antibiotics decrease the duration of illness and spread of lesions.
- Option D: Without treatment, the infection heals in 14-21 days. About 20% of cases resolve spontaneously. Scarring is rare but some patients may develop pigmentation changes. Some patients may develop ecthyma. With treatment, cure occurs within 10 days. Neonates may develop meningitis. A rare complication is acute post streptococcal glomerulonephritis, which occurs 2-3 weeks after the skin infection.
A female client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid exercise because it may:
- A. Dislodge the autografts.
- B. Increase edema in the arms.
- C. Increase the amount of scarring.
- D. Decrease circulation to the fingers.
Correct Answer: A. Dislodge the autografts.
Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. None of the other options results from exercise. Patients who suffer hand burns are at a high contracture risk, partly due to numerous cutaneous functional units, or contracture risk areas, located within the hand. Patients who undergo split-thickness skin grafting are often immobilized postoperatively for graft protection.
- Option B: Restricting mobility immediately following an STSG is thought to protect against subdermal edema and shear forces, factors that interrupt revascularization leading to STSG failure. However, there is limited evidence to support that absolute restriction of motion results in superior STSG adherence and that mobility does not produce shearing forces as commonly believed.
- Option C: Postoperative hand burn management following a skin graft can be challenging and takes meticulous coordination to mitigate contracture risk and ensure the best functional outcome. Patients who undergo split-thickness skin grafting (STSG) to the hand are often immobilized postoperatively for graft protection.
- Option D: The most common surgical dressing used is a silver-impregnated glove wrapped with either moistened gauze or a cotton outer glove. This is then followed by a resting hand splint fitted and applied in the post-anesthesia care unit. The dressing and splint remain in place for 3 to 5 days postoperatively at which time the graft is evaluated and ROM is initiated following this prescribed immobilization period.
Nurse Tamara discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:
- A. Wash hands, apply a pediculicide to the client’s scalp, and remove any observable mites.
- B. Isolate the client’s bed linens until the client is no longer infectious.
- C. Notify the nurse in the day surgery unit of a potential scabies outbreak.
- D. Place the client on enteric precautions.
Correct Answer: B. Isolate the client’s bed linens until the client is no longer infectious.
To prevent the spread of scabies in other hospitalized clients, the nurse should isolate the client’s bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Teach the patient, family, and caregivers, the purpose and proper technique for maintaining isolation; if infection occurs, teach the patient to take antibiotics as prescribed. Instruct the patient to take the full course of antibiotics even if symptoms improve or disappear.
- Option A: Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Wash hands and teach the patient and SO to wash hands before contact with patients and between procedures with the patient.
- Option C: Although the nurse should notify the nurse in the day surgery unit of the client’s condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. Bedding, clothing, and towels used by infected persons or their household, sexual, and close contacts anytime during the three days before treatment should be decontaminated by washing in hot water and drying in a hot dryer, by dry-cleaning, or by sealing in a plastic bag for at least 72 hours.
- Option D: This client doesn’t require enteric precautions because the mites aren’t found on feces. Monitor status of skin around the wound; monitor patient’s skincare practices, noting the type of soap or other cleansing agents used, the temperature of the water, and frequency of skin cleansing; tell the patient to avoid rubbing and scratching; provide gloves or clip the nails if necessary.
Dr. Martinez prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
- A. “This makes the skin feel soft.”
- B. “This prevents evaporation of water from the hydrated epidermis.”
- C. “This minimizes cracking of the dermis.”
- D. “This prevents inflammation of the skin.”
Correct Answer: B. “This prevents evaporation of water from the hydrated epidermis.”
Applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin’s upper layer. The water content of the stratum corneum ranges from 10% to 30% in healthy skin, as compared to 75% to 85% water content of stratum basale. This gradient is a key feature in its function as a barrier.
- Option A: Although emollients make the skin feel soft, this effect occurs whether or not the client has just bathed or showered. The role of water within the stratum corneum is pivotal to the maintenance of normal skin integrity and turnover. Water allows for the increased flexibility of the tissues and is a crucial component of the enzymatic reactions responsible for cleavage of the corneodesmosome connections between corneocytes during the desquamation process.
- Option C: An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). The stratum corneum contains high concentrations of osmotically active molecules, including amino acids and their derivatives, lactic acid, urea, and electrolytes. These molecules form from the breakdown of filaggrin and are referred to as natural moisturizing factor (NMF). The molecules that make up NMF are hygroscopic and absorb atmospheric water at concentrations as low as 50%.
- Option D: An emollient doesn’t prevent skin inflammation. The goals of moisturizing the skin are to improve the appearance and function of the skin. In patients with medical conditions associated with impaired barrier function of the skin, like atopic dermatitis, the diligent use of moisturizers is a fundamental component of their treatment.
Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:
- A. Range of motion
- B. Protein intake
- C. Going outdoors
- D. Fluid ingestion
Correct Answer: A. Range of motion
To prevent disruption of the artificial skin’s adherence to the wound bed, the client should restrict the range of motion of the involved limb. Skin grafting is the transfer of cutaneous tissue from one portion of the body to another, often used to cover large wounds. The rationale of skin grafts is to take skin from a donor site that will heal and transfer the skin to an area of need. After incorporation, skin grafts provide wounds with protection from the environment, pathogens, temperature, and excessive water loss like normal skin.
- Option B: Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Additionally, since many of these patients remain immobile, nurses should ensure they are on deep vein thrombosis. Wound dressing changes should take place according to the preference of the surgeon. Once the wounds have healed, some patients may require physical therapy. Others may need to wear compression garments to prevent hypertrophic scarring.
- Option C: Going outdoors is acceptable as long as the left arm is protected from direct sunlight. A tie over a bolster of petroleum-infused gauze, cotton balls, and non-dissolvable suture is frequently placed on smaller STSG recipient sites. A negative pressure wound vacuum is another viable option for areas that are difficult to bolster.
- Option D: Split-thickness skin grafts typically become adherent to the recipient wound bed 5 to 7 days following skin graft placement. The dressings placed intraoperatively are kept in place until 5 to 7 days postoperatively to minimize shear and traction to the healing skin graft. At 5 to 7 days postoperatively, the dressings are taken down, and the skin graft inspected.
A male client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:
- A. Fluid resuscitation
- B. Infection
- C. Body image
- D. Pain management
Correct Answer: D. Pain management
With a superficial partial-thickness burn such as a solar burn (sunburn), the nurse’s main concern is pain management. Pain is nearly always present to some degree because of the varying severity of tissue involvement and destruction but is usually most severe during dressing changes and debridement. Changes in location, character, intensity of pain may indicate developing complications (limb ischemia) or herald improvement and/or return of nerve function and sensation.
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- Option A: Fluid resuscitation becomes a concern if the burn extends to the dermal and subcutaneous skin layers. Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Replacement formulas vary but are based on the extent of injury, amount of urinary output, and weight. Note: Once initial fluid resuscitation has been accomplished, a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion.
- Option B: Infection becomes a concern if the burn extends to the dermal and subcutaneous skin layers. Dependent on the type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from a simple wound and/or skin to complete or reverse to reduce risk of cross-contamination and exposure to multiple bacterial flora.
- Option C: Body image disturbance is a concern that has lower priority than pain management. Traumatic episodes result in sudden, unanticipated changes, creating feelings of grief over actual or perceived losses. This necessitates support to work through to optimal resolution.
The nurse is providing home care instructions to a client who has recently had a skin graft. It’s most important that the client remember to:
- A. Use cosmetic camouflage techniques.
- B. Protect the graft from direct sunlight.
- C. Continue physical therapy.
- D. Apply lubricating lotion to the graft site.
Correct Answer: B. Protect the graft from direct sunlight.
To avoid burning and sloughing, the client must protect the graft from direct sunlight. Protect the grafted area and the donor site from direct exposure to sunlight. Keep it covered for the first year and then protect it with a sunblock thereafter. The other three interventions are helpful to the client and his recovery but are less important.
- Option A: Ask the surgeon about camouflage make-up if concerned about the appearance of the graft. Expect skin discoloration at both the graft and the donor sites. This will gradually improve over the following 9-12 months.
- Option C: The client should take it easy for two weeks, building up slowly into his normal routine. Do not exert the grafted area. Depending on where the graft is, how big it is and what type of job the client has he may need to take time off work, two weeks or more. Exercise that might stretch or injure the graft should be avoided for 3-4 weeks.
- Option D: Once healed, the client may use a moisturizing cream such as E45, Nivea cream or Vaseline two or three times a day, on both grafted site and the donor site for three months or longer if the area remains dry.
A male client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction?
- A. “Avoid sexual intercourse until you’ve completed treatment, which takes 14 to 21 days.”
- B. “Wash your hands thoroughly to avoid transferring the infection to your eyes.”
- C. “If you have intercourse before treatment ends, tell sexual partners of your status and have them wash well after intercourse.”
- D. “If you don’t get treatment, you may develop meningitis and suffer widespread central nervous system (CNS) damage.”
Correct Answer: B. “Wash your hands thoroughly to avoid transferring the infection to your eyes.”
Adults and children with gonorrhea may develop gonococcal conjunctivitis by touching the eyes with contaminated hands. In populations other than neonates, transmission can occur via direct sexual contact with infective secretions or indirectly, for example via manual or fomite transmission, though this is thought to be less likely since N. gonorrhea does not typically survive more than a few minutes outside the human body.
- Option A: The client should avoid sexual intercourse until treatment is completed, which usually takes 4 to 7 days, and a follow-up culture confirms that the infection has been eradicated. Untreated cases can result in severe complications such as vision loss if the bacteria penetrate further and cause corneal ulceration and scarring. Timely ophthalmology consultation is warranted due to the significant risks to the patient’s vision.
- Option C: A client who doesn’t refrain from intercourse before treatment is completed should use a condom in addition to informing sex partners of the client’s health status and instructing them to wash well after intercourse. Furthermore, attention should be given to appropriate treatment since fluoroquinolone resistance has become a growing issue, which is part of the reason why cephalosporins have become the mainstay of gonococcal treatment.
- Option D: Meningitis and widespread CNS damage are potential complications of untreated syphilis, not gonorrhea. The main concept is that N. gonorrhoeae can attach to and penetrate the epithelial cells of mucosal surfaces such as the conjunctiva. Once inside, the bacteria can proliferate and induce pro-inflammatory mechanisms. However, there is evidence that N. gonorrhoeae have developed methods for evading and even modulating immune responses, which can potentially lead to disseminated infection, for example, bacteremia or meningitis.
A female client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse teaches the client about the importance of protecting the skin from ultraviolet light before drug administration and for 8 hours afterward and stresses the need to protect the eyes. After administering medication for photochemotherapy, the client must protect the eyes for:
- A. 4 hours
- B. 8 hours
- C. 24 hours
- D. 48 hours
Correct Answer: D. 48 hours
To prevent eye discomfort, the client must protect the eyes for 48 hours after taking medication for photochemotherapy. Protecting the eyes for a shorter period increases the risk of eye injury. PUVA or photochemotherapy is a type of ultraviolet radiation treatment (phototherapy) used for severe skin diseases. PUVA is a combination treatment which consists of Psoralens (P) and then exposing the skin to UVA (long wave ultraviolet radiation). It has been available in its present form since 1976.
- Option A: Avoid photosensitizers such as certain oral medications, perfumes, cosmetics and applications of coal tar. If the eyes are not protected from UV radiation, keratitis may occur. This results in red sore gritty eyes and can be very unpleasant.
- Option B: The client must protect the skin and eyes from natural sunlight for twelve hours after taking methoxsalen tablets. During treatment, the client must wear special goggles provided. Wear wrap-around ultraviolet-protective sunglasses both indoors and outdoors, from the moment the client takes the methoxsalen tablets until nightfall on the treatment day. After dark, the glasses must still be worn under fluorescent lighting, but are not necessary outside or with incandescent lamps.
- Option C: An overdose of PUVA results in a sunburn-like reaction called phototoxic erythema. It is more likely in fair-skinned patients who sunburn easily. A burn is most likely 48–72 hours after the first two or three treatments. Sensitive areas such as breasts and buttocks may need to be covered for all or part of the treatment.
A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:
- A. Cancer of the ovaries
- B. Cancer of the uterus
- C. Cancer of the cervix
- D. Cancer of the vagina
Correct Answer: C. Cancer of the cervix
A female client with genital herpes simplex is at increased risk for cervical cancer. Genital herpes simplex isn’t a risk factor for cancer of the ovaries, uterus, or vagina. Herpes simplex virus-2, the cause of genital herpes, was detected in nearly half of women with invasive cervical cancer — nearly twice as often as in women without signs of cancer, researches report in a study published in the Nov. 6 issue of the Journal of the National Cancer Institute.
- Option A: The strongest risk factor of ovarian cancer is a positive family history of breast or ovarian cancer, where a personal history of breast cancer also augments the risk. Several studies have shown an increased risk of smoking, especially the risk of mucinous epithelial tumors.
- Option B: Endometrial adenocarcinoma or endometrioid carcinoma is the most common subtype of endometrial cancer. Endometrial adenocarcinoma develops as a result of unopposed estrogen exposure. Estrogen has a proliferative effect on the endometrium, which leads to endometrial hyperplasia. Unmonitored proliferation leads to dysplasia and later carcinoma.
- Option D: The malignant and premalignant lesions of the vagina are uncommon. Cancer of the vagina is a clinically heterogeneous disease. The human papillomavirus (HPV) is a known carcinogen for the tumor of the vagina; however, non-HPV based carcinogenic routes also exist. As with cervical cancer, the high-risk subtypes of HPV can be responsible for other malignancies of the head and neck, as well as the vulva or vagina.
Which of the following is the initial intervention for a male client with external bleeding?
- A. Elevation of the extremity
- B. Pressure point control
- C. Direct pressure
- D. Application of a tourniquet
Correct Answer: C. Direct pressure.
Applying direct pressure to an injury is the initial step in controlling bleeding. For severe or arterial bleeding, pressure point control can be used. Control the external source of bleeding by applying direct pressure to the bleeding site. External bleeding is controlled with firm, direct pressure on the bleeding site, using a thick dry dressing material. Prompt, effective treatment is needed to preserve vital organ function and life.
- Option A: Elevation reduces the force of flow, but direct pressure is the first step. If trauma has occurred, evaluate and document the extent of the client’s injuries; use a primary survey (or another consistent survey method) or ABCs: airway with cervical spine control, breathing, and circulation.
- Option B: Pressure points are those areas where large blood vessels can be compressed against bone: femoral, brachial, facial, carotid, and temporal artery sites. Maintaining an adequate circulating blood volume is a priority. The amount of fluid infused is usually more important than the type of fluid (crystalloid, colloid, blood). The amount of volume that can be infused is inversely affected by the length of the IV catheter; it is best to use large-bore catheters.
- Option D: A tourniquet may further damage the injured extremity and should be avoided unless all other measures have failed. For trauma victims with internal bleeding (e.g., pelvic fracture), military antishock trousers (MAST) or pneumatic antishock garments (PASGs) may be used. These devices are useful to tamponade bleeding. Hypovolemia from long-bone fractures (e.g., femur or pelvic fractures) may be uncontrolled by splinting with air splints. Hare traction splints or MAST and/or PASG trousers may be used to reduce tissue and vessel damage from the manipulation of unstable fractures.
Nurse JV is performing wound care. Which of the following practices violates surgical asepsis?
- A. Holding sterile objects above the waist.
- B. Considering a 1″ edge around the sterile field as being contaminated.
- C. Pouring solution onto a sterile field cloth.
- D. Opening the outermost flap of a sterile package away from the body.
Correct Answer: C. Pouring solution onto a sterile field cloth.
Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The purpose of creating a sterile field is to reduce the number of microbes present to as few as possible. The sterile field is used in many situations outside the operating room as well as inside the operating room when performing surgical cases. The other options are practices that help ensure surgical asepsis.
- Option A: Another area considered unsterile is anything below table height. Once the back table is opened, bend down and move the table closer to the wall by grasping the lower leg of the table. This allows less chance of someone contaminating the table and gets it out of the way.
- Option B: The back table allows a large surface to open all other supplies onto it during set-up and is the main sterile field. Once the back table cover is opened, it is important to note that an imaginary 1-inch border exists along the edges of the table. This border is considered unsterile and should be avoided when tossing items onto the field.
- Option D: The next item is the ring stand that will hold the basin sets; open the first flap away from you, then each side flap, and lastly the flap closest to you. Bend down and marry (move) the ring stand closer to the back table and close the space between them. The sterile flap will be against the back sterile table drape.
During the acute phase of a burn, the nurse in-charge should assess which of the following?
- A. Client’s lifestyle
- B. Alcohol use
- C. Tobacco use
- D. Circulatory status
Correct Answer: D. Circulatory status
During the acute phase of a burn, the nurse should assess the client’s circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client’s lifestyle and alcohol and tobacco use may be obtained later when the client’s condition has stabilized.
- Option A: Assess color, sensation, movement, peripheral pulses, and capillary refill on extremities with circumferential burns. Compare with findings of unaffected limb. Edema formation can readily compress blood vessels, thereby impeding circulation and increasing venous stasis or edema. Comparisons with unaffected limbs aid in differentiating localized versus systemic problems.
- Option B: Obtain BP in unburned extremity when possible. Remove BP cuff after each reading, as indicated. If BP readings must be obtained on an injured extremity, leaving the cuff in place may increase edema formation and reduce perfusion, and convert partial thickness burn to a more serious injury.
- Option C: Check for irregular pulses. Cardiac dysrhythmias can occur as a result of electrolyte shifts, electrical injury, or release of myocardial depressant factor, compromising cardiac output.
Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first?
- A. Assess the drainage in the dressing.
- B. Slowly remove the soiled dressing.
- C. Wash hands thoroughly.
- D. Put on latex gloves.
Correct Answer: C. Wash hands thoroughly.
When caring for a client, the nurse must first wash her hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed. When applying or changing dressings, an aseptic technique is used in order to avoid introducing infections into a wound. Even if a wound is already infected, an aseptic technique should be used as it is important that no further infection is introduced.
- Option A: Complete a wound assessment. This includes a visual check and comparing and evaluating the smell, amount of blood or ooze (excretions) and their colour, and the size of the wound. If the site has not improved as expected, then the treating physician or senior charge nurse must be informed so they too can evaluate it and consider changing the care plan.
- Option B: Wash hands and put on non-sterile gloves (to protect yourself) before removing an old dressing. Dispose of this dressing in a separate dirty clinical waste bag. Start from the dirty area and then move out to the clean area. Be very careful when doing this as the tissue or skin may be tender and there may also be sutures in place. Clean the area without causing further damage or distress to the patient.
- Option D: Wash hands and put on sterile gloves. If the gloves become desterilised, remove them, re-wash hands and put on new sterile gloves. This is best practice, but where resources are not available, safe modifications to this process can be made, for example by using non-sterile gloves to protect the nurse while removing the dressing and then washing the hands with gloves on and using alcohol gel on the gloves to make them clean enough to clean the wound and redo the dressing. This then protects both the nurse and the patient.
Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?
- A. Turn and reposition the client at least once every 8 hours.
- B. Vigorously massage lotion into bony prominences.
- C. Post a turning schedule at the client’s bedside.
- D. Slide the client, rather than lifting, when turning.
Correct Answer: C. Post a turning schedule at the client’s bedside.
A turning schedule with a signing sheet will help ensure that the client gets turned and, thus, help prevent pressure ulcers. Set goals with the patient or significant other for cooperation in activities or exercise and position changes. This enhances a sense of anticipation of progress or improvement and gives some sense of control or independence.
- Option A: Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. Keep limbs in functional alignment with one or more of the following: pillows, sandbags, wedges, or prefabricated splints. This avoids foot drop and too much plantar flexion or tightness. Maintain feet in dorsiflexed position.
- Option B: The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. Assess the skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of the head). These areas are at highest risk for breakdown resulting from tissue ischemia from compression against a hard surface.
- Option D: When moving the client, the nurse should lift — rather than slide — the client to avoid shearing. Assess the client’s ability to move (shift weight while sitting, turn over in bed, move from the bed to a chair). Immobility is a huge risk factor for pressure ulcer development among adult hospitalized clients.
Nurse Jody formulates a nursing diagnosis of Impaired physical mobility for a client with third-degree burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?
- A. Related to fat emboli.
- B. Related to infection.
- C. Related to femoral artery occlusion.
- D. Related to circumferential eschar.
Correct Answer: D. Related to circumferential eschar.
As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. Note circulation, motion, and sensation of digits frequently. Edema may compromise circulation to extremities, potentiating tissue necrosis and development of contractures.
- Option A: This client isn’t likely to develop fat emboli unless long bone or pelvic fractures are present.Maintain proper body alignment with supports or splints, especially for burns over joints. Promotes functional positioning of extremities and prevents contractures, which are more likely over joints.
- Option B: Infection doesn’t alter physical mobility. Perform ROM exercises consistently, initially passive, then active. Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium from the bone.
- Option C: A client with burns on the lower portions of both legs isn’t likely to have femoral artery occlusion. Medicate for pain before activity or exercise. Reduces muscle and tissue stiffness and tension, enabling the patient to be more active and facilitating participation.
The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands which body area would provide the best assessment?
- A. Lips
- B. Sacrum
- C. Earlobes
- D. Back of the hands
Correct Answer: A. Lips
In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge. When the oxygen level has dropped only a small amount, cyanosis may be hard to detect. In dark-skinned people, cyanosis may be easier to see in the mucous membranes (lips, gums, around the eyes) and nails.
- Option B: Skin color is particularly important in detecting cyanosis and staging pressure ulcers. Cyanosis occurs when a person has 5 g/dL of unoxygenated hemoglobin in the arterial blood. Central cyanosis (cyanosis of the lips, mucous membranes, and tongue) occurs when arterial oxygen saturation falls below 85% in patients with normal hemoglobin levels.
- Option C: But in dark-skinned patients, cyanosis may present as gray or whitish (not bluish) skin around the mouth, and the conjunctivae may appear gray or bluish. In patients with yellowish skin, cyanosis may cause a grayish-greenish skin tone.
- Option D: When checking for pressure ulcers in dark-skinned patients, remember that dark skin rarely shows the blanch response. Instead, after applying light pressure, look for an area that’s darker than the surrounding skin or that’s taut, shiny, or indurated (hardened).
Which of the following individuals is least likely to be at risk of developing psoriasis?
- A. A 32 year-old-African American.
- B. A woman experiencing menopause.
- C. A client with a family history of the disorder
- D. An individual who has experienced a significant amount of emotional distress.
Correct Answer: A. A 32 year-old-African American.
Psoriasis occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups. Psoriasis has a prevalence ranging from 0.2% to 4.8%. The exact etiology is unknown, but it is considered to be an autoimmune disease mediated by T lymphocytes. There is an association of HLA antigens seen in many psoriatic patients particularly in various racial and ethnic groups.
- Option B: Psoriasis can present at any age. A bimodal age of onset has been recognized. The mean age of onset for the first presentation of psoriasis can range from 15 to 20 years of age, with a second peak occurring at 55 to 60 years.
- Option C: A genetic predisposition has been recognized in some cases. Familial occurrence suggests its genetic predisposition. Psoriasis occurs worldwide, and its prevalence varies. In the United States, about 2% of the population is affected. High rates of psoriasis have been reported in the Faroe Islands. The prevalence of psoriasis is low in Japan and may be absent in Aboriginal Australians and Indians from South America.
- Option D: Emotional distress, trauma, systemic illness, seasonal changes, and hormonal changes are linked to exacerbations. Generally, summer improves psoriasis while winter aggravates it. Apart from above factors infections, psychological stress, alcohol, smoking, obesity, and hypocalcemia are other triggering factors for psoriasis.
Which of the following clients would least likely be at risk of developing skin breakdown?
- A. A client incontinent of urine feces.
- B. A client with chronic nutritional deficiencies.
- C. A client with decreased sensory perception.
- D. A client who is unable to move about and is confined to bed.
Correct Answer: C. A client with decreased sensory perception.
Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk, as presented in the options, is the decreased sensory perception. Options A, B, and D identify physiological conditions, which are the risk priorities.
- Option A: Assess for fecal/urinary incontinence. Stool may contain enzymes that cause skin breakdown. The urea in urine turns into ammonia within minutes and is caustic to the skin. Use of diapers and incontinence pads hastens skin breakdown.
- Option B: Usually, individuals change position off pressure areas every few minutes; these occur automatically even during sleep. Patients who are unaware of sensation tend to do nothing thus results in prolonged pressure on skin capillaries and eventually in skin ischemia.
Option D: Specific areas where the skin is stretched tautly are at higher risk for breakdown because the possibility of ischemia to the skin is high as a result of compression of skin capillaries between a hard surface (e.g., mattress, chair, or table) and the bone. For lightly pigmented skin, pressure areas appear to be red. For darker skin tones, these areas appear to be red, blue, or purple hue spots.
The nurse prepares to care for a male client with acute cellulitis of the lower leg. The nurse anticipates which of the following will be prescribed for the client?
- A. Cold compress to the affected area.
- B. Warm compress to the affected area.
- C. Intermittent heat lamp treatments four times daily.
- D. Alternating hot and cold compresses continuously.
Correct Answer: B. Warm compress to the affected area.
Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia.
- Option A: Cold compresses and alternating cold and hot compresses are not the best measures. Identify aggravating factors. Inquire about recent changes in use of products such as soaps, laundry products, cosmetics, wool or synthetic fibers, cleaning solvents, and so forth.
- Option C: Heat lamps can cause more disruption to already inflamed tissue. Patients may develop cellulitis in response to changes in their environment. Extremes of temperature, emotional stress, and fatigue may contribute to cellulitis.
- Option D: Bathe or shower using lukewarm water and mild soap or nonsoap cleansers. Long bathing or showering in hot water causes drying of the skin and can aggravate itching through vasodilation.
The clinic nurse is assessing the skin of a white client who is diagnosed with psoriasis. Which of the following characteristics is associated with this skin disorder?
- A. Clear, thin nail beds.
- B. Red-purplish scaly lesions.
- C. Oily skin and no episodes of pruritus.
- D. Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions.
Correct Answer: D. Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions.
Psoriatic patches are covered with silvery-white scales. Affected areas include the scalp, elbows, knees, shins, trunk, and sacral area. Psoriasis presents as well defined erythematous plaques covered with silvery scales commonly over the scalp, extensors of extremity particularly over knees and elbows and lumbosacral region. Psoriasis is classified into two types. Type 1 psoriasis, which has a positive family history, starts before age 40 and is associated with HLA-Cw6; while type 2 psoriasis does not show a family history, presents after age 40, and is not associated with HLA-Cw6.
- Option A: Nail changes in psoriasis are seen as pitting, oil spots, subungual hyperkeratosis, nail dystrophy, and anchylosis. Psoriasis can present with different morphology in the form of plaque, guttate, rupioid, erythrodermic, pustular, inverse, elephantine, and psoriatic arthritis. Variation in a site is seen with the involvement of scalp, palmoplantar region, genitals, and nails.
- Option B: Guttate psoriasis also called as eruptive psoriasis is commonly seen in children after an upper respiratory tract infection with the streptococcal organism. It presents with erythematous and scaly raindrop-shaped lesions mainly over the trunk and back. It is the type of psoriasis having the best prognosis.
Option C: Plaque psoriasis typically presents as erythematous plaques with silvery scales most commonly over extensors of extremities, i.e., on the elbows, knees, scalp, and back. It is the most common type of psoriasis which affects 85% to 90% patients. On successive removal of psoriatic scales pinpoint bleeding points are seen. This is called the Auspitz sign which is used to confirm the diagnosis clinically.