Nokea
A client is having cryosurgery to remove a growth on the leg. How long will the client be informed that healing will take?
- A. 3 to 5 days
- B. Up to 1 week
- C. 2 to 4 weeks
- D. 4 to 6 weeks
Correct Answer: D
Rationale: Cryosurgery is the application of extreme cold to destroy tissue. After application of extreme cold, the area thaws and becomes gelatin-like in appearance. A scab forms at the site. Healing takes approximately 4 to 6 weeks.
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An older adult client is prescribed a topical antifungal medication to treat a skin infection. The client comes back to the clinic in 7 days and informs the nurse that the treatment was not effective. What does the nurse know can occur in the older adult client with topical drugs?
- A. Age-related changes to the skin could decrease the absorption of topical drugs.
- B. Older adult clients are often not compliant with medication administration.
- C. The drug absorption is increased and does not give the medication time to work on the skin infection.
- D. The bacteria may be resistant to the medication.
Correct Answer: A
Rationale: Age-related changes in topical drugs may be altered and therefore decrease the ability to absorb the topical antifungal cream. Older adults are no less compliant than any other age group. Drug absorption would be decreased. The skin infection is related to a fungus, not a bacterium.
The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?
- A. Radiation
- B. Evaporation
- C. Conduction
- D. Convection
Correct Answer: C
Rationale: Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water. Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body.
A client has a wart on the left knee but wants to try an over-the-counter medication to dissolve the wart. What type of solution would the nurse educate the client about?
- A. Antiseborrheic agents
- B. Antihistamine
- C. Antiseptics
- D. Keratolytics
Correct Answer: D
Rationale: Keratolytics dissolve thickened, cornified skin such as warts, corns, and calluses. Their action causes the treated area to soften and swell, facilitating removal. Antiseborrheic agents are applied to the scalp or incorporated into shampooing products to control dandruff. Antihistamines are used to relieve itching. An antiseptic would be used to reduce bacteria on the arm.
The nurse is changing a brief for a client that has been incontinent of stool and observes an area over the left trochanter that is reddened and in the center of the area is a shallow skin tear. The nurse takes a picture of the wound for the chart. How will the nurse stage this wound?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: B
Rationale: A stage II pressure sore is red and is accompanied by blistering or a shallow break in the skin, sometimes described as a skin tear. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
The nurse is caring for a client in the long-term care facility who had been living at home and being cared for by a family member. The family member states having had a difficult time getting the client to eat or drink and that the client developed a 'bed sore.' The nurse observes a serous drainage covering the dressing and a 2x2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure sore as?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: C
Rationale: Stage III pressure sores involve superficial skin impairment that progresses to a shallow crater extending to the subcutaneous tissue, often with serous drainage. Stage I is characterized by redness of intact skin. Stage II includes a blister or shallow break in the skin. Stage IV involves deep ulceration exposing muscle or bone.