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A 30-year-old male patient has just returned from the operating room after having a flap done following a motorcycle accident. The patients wife asks the nurse about the major complications following this type of surgery. What would be the nurses best response?
- A. The major complication is when the patient develops chronic pain.
- B. The major complication is when the patient loses sensation in the flap.
- C. The major complication is when the pedicle tears loose and the flap dies.
- D. The major complication is when the blood supply fails and the tissue in the flap dies.
Correct Answer: D
Rationale: Flap necrosis due to failed blood supply is the primary complication, as it leads to tissue death. Pedicle tearing is less likely, and chronic pain or sensory loss are secondary concerns.
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A nurse is caring for a patient whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform?
- A. Teach the patient about early signs of secondary blistering diseases.
- B. Teach the patient about self-care after treatment.
- C. Assess the patients risk for recurrent malignancy.
- D. Assess the patient for adverse effects of radiotherapy.
Correct Answer: B
Rationale: The nurse's role includes teaching self-care after skin cancer excision. Assessing malignancy risk is the physician's role, blistering diseases are unrelated, and radiotherapy is not typically used.
A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?
- A. Deficient Knowledge about Early Signs of Melanoma
- B. Chronic Pain Related to Surgical Excision and Grafting
- C. Depression Related to Reconstructive Surgery
- D. Anxiety Related to Lack of Social Support
Correct Answer: A
Rationale: Advanced melanoma suggests a lack of early detection, indicating deficient knowledge about melanoma signs. Excision does not cause chronic pain, and depression or anxiety may not be primary concerns.
A patient is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the patient, the nurse would be alert to what precipitating factor?
- A. Recent heavy ultraviolet exposure
- B. Substandard hygienic conditions
- C. Recent administration of new medications
- D. Recent varicella infection
Correct Answer: C
Rationale: TEN is commonly triggered by medications, such as antibiotics or antiseizure drugs. UV exposure, hygiene, and varicella are not typical causes.
A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?
- A. Chemotherapy
- B. Radiation therapy
- C. Surgical excision
- D. Biopsy of sample tissue
Correct Answer: C
Rationale: Surgical excision is the primary treatment for squamous cell carcinoma to remove the tumor entirely. Radiation is used for non-surgical candidates, chemotherapy is less common, and biopsy is diagnostic, not therapeutic.
A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient?
- A. Wash your face with water and gentle soap each morning and evening.
- B. Before bedtime, clean your face with rubbing alcohol on a cotton pad.
- C. Gently burst new pimples before they form a visible head.
- D. Set aside time each day to squeeze blackheads and remove the plug.
Correct Answer: A
Rationale: Washing with mild soap and water twice daily removes oils and prevents gland obstruction in acne. Alcohol is too harsh, and manipulating pimples or blackheads worsens symptoms.