Chapter 59 My Nursing Test Banks

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Chapter 59

Question 1

Type: MCSA

The mother of a teenaged female with a severe case of acne expresses concern about her daughters hygiene habits. Which response by the nurse is most helpful?

1. Improving facial hygiene is the best way to treat your daughters acne.

2. The most important causative factor for acne is poor diet, not inadequate hygiene.

3. Do you think your daughter is embarrassed by her appearance?

4. What are your concerns about her hygiene practices?

Correct Answer: 4

Rationale 1: Improving facial hygiene should be included in the treatment plan, but it is not the best treatment for severe acne. Isotretinoin (Accutane) and laser and light treatments are used to treat severe acne.

Rationale 2: No connections have been found between diet and acne.

Rationale 3: This question would elicit important information, but it should be addressed to the daughter, not the mother. It also does not address the mothers statement about hygiene.

Rationale 4: Eliciting more specific information about the daughters hygiene practices is primary. Identifying specific concerns will allow the nurse to begin to address the disorder.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-4

Question 2

Type: MCSA

A patient has a lesion in the left axilla that is deep, painful, and contains pus. The lesion is three centimeters in diameter and is walled off. The nurse anticipates treatment to be initiated for which condition?

1. A furuncle

2. Folliculitis

3. A carbuncle

4. Herpes zoster

Correct Answer: 1

Rationale 1: A furuncle is a walled-off, deep, painful, firm mass that contains pus. It is usually 1 to 5 centimeters in diameter.

Rationale 2: Folliculitis is inflammation of the hair follicles. It presents as circular papules and pustules associated with the hair follicles and surrounded by an area of erythema.

Rationale 3: A carbuncle is a larger abscess that interconnects several hair follicles and is about 3 to 10 centimeters in diameter.

Rationale 4: Herpes zoster is a viral skin infection that manifests as erythematous vesicles scattered over the skin surface along one or two adjacent dermatomes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 59-1

Question 3

Type: MCSA

An African American male patient has recurring folliculitis on the face. Which information should the nurse provide about shaving?

1. Use an electric razor.

2. Shave daily.

3. Shave very closely.

4. Shave in the opposite direction of hair growth.

Correct Answer: 1

Rationale 1: Folliculitis is inflammation of the hair follicles. African Americans are particularly susceptible to folliculitis caused by ingrown hairs because of their curly hair. Using an electric razor instead of a straightedge blade may be helpful.

Rationale 2: The patient should be instructed to shave every few days rather than daily.

Rationale 3: The patient should avoid shaving too closely.

Rationale 4: The patient should shave in the direction of hair growth.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-1

Question 4

Type: MCSA

The nurse is counseling a patient who has atopic dermatitis (eczema) and has developed a secondary Staphylococcus aureus infection. To prevent this type of infection from recurring in the future, the nurse should recommend which action?

1. Apply an emollient to the area at least once daily.

2. Take antibiotics for 3 weeks of each month.

3. Take a warm shower each morning and again before bedtime.

4. Have allergy testing performed.

Correct Answer: 1

Rationale 1: A secondary S. aureus infection can develop due to skin trauma and breakdown from scratching. Application of an emollient to the area at least once daily can help prevent dryness and the accompanying itching and scratching.

Rationale 2: Intermittent antibiotic therapy is not indicated.

Rationale 3: Frequent bathing may dry out the skin and increase itching.

Rationale 4: It is important to identify the irritants that cause the lesions, but this will not prevent a secondary infection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-2

Question 5

Type: MCSA

A patient has a small, red, scaling lesion that is sitting on an elevated base on the forehead. The patient states that the lesion appeared several weeks ago and will not heal. The nurse is concerned that the patient has which type of lesion?

1. Squamous cell carcinoma

2. Melanoma

3. Psoriasis

4. Seborrheic keratosis

Correct Answer: 1

Rationale 1: Squamous cell carcinoma consists of tumors of the outer epidermis that develop with frequent exposure to the sun. The

scaling lesions sit on an elevated base with an irregular border that may itch or be a nonhealing lesion after minor trauma.

Rationale 2: Melanoma appears as a changing or unusual mole with an irregular border, an uneven surface, and a varying size and shape.

Rationale 3: Psoriasis lesions are erythematous papules and plaques with silver-white scales that are sharply demarcated.

Rationale 4: Seborrheic keratosis lesions are warty, dirty yellow to black papules with sharp margins.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 59-4

Question 6

Type: MCSA

A patient diagnosed with scabies asks the nurse how she caught the disorder. What information should be provided to the patient?

1. The disorder is transmitted by contact with infected persons or their possessions.

2. The disorder is transmitted via the feces of infected animals.

3. Scabies is a bacterial infection transmitted by direct contact with infected persons.

4. Scabies is a fungal infection transmitted by contact with infected respiratory secretions.

Correct Answer: 1

Rationale 1: Scabies is transmitted via contact with infected people or their contaminated articles.

Rationale 2: Scabies is the result of infestation of the itch mite.

Rationale 3: Scabies is a parasitic disorder.

Rationale 4: Scabies is not fungal and is not transmitted via respiratory secretions.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-4

Question 7

Type: MCSA

The nurse is planning care for a patient recently diagnosed with herpes zoster. Which nursing diagnosis will the nurse give highest priority?

1. Acute Pain

2. Ineffective Health Maintenance

3. Anxiety

4. Deficient Knowledge

Correct Answer: 1

Rationale 1: In the initial period of the disorder, pain is a primary concern.

Rationale 2: Health maintenance behaviors cannot be altered until one of the other diagnoses is addressed.

Rationale 3: Anxiety cannot be addressed adequately until one of the other diagnoses is addressed.

Rationale 4: Teaching will not be effective until another diagnosis is addressed.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 59-1

Question 8

Type: MCMA

A patient at risk for the development of skin cancer is discussing sun exposure prevention with the nurse. What guidelines should the nurse offer?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Limit the time spent in the sun between 10 a.m. and 3 p.m.

2. Sunglasses should wrap around the face.

3. Apply a sunscreen with an SPF of 15 or more.

4. The higher the sunscreen rating, the less the protection provided.

5. When swimming, sunscreen should be reapplied every 4 hours.

Correct Answer: 1,2,3

Rationale 1: The patient should be taught to seek shade during midday.

Rationale 2: Sun exposure can occur through the sides of sunglasses unless they wrap around the head.

Rationale 3: The higher the level of the sunscreens rating, the greater the protection, but a minimum of 15 is recommended.

Rationale 4: The higher the level of the sunscreens rating, the greater the protection, but a minimum of 15 is recommended.

Rationale 5: When swimming, sunscreen should be reapplied hourly.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-3

Question 9

Type: MCSA

A patient asks the nurse about possible options regarding treatment for a malignant melanoma lesion on the arm. Which response by the nurse would be most accurate?

1. The preferred method of treatment is to remove all the cancer surgically.

2. An anticancer cream will be used to dissolve the lesion.

3. Radiation to the skin lesion will be the first method of treatment.

4. Intravenous chemotherapy will be the initial method of treatment.

Correct Answer: 1

Rationale 1: Surgical excision is the preferred treatment for malignant melanoma.

Rationale 2: A topical cream would not be used for a melanoma.

Rationale 3: Radiation is generally used for lesions that are inoperable because of their location, which is not the case here.

Rationale 4: Intravenous chemotherapy would not be used for a localized skin lesion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-5

Question 10

Type: MCSA

A patient with a history of tinea pedis is concerned about developing the disorder again. Which intervention can the nurse suggest to reduce the likelihood of a recurrence?

1. Wear sandal-style footwear.

2. Wear cotton undergarments.

3. Soak affected extremities in salted water nightly.

4. Apply lotion to moisturize potential areas of outbreak daily.

Correct Answer: 1

Rationale 1: Tinea pedis is a fungal infection of the soles of the feet, toes, and toenails. The condition is chronic and occurs in the presence of warmth and perspiration. Wearing open-style shoes such as sandals allows the feet to be open to the air.

Rationale 2: Cotton undergarments would not impact tinea pedis. They could assist in the management of tinea corporis.

Rationale 3: Salt water is not indicated in the management of tinea pedis.

Rationale 4: Lotion would increase moisture to the areas and potentially cause additional problems.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-1

Question 11

Type: MCMA

Several individuals from a homeless shelter have been diagnosed with pediculosis. The nurse, planning to train staff in the control and prevention of this infection, should include which information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pediculosis is spread by contact with personal items such as hats and blankets.

2. Pediculosis is more common in people who lack the proper facilities for bathing and washing clothes.

3. Crabs is another name for pediculosis.

4. Pediculosis affects children only.

5. Pediculosis is infestation by mites.

Correct Answer: 1,2,3

Rationale 1: Pediculosis is a contagious infestation with lice transmitted by personal contact. It can be spread through combs, animals, hats, blankets, telephones, and theater seats.

Rationale 2: Poor hygienic practices increase the risk of spreading lice.

Rationale 3: Pubic lice are referred to as crabs by some people.

Rationale 4: Anyone can contract pediculosis.

Rationale 5: Infestation by mites is scabies, not pediculosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-4

Question 12

Type: MCMA

When reviewing the history and physical records of a patient who has alopecia, the nurse should recognize which conditions as a possible cause?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A thyroid disorder

2. Solar lentigo

3. Three months of chemotherapy for cancer

4. Cushings syndrome

5. Hypoglycemia

Correct Answer: 1,3

Rationale 1: Systemic causes of alopecia include thyroid disorders.

Rationale 2: Solar lentigo is not associated with alopecia.

Rationale 3: Numerous drugs can cause alopecia, including many chemotherapeutic drugs used to treat cancer.

Rationale 4: Cushings syndrome is more likely to result in hirsutism.

Rationale 5: Insulin resistance and the resulting hyperglycemia, not hypoglycemia, are related to hair loss.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 59-6

Question 13

Type: MCSA

A patient has paronychia involving several fingers on one hand. The patient reports having the condition for several months. Which treatment would the nurse recommend in addition to prescribed antibiotics?

1. Application of vitamin E oil

2. Hot compresses

3. Increasing dietary protein intake

4. Soaking the hands in cool water two or three times daily

Correct Answer: 2

Rationale 1: Vitamin E oil is not indicated in the treatment of chronic paronychia.

Rationale 2: Application of hot compresses is part of the therapy for paronychia.

Rationale 3: Increasing dietary intake protein is not part of the treatment of paronychia.

Rationale 4: Therapy would include keeping the area dry, as the initial causative factor may be a fungus.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 59-1

Question 14

Type: MCMA

A female patient is prescribed isotretinoin (Accutane). Which information should the nurse provide when teaching about the medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Avoid prolonged exposure to sunlight.

2. Avoid the use of vitamin A supplements.

3. The medication may cause intolerance to contact lenses.

4. Take the pills on an empty stomach to avoid nausea and vomiting.

5. Pregnancy prevention is essential.

Correct Answer: 1,2,3,5

Rationale 1: The medication can cause hypersensitivity to sunlight.

Rationale 2: Vitamin A supplements are to be avoided, as they may increase the effects of the medication.

Rationale 3: Changes in the skin of the eyes may cause intolerance to contact lenses.

Rationale 4: The medication should be taken with meals.

Rationale 5: Isotretinoin is teratogenic, so pregnancy should be avoided.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-4

Question 15

Type: MCSA

A patient diagnosed with psoriasis is being treated with topical corticosteroids. How should the nurse instruct the patient to apply the medication?

1. Apply the medication in a thin layer.

2. Avoid rubbing the medication into the skin.

3. Dry the skin thoroughly before applying the medication.

4. Continue the medication even if lesions worsen, because it is only a temporary reaction.

Correct Answer: 1

Rationale 1: Topical corticosteroids should be applied in a thin layer.

Rationale 2: Topical corticosteroids should be rubbed in thoroughly.

Rationale 3: Topical corticosteroids should be applied to wet skin.

Rationale 4: Some infections may be made worse by corticosteroids. If the lesions worsen, the medication should be discontinued and the health care provider notified.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-4

Question 16

Type: MCMA

A patient is receiving the first ultraviolet light therapy treatment for psoriasis. What should the nurse include in this patients teaching?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The skin will appear red after the treatment.

2. The patient will have one treatment a week for 6 months.

3. Clearing of lesions may take 7 weeks or more.

4. This is the treatment of choice for patients with psoriasis on 10% of the body.

5. A photosensitizing medication may be given before the treatment.

Correct Answer: 1,3,5

Rationale 1: Treatment is intense enough to cause erythema.

Rationale 2: Therapy is usually given three to five times a week.

Rationale 3: Clearing of lesions takes an average of 7 weeks.

Rationale 4: Patients with generalized psoriasis or with psoriasis over 30% of the body are generally treated with phototherapy.

Rationale 5: Psoralen is given prior to exposure to ultraviolet light.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-4

Question 17

Type: MCSA

A 68-year-old male patient comes into the clinic with a strange painful rash on the left side of his upper chest. The nurse would conduct additional assessment for which condition?

1. Herpes zoster

2. Herpes simplex

3. Verruca plana

4. Condylomata acuminata

Correct Answer: 1

Rationale 1: This patient is most likely experiencing herpes zoster. Vesicles usually appear unilaterally on the skin of the face, trunk, or thorax. The patient often experiences severe pain for up to 48 hours before and during eruption of the lesions. The pain may continue for weeks to months.

Rationale 2: Herpes simplex is usually located on the face, mouth, or genital regions.

Rationale 3: The clinical manifestations that this patient reports are inconsistent with verruca.

Rationale 4: The clinical manifestations that this patient reports are inconsistent with condylomata.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 59-1

Question 18

Type: MCSA

A female patient comes to the clinic with an itchy, reddened area on both hands. What nursing assessment is indicated?

1. Ask the patient if she has changed soap or perfume.

2. Ask the patient if she might be pregnant.

3. Auscultate the patients lungs for rhonchi or wheezes.

4. Assess the patients hand grasp strength.

Correct Answer: 1

Rationale 1: This patients description fits that of contact dermatitis. This is caused by a hypersensitivity response or chemical irritation. The major sources are dyes, perfumes, poison plants, chemicals, and metals. A focused assessment is indicated.

Rationale 2: This rash is not likely to be associated with pregnancy.

Rationale 3: There is no indication that this condition is associated with rhonchi or wheezes.

Rationale 4: There is no indication that this rash is related to a change in musculoskeletal strength.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 59-3

Question 19

Type: MCMA

The nurse is preparing a teaching plan for a group of community teenagers about acne. Which information should be included in this teaching plan?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Avoid wearing makeup to reduce acne outbreak.

2. Keep hair clean with frequent shampoos.

3. Avoid eating chocolate.

4. Wearing a cap or hat may increase acne on the forehead.

5. Open pimples when they develop.

Correct Answer: 2,4

Rationale 1: Makeup is not implicated in the development of acne.

Rationale 2: The teaching plan for the patient with acne should include shampooing the hair often enough to prevent oiliness.

Rationale 3: Diet is not implicated in the development of acne.

Rationale 4: Hats, sweatbands, and shirt collars can contribute to the collection of oil on the forehead, neck, and back and thus can contribute to an outbreak.

Rationale 5: The patient should not pick or squeeze pimples that develop.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 59-2

Question 20

Type: MCSA

A 52-year-old male patient is diagnosed with basal cell cancer on the face and forehead. What should the nurse include when teaching this patient about his diagnosis?

1. This type of skin cancer usually occurs on the head and neck.

2. This is a virulent form of skin cancer.

3. This type of skin cancer should be left alone.

4. This type of skin cancer is rare.

Correct Answer: 1

Rationale 1: This type of cancer occurs most often in sun-exposed areas such as the head and neck.

Rationale 2: Basal cell cancer is the least aggressive type of skin cancer. Malignant melanoma is the most virulent form.

Rationale 3: No cancer should be left alone.

Rationale 4: Basal cell cancer is the most common type of skin cancer.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-4

Question 21

Type: MCSA

A 35-year-old female patient is diagnosed with malignant melanoma. The nurse considers which information when planning care for this patient?

1. Prognosis is uncertain.

2. Prognosis is poor due to the patients age.

3. The patient will likely be cured with surgery.

4. The patient will need chemotherapy and radiation.

Correct Answer: 1

Rationale 1: The prognosis for survival for people diagnosed with malignant melanoma is determined by tumor stage.

Rationale 2: There is not enough information to determine prognosis.

Rationale 3: There is not enough information to predict that the patient will be completely cured with surgery.

Rationale 4: There is not enough information to predict that the patient will need chemotherapy and radiation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 59-5

Question 22

Type: MCSA

The nurse instructs a patient with melanoma to eat foods rich in protein and calories. This intervention is most likely associated with which nursing diagnosis?

1. Impaired Skin Integrity

2. Hopelessness

3. Anxiety

4. Fluid Volume Deficit

Correct Answer: 1

Rationale 1: When planning care for a patient with Impaired Skin Integrity, interventions should include adequate caloric and protein intake for wound healing.

Rationale 2: Psychological alterations such as hopelessness cannot be managed by a diet rich in protein and calories.

Rationale 3: Psychological alterations such as anxiety cannot be managed by a diet rich in protein and calories.

Rationale 4: Fluid volume is not directly impacted by a diet high in protein and calories.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-5

Question 23

Type: MCSA

A 40-year-old male patient says, I wish I could have all of these tattoos removed. The nurse would provide information about which method of tattoo removal?

1. Dermabrasion

2. Rhytidectomy

3. Skin graft

4. Blepharoplasty

Correct Answer: 1

Rationale 1: Dermabrasion uses a sanding process to remove the outer layer of skin and lighten the tattoo.

Rationale 2: Rhytidectomy is surgery on the skin to eliminate wrinkles and improve the appearance of the face. It is also referred to as a face-lift.

Rationale 3: Skin grafting involves removing skin from another body area and causes scarring; it is not an acceptable management tool for this patients problem.

Rationale 4: Blepharoplasty is a cosmetic surgical procedure on the eyes.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-6

Question 24

Type: MCSA

A 55-year-old patient who is recovering from a face-lift performed 2 days ago says, I think this was a waste of time and money. I look horrible! How should the nurse respond?

1. It takes a while for the skin to heal.

2. You could use makeup.

3. I would complain to the doctor.

4. What did you expect?

Correct Answer: 1

Rationale 1: This patient needs to be reminded that there will be bruising and swelling that might take several weeks to disappear.

Rationale 2: The use of makeup is not needed and is premature.

Rationale 3: Filing a complaint with the doctor is not indicated.

Rationale 4: This is not a therapeutic response. The patients emotional state warrants a more empathetic response.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-6

Question 25

Type: MCMA

A patient has been diagnosed with cellulitis from an insect bite on the hand. In addition to taking the prescribed antibiotic, the nurse would recommend which treatments?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Get plenty of rest with the hand elevated on a pillow.

2. Soak the hand in cool Burrows solution.

3. Report any pain in the hand.

4. Wrap the hand and arm in warm towels.

5. Protect the blisters from rupture if possible.

Correct Answer: 1,2,5

Rationale 1: Rest and elevation of the affected extremity are recommended.

Rationale 2: Soaking in cool Burrows solution can help relieve the tension and pain.

Rationale 3: Cellulitis is often painful, so this is an expected finding.

Rationale 4: Warm towel wraps are not recommended.

Rationale 5: If possible, the blisters should be protected.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-1

Question 26

Type: MCMA

A 3-year-old is diagnosed with impetigo. Which instructions should the nurse provide this childs caregiver?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The crusts can be softened with warm tap water.

2. Use a gentle antibacterial soap to cleanse the area of crusts.

3. Bring the child back to the clinic for another infusion of intravenous antibiotic in 2 days.

4. Do not allow any other family members to use the same towels as this child.

5. Use an emollient lotion on the area until healing occurs.

Correct Answer: 1,2,4

Rationale 1: Removal of crusts requires soaking the area with warm tap water.

Rationale 2: A gentle antibacterial soap can be used to cleanse the area of crusts.

Rationale 3: Oral antibiotics may be ordered, but treatment with intravenous antibiotic is not indicated.

Rationale 4: This infection can be spread to others by sharing towels or sheets.

Rationale 5: It is not necessary to use lotion on the area.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-1

Question 27

Type: MCMA

A veterinarian comes to the urgent care clinic and says, I think I was bitten on the hand by something earlier in the week and the area isnt healing. Assessment reveals a painless lesion with a black center. Axillary lymph nodes are enlarged. The nurse suspects cutaneous anthrax. Which actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Immediately contact the clinic health care provider with this assessment.

2. Prepare to obtain a culture.

3. Isolate the patient from others in the clinic.

4. Ask the patient about allergy to antibiotics.

5. Ask the patient if any strangers were in the veterinary clinic last week.

Correct Answer: 2,4

Rationale 1: There is no need for immediate collaboration with the health care provider. The patient should be seen, but the situation is not an emergency.

Rationale 2: A skin culture will probably be needed for diagnosis.

Rationale 3: This lesion is not contagious.

Rationale 4: Doxycycline and ciprofloxacin are used to treat cutaneous anthrax.

Rationale 5: Anthrax occurs naturally in soil, and people working with animals can come into contact with it. There is no indication that this anthrax exposure was purposeful.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-3

Question 28

Type: MCMA

A patient sustained an injury to the arm 2 days ago. The patient presents today concerned that the wound is not healing. Which findings would the nurse immediately communicate to the health care provider?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The skin over the area is tight and red.

2. The pain from the wound seems out of proportion to the injury.

3. The wound edges have separated.

4. Crepitus is present around the wound.

5. The patient reports flulike symptoms.

Correct Answer: 1,2,4,5

Rationale 1: Edema and erythema may indicate progression to necrotizing fasciitis.

Rationale 2: A hallmark finding associated with necrotizing fasciitis is that the amount of pain is not proportional to the wound and mechanism of injury.

Rationale 3: Separation of wound edges may or may not be a significant factor.

Rationale 4: Crepitus occurs when gas is present in the tissues.

Rationale 5: Systemic symptoms may be present when infection occurs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-5

Question 29

Type: MCMA

A child has been admitted for treatment of Stevens-Johnson syndrome (SJS). The nurse assuming care for this patient would expect which assessment findings?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Blue-tinged target lesions

2. Positive Nikolskys sign

3. Lesions on the face, neck, and extremities

4. Initial involvement of less than 20% of total body surface area

5. Involvement of at least two mucous membranes

Correct Answer: 2,3,4,5

Rationale 1: The target lesions of SJS have bright pink or red coloration.

Rationale 2: Nikolskys sign is epidermal detachment with light lateral pressure and is a finding associated with SJS.

Rationale 3: The lesions associated with SJS are initially focused on the face, neck, and extremities.

Rationale 4: SJS commonly involves less than 20% of total body surface area when first diagnosed.

Rationale 5: SJS affects both skin and mucous membranes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 59-5

Question 30

Type: MCMA

A patient with toxic epidermal necrolysis (TEN) was admitted with a SCORTEN score of 4. What should the nurse teach the patients family about this score?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The scoring will be repeated every 12 hours for the first 3 days of hospitalization.

2. The patients heart rate is part of this score.

3. The patients condition is very serious.

4. This score will help evaluate the effectiveness of treatment.

5. One of the components scored is the patients level of consciousness.

Correct Answer: 2,3,4

Rationale 1: The score is performed on two occasions.

Rationale 2: The scoring system includes assessment of the heart rate.

Rationale 3: A score of 0 to 1 predicts mortality of 3.2%, and a score of 5 or more predicts a mortality of at least 90%. Therefore, a score of 4 indicates a very serious condition.

Rationale 4: Treatment effectiveness can be evaluated by changes in this score.

Rationale 5: Level of consciousness is not included in the SCORTEN score.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-5

Question 31

Type: MCSA

A patient has an infection in a piercing of the upper ear cartilage. Which information should the nurse provide?

1. Cleanse the area with hydrogen peroxide three times a day.

2. Keep the area covered with ointment.

3. This infection will clear after a course of oral antibiotics.

4. Cartilage infections can cause changes to the shape of your ear.

Correct Answer: 4

Rationale 1: Hydrogen peroxide can dry and damage the skin and should be avoided.

Rationale 2: Ointments can keep oxygen from reaching the piercing and can leave a sticky residue.

Rationale 3: Cartilage does not have its own blood supply, so antibiotics are ineffective.

Rationale 4: Cartilage infections are difficult to treat and can lead to permanent deformity.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 59-1

Question 32

Type: MCSA

The parent of a newborn is concerned because the baby has a quarter-sized, raised, and reddened hemangioma on the lower abdomen. What information should the nurse provide?

1. Surgery will be required to remove this lesion.

2. Because of their bright red color, these lesions are called raspberry hemangiomas.

3. Chances are good that this hemangioma will go away on its own by the time the child reaches age 9.

4. This hemangioma is caused by birth trauma and will clear up in the same time period as a bruise heals.

Correct Answer: 3

Rationale 1: It is not likely that this lesion will be surgically removed.

Rationale 2: These lesions are called strawberry hemangiomas.

Rationale 3: Up to 85% to 90% of these hemangiomas spontaneously resolve by age 9.

Rationale 4: Hemangiomas are not caused by birth trauma and do not heal like bruises.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 59-4

Question 33

Type: MCSA

Inspection of a patients skin reveals the presence of an irregularly shaped brown patch covered with hair. The patch is palm-sized and is located on the patients shoulder. The nurse anticipates which diagnosis of this finding?

1. Intradermal nevus

2. Halo nevus

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