Integumentary Disorders

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1. A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Explanation

RATIONALE: Immediately covering the wound with moistened gauze prevents the organs from drying. The gauze and the saline solution must be sterile to reduce the risk of infection. Although providing support to reduce the client's anxiety is important, it isn't the priority nursing action. The organs shouldn't be pushed back into the abdomen; doing so may tear or damage them. Evisceration requires emergency surgery; therefore, the nurse should put the client on nothing-by-mouth status immediately.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 546.

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About This Quiz
Integumentary Disorders - Quiz

This quiz assesses knowledge on Integumentary Disorders, focusing on client care, medication effects, and clinical manifestations post-injury. It is designed for nursing professionals and students to enhance understanding of integumentary system management and patient education.

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2. A nurse is changing a dressing and providing wound care. Which activity should she perform first?

Explanation

RATIONALE: 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.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1230.

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3. A physician orders 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?

Explanation

RATIONALE: The nurse should tell the client that applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer. Although emollients make the skin feel soft, this effect occurs whether or not the client has just bathed or showered. An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). An emollient doesn't prevent skin inflammation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1949.

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4. A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?

Explanation

RATIONALE: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2008.

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5. When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Explanation

RATIONALE: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process isn't appropriate because burns aren't a disease. Disturbed sleep pattern related to facility environment and Risk for infection related to breaks in the skin may be appropriate, but they don't command a higher priority than Ineffective airway clearance because they don't reflect immediately life-threatening problems.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2010.

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6. A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. What should the nurse say?

Explanation

RATIONALE: The nurse must advise the client's roommate that she can't discuss the other client's health care information. Providing specific or even vague information about the client's diagnosis is a breech of confidentiality. Advising the roommate that it's none of his business is rude and isn't therapeutic communication.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 129.

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7. During the acute phase of a burn, a nurse should assess:

Explanation

RATIONALE: 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.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2009.

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8. A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? __ %

Explanation

RATIONALE: The anterior and posterior portion of one leg is 18%. If both legs are burned, the total is 36%.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1998.

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9. A client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to order:

Explanation

RATIONALE: Although many drugs are used to treat skin disorders, topical agents — not I.V. or oral agents — are the mainstay of treatment.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1948.

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10. While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

Explanation

RATIONALE: When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1963.

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11. A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:

Explanation

RATIONALE: After maintaining respirations, the most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Planning for the client's rehabilitation and discharge, providing emotional support, and preserving full range of motion in all affected joints are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2005.

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12. Which nursing intervention can help a client maintain healthy skin?

Explanation

RATIONALE: Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body's first line of defense. To help a client maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn't remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 208.

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13. A client, who is bound to a wheelchair, comes to the clinic for follow-up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid dressings every 3 to 5 days. During the past few weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair he uses a cushion. During his appointment the nurse notes that he isn't using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse approach the client about his treatment regimen?

Explanation

RATIONALE: The nurse should provide further teaching to the client in terms that he understands. The client should be using a cushion to sit on to reduce pressure and the wound should be kept moist to promote healing. The client can make his own care decisions; however, the nurse must ensure that he has available knowledge to make an informed decision. Although the client isn't following the treatment plan, the nurse should explore the reason why. She shouldn't recommend that he not return to the clinic. An anatomy and physiology lesson isn't necessary.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 513.

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14. A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:

Explanation

RATIONALE: 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. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2023.

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15. A female client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

Explanation

RATIONALE: A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times per day for 7 days. Terconazole and tioconazole treat vulvovaginal candidiasis. Sulconazole nitrate treats tinea versicolor.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 76.

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16. A nurse visits the employee health department because of mild itching and a rash on both hands. During the assessment interview, the employee health nurse should focus on:

Explanation

RATIONALE: Because the itching and rash are localized, the employee health nurse should suspect an environmental cause in the workplace. With the advent of standard precautions, many nurses have experienced allergies to latex gloves. Allergies to medications, laundry detergents, or bath soaps or dermatologic reactions to stress usually elicit a more generalized or widespread rash.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1881.

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17. Which nutritional deficiency may delay wound healing?

Explanation

RATIONALE: Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 208.

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18. A client with a sacral pressure ulcer is limited to 2 hours of chair sitting two times per day. She is scheduled for physical therapy three times per day and dressing changes two times per day. How can the nurse best coordinate this client's care?

Explanation

RATIONALE: The nurse should attempt to coordinate physical therapy with getting the client out of bed for breakfast and dinner. She should then request bedside physical therapy for the third session until the client has no activity limitations. Coordinating the client's activities optimizes the client's ability to participate in physical therapy because she can go to the physical therapy department for therapy. Discontinuing therapy sessions places the client at risk for complications associated with immobility.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 313.

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19. A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

Explanation

RATIONALE: Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature birth. Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1667.

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20. A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan?

Explanation

RATIONALE: The nurse should instruct the client to use a topical skin moisturizer daily to help keep the skin hydrated. Likewise, the client should be encouraged to bathe daily. To minimize irritation, the client should wear only cotton fabrics. The client should maintain a room temperature between 68° F (20° C) and 72° F (22.2° C).

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1878.

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21. A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates effective teaching?

Explanation

RATIONALE: For effective tissue healing, adequate intake of protein, and vitamins A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high-protein diet with plenty of fruits and vegetables to provide these nutrients. The bandage should be secure but not tight enough to impede circulation to the area (which is needed for tissue repair). If the client's foot feels cold, circulation is impaired, thus inhibiting wound healing.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 212.

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22. In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

Explanation

RATIONALE: 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. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2005.

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23. To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?

Explanation

RATIONALE: Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1955.

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24. Which instruction is the most important to give a client who has recently had a skin graft?

Explanation

RATIONALE: To prevent burning and sloughing, the nurse must instruct the client to protect the graft from direct sunlight. Continuing physical therapy, using cosmetic camouflage techniques, and applying lotion to the graft site are appropriate instructions, but they aren't the most important concern in the client's recovery.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2035.

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25. In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Explanation

RATIONALE: The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Lindane is a pediculicide used to treat lice infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2016.

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26. Which term describes a fungal infection of the scalp?

Explanation

RATIONALE: Tinea capitis is a fungal infection of the scalp. Tinea corporis involves fungal infections of the body. Tinea cruris describes fungal infections of the inner thigh and inguinal creases. Tinea pedis is the term for fungal infections of the foot.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1961.

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27. After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

Explanation

RATIONALE: Incontinence and right-sided hemiparesis place the client at risk for skin breakdown. Visual deficits, dysarthria, constipation, and lower extremity weakness don't place the client at risk for skin breakdown.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 208.

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28. A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status?

Explanation

RATIONALE: It's within the scope of LPN practice to communicate with the physician; however, the RN should communicate daily with the LPN about the condition of each nursing home resident. The RN should be kept abreast of all changes in clients' conditions as they occur.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 323.

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29. A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect?

Explanation

RATIONALE: Signs and symptoms of scabies include gray-brown burrows, epidermal curved or linear ridges, and follicular papules. Clients complain of severe itching that usually occurs at night. Scabies commonly occurs in school-age children. The most common areas of infestation are the finger webs, flexor surface of the wrists, and antecubital fossae. Impetigo is a contagious, superficial skin infection characterized by a small, red macule that turns into a vesicle, becoming pustular with a honey-colored crust. Contact dermatitis is an inflammation of the skin caused by contact with an irritating chemical or allergen. Dermatophytosis, or ringworm, is a disease that affects the scalp, body, feet, nails, and groin. It's characterized by erythematous patches and scaling.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1963.

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30. A 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?

Explanation

RATIONALE: 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.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 569.

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31. A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

Explanation

RATIONALE: Adult lice usually bite the scalp behind the ears and along the back of the neck. Because such lice are tiny (1 to 2 mm) with grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions. Although lice may bite any part of the scalp, bites are less common on the temporal area, top of the head, and middle area.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1962.

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32. At an outpatient clinic, a nursing assistant interviews a client and documents her findings as follows. After reading the chart note, a nurse begins planning based on which nursing diagnosis?

Explanation

RATIONALE: The documentation reveals that the client is anxious about his symptoms. Asymmetry, variable color, and border irregularity most closely resemble malignant melanoma. Therefore, Fear related to potential diagnosis of malignant melanoma is the most appropriate nursing diagnosis. The documentation doesn't indicate that the client has deficient knowledge. The characteristics of the lesion aren't consistent with basal or squamous cell carcinoma or a benign nevus (mole), making Risk for impaired skin integrity related to potential squamous cell carcinoma and Readiness for enhanced knowledge of skin care precautions related to benign mole inappropriate nursing diagnoses for this client.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1979.

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33. A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should:

Explanation

RATIONALE: The most important intervention for maintaining skin integrity 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 pressure ulcer formation. 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. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.

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34. A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Explanation

RATIONALE: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2003.

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35. A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should:

Explanation

RATIONALE: Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. The nurse shouldn't use maximum bandages because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2024.

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36. The physician orders "acyclovir (Zovirax), 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause:

Explanation

RATIONALE: Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting. It isn't associated with palpitations, dizziness, or a metallic taste.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 77.

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37. A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter?

Explanation

RATIONALE: When assessing skin integrity, the overall risk potential of developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 208.

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38. Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

Explanation

RATIONALE: A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 728.

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39. A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

Explanation

RATIONALE: The client requires further teaching if he states he will gargle to help alleviate tingling in the lips or mouth. Allergy testing introduces potentially irritating substances to the client. Tingling in the mouth, lips, or throat indicates the onset of a severe reaction and the need for immediate medical intervention. The testing may cause irritation and itching at the test site. The physician may order an epinephrine pen (EpiPen) for the client to self-administer epinephrine if he experiences an allergic reaction away from the office setting.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1864.

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40. A nurse is caring for a client who requires a wheelchair. Which piece of equipment impedes circulation to the area it's meant to protect?

Explanation

RATIONALE: The nurse shouldn't use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client's weight, and water beds distribute pressure over the entire surface.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.

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41. A nurse 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:

Explanation

RATIONALE: To prevent the spread of scabies to 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. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. 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. This client doesn't require enteric precautions because the mites aren't found in feces.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1964.

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42. A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

Explanation

RATIONALE: 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.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1998.

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43. A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Explanation

RATIONALE: 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. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2014.

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44. A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

Explanation

RATIONALE: Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 538.

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45. A client has a foot ulcer that hasn't shown signs of improvement over the past several months. Which medical condition is most likely causing the delay in wound healing?

Explanation

RATIONALE: Peripheral vascular disease causes cellular damage that leads to decreased blood supply to the extremities. When blood supply is deficient, wound healing can't take place. Macular degeneration causes vision loss; it isn't a factor in wound healing. Asthma can interfere with the client's ability to oxygenate, but when controlled, it shouldn't impact wound healing. Multiple sclerosis is a neurologic disorder that impairs mobility, not wound healing.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1191.

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46. A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Explanation

RATIONALE: A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.

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47. A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

Explanation

RATIONALE: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2005.

Submit
48. A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Explanation

RATIONALE: 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 occur with psoriasis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1938.

Submit
49. A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?

Explanation

RATIONALE: A wet-to-damp saline dressing should always keep the wound moist. Tight or dry packing can cause tissue damage and pain. A dry gauze dressing — not a plastic sheet-type dressing — should cover the wet dressing.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1234.

Submit
50. A 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 best prevents skin damage?

Explanation

RATIONALE: Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 3 p.m. (11 a.m. to 4 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. 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.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1980.

Submit
51. A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education?

Explanation

RATIONALE: The client shouldn't shave the surgical area at home. Any necessary clipping of hair will be done at the surgical center. Allowing the client to shave the area with a razor could cause skin abrasions and subsequent infections. Washing with an antibacterial soap for a few days before surgery reduces the skin's bacterial count. The client shouldn't use lotions or cosmetics on the day of the surgery. The client can shower before coming to the hospital.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 891.

Submit
52. While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:

Explanation

RATIONALE: The client's warm, red skin is consistent with a stage I pressure ulcer. Documenting the findings will provide a permanent record of the condition. If the nurse fails to take action, the client may experience further skin trauma. Donut rings reduce circulation to the sacral area when the client sits on them; they're contraindicated in this instance. There's no reason for the nurse to contact the client's family at this time; doing so might violate the client's right of privacy.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.

Submit
53. A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

Explanation

RATIONALE: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2477.

Submit
54. Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

Explanation

RATIONALE: Nutrition support should be consulted to evaluate the client's caloric needs for wound healing. Orthotics should also be consulted for specialized footwear designed to keep pressure off the client's heel. Physical therapy is necessary to help the client achieve the highest level of functioning; however, a respiratory consult isn't necessary unless the client has a coexisting respiratory problem. Occupational therapy may be helpful to assist with activities of daily living, but an infectious disease consult isn't necessary unless the client has a coexisting infection. A plastic surgery consult may be necessary if debridement or grafting is likely, but nothing indicates that a cardiology consult is needed.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.

Submit
55. A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?

Explanation

RATIONALE: Herpes zoster, a highly contagious infection, is transmitted by direct contact with vesicular fluid or airborne droplets from the infected host's respiratory tract. Placing the client with a client diagnosed with pneumonia places that client at risk for contracting herpes zoster. An isolation room with negative airflow isn't necessary for the client with herpes zoster. The nurse should assign the client to a private room. The client could safely room with the client who already had chickenpox; however, visitors might be unnecessarily exposed.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1958.

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56. Sudoriferous glands secrete which type of substance?

Explanation

RATIONALE: Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1930.

Submit
57. A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that his son works and no one has time to assist him with his self-care activities. The nurse should:

Explanation

RATIONALE: A nurse has a legal responsibility to report suspected abuse or neglect of an elderly client or a child. She must follow the chain of command and facility policies for reporting such suspicions. Notifying the family isn't the nurse's primary concern or responsibility. The police will be notified after the nurse has fulfilled the facility's policies.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 461.

Submit
58. Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences?

Explanation

RATIONALE: The air-fluidized surface is the best choice for this client because this surface protects the skin from moisture — an important feature for the client who can't change position on her own. However, the client maintained on this surface should be monitored closely because this bed places the client at risk for dehydration. The static support surface is designed to prevent stage II pressure ulcers; it isn't designed to care for the client with multiple stage III wounds. Although the alternating air surface is effective for a client with multiple wounds, it doesn't offer enough pressure reduction for complex wounds occurring on multiple surfaces. The low-air-loss surface protects the skin from moisture, but it doesn't offer enough pressure reduction for this client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 212.

Submit
59. A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?

Explanation

RATIONALE: Vesicles are elevated, sharply defined lesions that are usually less than 0.5 cm in diameter and contain serous fluid. Common examples of vesicles include blisters and the lesions caused by chickenpox and herpes simplex. Bullae are elevated, fluid-filled lesions greater than 0.5 cm in diameter; an example is a 0.5 blister. Cysts, such as sebaceous cysts, are elevated, thick-walled lesions containing fluid or semisolid matter. Pustules are elevated lesions less than 1 cm in diameter containing purulent material; examples include impetigo and acne lesions.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1937.

Submit
60. A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

Explanation

RATIONALE: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2012.

Submit
61. A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Explanation

RATIONALE: A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.

Submit
62. A client with atopic dermatitis is ordered 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?

Explanation

RATIONALE: 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. Topical corticosteroids aren't involved in significant drug interactions. These preparations cause vasoconstriction, not vasodilation. A potent topical corticosteroid is rarely ordered for use on the face, neck, or intertriginous sites because application on these areas may lead to increased adverse effects.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1950.

Submit
63. Which initial intervention should a nurse perform for a client with external bleeding?

Explanation

RATIONALE: Applying direct pressure to an injury is the initial step in controlling bleeding. Elevation reduces the force of flow, but direct pressure is the first step. The nurse may use pressure point control for severe or arterial bleeding. Pressure points (those areas where large blood vessels can be compressed against bone) include femoral, brachial, facial, carotid, and temporal artery sites. The nurse should avoid applying a tourniquet unless all other measures have failed, because it may further damage the injured extremity.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1091.

Submit
64. A nurse has noticed an increase in the development of pressure ulcers on the nursing unit. Given the seriousness of the matter, what should the nurse do first?

Explanation

RATIONALE: A nurse who identifies issues involving quality of care must follow the chain of command. Although there may be a need for an investigation, the nurse shouldn't initiate one without discussion with the nurse-manager. Charts should be reviewed after a formal investigation is established. The nurse's responsibilities include identifying and reporting issues and concerns involving client care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 341.

Submit
65. A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm m 2 cm m 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown?

Explanation

RATIONALE: The area of skin breakdown was most likely caused by the specialty boot — ordered to reduce pressure in the heels — rubbing against the skin. Although the wheelchair leg rest is located near the wound site, the wound described is likely to be caused by pressure, not a laceration caused by contact with the leg rest. Immobility and decreased sensation places the client at risk for skin breakdown, but these factors aren't the direct cause of this wound. A paraplegic is capable of sitting in a wheelchair for extended periods because he can shift his weight throughout the day.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 208.

Submit
66. In a client with burns on the legs, which nursing intervention helps prevent contractures?

Explanation

RATIONALE: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2026.

Submit
67. While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:

Explanation

RATIONALE: The "ABCDs" of melanoma are Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter. Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest melanoma. Squamous cell carcinoma commonly develops on the skin of the face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas. Early lesions appear as opaque, firm nodules with indistinct borders, scaling, and ulceration. Actinic keratosis is a premalignant skin lesion. Basal cell carcinoma presents as lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1981.

Submit
68. A client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction?

Explanation

RATIONALE: Adults and children with gonorrhea may develop gonococcal conjunctivitis by touching the eyes with contaminated hands. The client should avoid sexual intercourse until treatment is completed, and a follow-up culture confirms that the infection has been eradicated (which usually takes 4 to 7 days). 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. Meningitis and widespread CNS damage are potential complications of untreated syphilis, not gonorrhea.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2508.

Submit
69. A client presents to the physician's office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The physician diagnoses scabies. Which teaching points should the nurse review with the client? Select all that apply.

Explanation

RATIONALE: The nurse should inform the client that scabies is a contagious disorder caused by a tiny mite that burrows under the skin. It's transmitted by close person-to-person contact or contact with infected linens or clothing. It causes severe itching, especially at night, in addition to the familiar papular rash. All of the client's linens and clothing should be washed promptly to reduce the risk of reinfestation. Scabies is transmissible from the time of infection to the time the burrows and papules appear, which may occur several weeks afterward. It remains transmissible until it's eradicated by a prescription cream or an oral medication. Scabies is most commonly seen in the finger webs, flexor surface of the wrists, and the antecubital fossae. If a family member is diagnosed with scabies, all family members must be treated with medication, and their clothing and linens must be washed to prevent transmission and reinfestation.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1963.

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70. A client has a circular rash on her leg, accompanied by malaise, fever, headache, and joint aches. Laboratory studies and physical examination findings confirm that she has Lyme disease. Her physician orders tetracycline hydrochloride (Sumycin), 500 mg P.O. q.i.d. Which instruction about taking tetracycline should the nurse give the client?

Explanation

RATIONALE: The nurse should instruct the client to take tetracycline on an empty stomach because certain foods, such as dairy products, can bind with the drug, preventing its absorption. Additionally, the drug shouldn't be taken with calcium, magnesium, aluminum, or iron because these substances also bind with tetracycline, preventing its absorption.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Karch, A.M. 2007 Lippincott's Nursing Drug Guide. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1121.

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71. When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?

Explanation

RATIONALE: Impetigo is a contagious, superficial skin infection caused by Staphylococcus aureus. If the condition is severe, the physician typically orders systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication. The client's nails should be kept trimmed to avoid scratching; however, mitts aren't necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetigo.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1956.

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72. During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Explanation

RATIONALE: Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1936.

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73. A day-care worker comes to the clinic for mild itching and rash of both hands. The nurse suspects contact dermatitis. The diagnosis is confirmed if the rash appears:

Explanation

RATIONALE: Contact dermatitis is caused by exposure to a physical or chemical allergen, such as skin care products, cleaning products, and latex gloves. Initial symptoms of itching, erythema, and raised papules occur at the site of exposure and can begin within 1 hour of exposure. Allergic reactions tend to be red, not scaly or flaky. Weeping, crusting lesions are also uncommon unless the reaction is severe or has been present for a long time. Excoriation is more common in skin disorders associated with a moist environment.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1964.

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74. A nurse plans to apply dexamethasone cream to a client's dermatitis over the anterior chest. How should the nurse apply this topical agent?

Explanation

RATIONALE: 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.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 802.

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75. Which intervention has the highest priority when providing skin care to a bedridden client?

Explanation

RATIONALE: Keeping the skin clean and dry is always the highest priority. Changing the client's position frequently and gently massaging the skin around the pressure areas are also important but only after the skin is cleaned. The nurse should rub lotion around, not directly over, pressure areas to avoid skin breakdown.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.

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76. When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Explanation

RATIONALE: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2010.

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77. A nurse is providing education to the family of a client scheduled for discharge. The client, who has severe cognitive impairments, is a recent quadriplegic. The family has questions about the need to perform range-of-motion of exercises with the client. What information should the teaching session include? Select all that apply.

Explanation

RATIONALE: The use of sheepskin padding in the bed and wheelchair will reduce friction. A paralyzed client, who may be unable to assist with position changes, has an increased risk of skin loss due to friction and shear. Skin and underlying structures may become anoxic after less than 2 hours of unrelieved pressure. Thirty degrees from the head of the bed is the most therapeutic angle of positioning. The family should perform range-of-motion exercises every time they reposition the client.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2258.

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78. A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

Explanation

RATIONALE: A wound (regardless of its size) that contains tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place. Although option A describes a large wound, it's showing signs of healing, so a consult isn't necessary. Option B describes a stage II wound that has a clean wound bed; a wound nurse consult isn't necessary for this type of wound. The wound described in option D is small and shows signs of healing; a wound care consult isn't required at this time.

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.

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79. During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring?

Explanation

RATIONALE: Applying continuous-compression wraps helps skin healing and prevents hypertrophied tissue from forming. Removing eschar from the skin, wearing clothing to protect the burn from the sun, and maintaining wound care irrigation are appropriate for the client with a burn wound, but these interventions don't necessarily help minimize scarring.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2032.

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80. When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved him. He tells the nurse, "The nursing assistant on the last shift was rough. I asked her to look at my backside, but she told me she was too busy." What should the nurse do first?

Explanation

RATIONALE: The nurse must first document her assessment findings; timely documentation helps ensure accuracy. The nurse should notify the shift supervisor after completing the documentation. She must follow the chain of command. The nurse isn't a manager or supervisor and may not have the authority to administer discipline. Although it might be appropriate for the nurse to make an incident report, she doesn't yet have adequate information to prepare a complete report.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 129.

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81. A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

Explanation

RATIONALE: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1998.

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82. A client from a nursing home arrives at an acute care facility for treatment related to complications of chronic obstructive pulmonary disease. A nurse performing the admission assessment notes the presence of a large stage III pressure ulcer. The client's daughter asks if the hospital can "treat the sore." What initial action should the nurse take?

Explanation

RATIONALE: As a member of the health care team, the nurse should initiate collaboration between other team members. She'll need a physician's order to establish contact between the client and the wound care nurse. After the client's admission to the acute care facility, his physician must provide orders for referrals and consultations with the services the client needs. This isn't the responsibility of the long-term care facility's administrative team. There's no need for social service intervention at this time.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 160.

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83. A 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?

Explanation

RATIONALE: Intertrigo refers to irritation of opposing skin surfaces caused by friction. Spontaneously occurring wheals occur in hives. A fungus that enters the skin surface and causes infection is a dermatophyte. Inflammation of a hair follicle is called folliculitis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1936.

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84. A client presents in the emergency department with complaints of cough, headache, and generalized aches and pains. Upon assessment, the nurse documents a temperature of 102.5° F (39.2° C) and redness on the arms, legs, and upper chest. She also notes that the client takes eight different medications each day. What nursing diagnosis is the priority for this client?

Explanation

RATIONALE: The client is showing signs of Stevens-Johnson Syndrome (SJS), which is triggered by a reaction to medications. Signs and symptoms of SJS include conjunctival burning, fever, cough, sore throat, headache, aches and pains, and erythema and mucous membranes. As the disease progresses, large portions of the epidermis are shed, exposing the dermis and causing tender skin and a weeping surface. Keeping the tissue intact is the main priority for this client. Although Impaired physical mobility, Impaired thermoregulation, and Ineffective therapeutic regimen management apply to this client, these nursing diagnoses are lower priorities than Impaired tissue integrity.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1974.

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85. A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

Explanation

RATIONALE: During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits. Urinary output increases during this phase as renal perfusion increases. Loss of serum sodium leads to metabolic acidosis, not metabolic alkalosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2015.

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86. A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?

Explanation

RATIONALE: A small waxy nodule with pearly borders may indicate a basal cell carcinoma. This finding requires further investigation and treatment. Yellow, waxy deposits on the lower eyelids, bright red moles on the hands, and areas of dry, scaly skin are normal age-related changes to skin.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1979.

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87. A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client's nursing care plan? Select all that apply.

Explanation

Avoid the uRATIONALE: Using a pressure-reduction device, repositioning every 2 hours, and cleaning the area around the wound with a mild soap will aid in healing or will prevent further skin breakdown. Teaching the family how to care for the wound will assist with discharge planning. Protein, not carbohydrate, intake should be increased to promote wound healing. Support-surface therapy is a major therapeutic method for managing pressure, friction, and shear on tissues.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 210.se of support-surface therapy.

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88. A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, his vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.

Explanation

RATIONALE: The goal of immediate interventions for this client should be to stop the burning and relieve the pain. To prevent hypovolemic shock and maintain cardiac output, the nurse should begin I.V. therapy with a crystalloid such as lactated Ringer's solution. To treat pain, she should administer 2 to 25 mg of morphine or 5 to 15 mg of meperidine (Demerol) I.V. in small increments. The nurse should also administer tetanus prophylaxis as ordered. Hydrogen peroxide and povidone-iodine solution could cause further damage to tissue, and saline-soaked towels could lead to hypothermia. Placing ice directly on burn wounds could cause further thermal damage.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2004.

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89. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is:

Explanation

RATIONALE: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., et al. Brunner and Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2359.

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90. A client returns from the operating room with a partial-thickness skin graft on his left arm. The donor tissue was taken from his left hip. In planning his immediate postoperative care, which interventions should the nurse include? Select all that apply.Change the dressing on the graft site every 8 hours.

Explanation

RATIONALE: The left arm should be elevated to reduce edema. Complete rest of the arm is needed to allow the graft to adhere. The donor site is usually more painful than the graft site and the client will require pain medication to obtain relief. Because adequate circulation is needed for graft healing, it's important to monitor for pulse presence. Changing the dressing every 8 hours, performing ROM exercises, and ambulating are inappropriate because postoperative graft sites require immobilization for 3 to 5 days.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1986.

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A nurse is caring for a client with a postoperative wound...
A nurse is changing a dressing and providing wound care. Which...
A physician orders an emollient for a client with pruritus of recent...
A client has partial-thickness burns on both lower extremities and...
When planning care for a client with burns on the upper torso, which...
A client in a semiprivate room is diagnosed with pediculosis corpus. A...
During the acute phase of a burn, a nurse should assess:
A triage nurse in the emergency department admits a male client with...
A client visits the physician's office for treatment of a skin...
While in a skilled nursing facility, a client contracts scabies, which...
A nurse is developing a care plan for a client recovering from a...
Which nursing intervention can help a client maintain healthy skin?
A client, who is bound to a wheelchair, comes to the clinic for...
A client with deep partial-thickness and full-thickness burns on the...
A female client is diagnosed with primary herpes genitalis. Which...
A nurse visits the employee health department because of mild itching...
Which nutritional deficiency may delay wound healing?
A client with a sacral pressure ulcer is limited to 2 hours of chair...
A client is diagnosed with herpes simplex. Which statement about...
A nurse is preparing a discharge teaching plan for a client with...
A nurse is teaching a client with a leg ulcer about tissue repair and...
In an industrial accident, a client who weighs 155 lb (70 kg)...
To treat a client with acne vulgaris, the physician is most likely to...
Which instruction is the most important to give a client who has...
In a client who has been burned, which medication should the nurse...
Which term describes a fungal infection of the scalp?
After sustaining a stroke, a client is transferred to the...
A registered nurse (RN) is working with the licensed practical nurse...
A 10-year-old child is brought to the office with complaints of severe...
A client with a severe staphylococcal infection is receiving the...
A nurse is examining a client's scalp for evidence of lice. The...
At an outpatient clinic, a nursing assistant interviews a client and...
A client who suffered a stroke is too weak to move on his own. To help...
A client presents with blistering wounds caused by an unknown chemical...
A nurse is caring for a client with skin grafts covering...
The physician orders "acyclovir (Zovirax), 200 mg P.O., every 4...
A nurse is performing a baseline assessment of a client's skin...
Hyperbaric oxygen therapy increases the blood's capacity to carry...
A client reports to a physician's office for intradermal allergy...
A nurse is caring for a client who requires a wheelchair. Which piece...
A nurse discovers scabies when assessing a client who has just been...
A client is brought to the emergency department with partial-thickness...
A nurse formulates a nursing diagnosis of Impaired physical mobility...
A nurse is caring for a client who underwent a skin biopsy and has...
A client has a foot ulcer that hasn't shown signs of improvement...
A nurse is caring for an elderly bedridden adult. To prevent pressure...
A nurse is assessing a client admitted with deep partial-thickness and...
A client with psoriasis visits the dermatology clinic. When inspecting...
A nurse is providing care for a client who has a sacral pressure ulcer...
A client comes to the physician's office for treatment of severe...
A nurse provides preoperative education to a client scheduled to...
While repositioning an immobile client, a nurse notes that the...
A client who was bitten by a wild animal is admitted to an acute care...
Which disciplines should be consulted when caring for a client with a...
A night-shift nurse receives a call from the emergency department...
Sudoriferous glands secrete which type of substance?
A client arrives at the emergency department after falling in the...
Which support surface is best for a comatose client who has multiple...
A client comes to the dermatology clinic with numerous skin lesions....
A client with a superficial partial-thickness solar burn (sunburn) of...
A nurse is performing an admission assessment on a client entering a...
A client with atopic dermatitis is ordered a potent topical...
Which initial intervention should a nurse perform for a client with...
A nurse has noticed an increase in the development of pressure ulcers...
A nursing assistant tells the nurse that a client with paraplegia has...
In a client with burns on the legs, which nursing intervention helps...
While assessing the skin of a 45-year-old, fair-skinned female client,...
A client is diagnosed with gonorrhea. When teaching the client about...
A client presents to the physician's office with gray-brown...
A client has a circular rash on her leg, accompanied by malaise,...
When caring for a client with severe impetigo, the nurse should...
During a routine examination of a client's fingernails, the nurse...
A day-care worker comes to the clinic for mild itching and rash of...
A nurse plans to apply dexamethasone cream to a client's...
Which intervention has the highest priority when providing skin care...
When assessing a client with partial-thickness burns over 60% of the...
A nurse is providing education to the family of a client scheduled for...
A nurse is evaluating a stage II pressure ulcer on a client. Which...
During the late stages of healing, which intervention helps a burn...
When assessing an elderly client, a nurse on the day shift notes...
A client received burns to his entire back and left arm. Using the...
A client from a nursing home arrives at an acute care facility for...
A client sees a dermatologist for a skin problem. Later, the nurse...
A client presents in the emergency department with complaints of...
A nurse is preparing a care plan for a client burned over 36% of his...
A nurse is conducting a detailed skin assessment on an 80-year-old...
A nurse is planning the care for a client with a pressure ulcer. Which...
A client arrives at the emergency department with deep...
Following a small-bowel resection, a client develops fever and anemia....
A client returns from the operating room with a partial-thickness skin...
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