Nokea
A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond?
- A. Liaise with the physical therapist to ensure that the patient is performing exercises safely.
- B. Validate the patients efforts to increase blood perfusion to the graft site.
- C. Remind the patient that ROM exercises should be passive, not active.
- D. Remind the patient of the need to immobilize the graft to facilitate healing.
Correct Answer: D
Rationale: Immobilization of the graft site is critical to promote healing and prevent damage. Active or passive ROM exercises can disrupt the graft, and perfusion is not enhanced by early movement.
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A patient requires a full-thickness graft to cover a chronic wound. How is the donor site selected?
- A. The largest area of the body without hair is selected.
- B. Any area that is not normally visible can be used.
- C. An area matching the color and texture of the skin at the surgical site is selected.
- D. An area matching the sensory capability of the skin at the surgical site is selected.
Correct Answer: C
Rationale: Donor site selection for full-thickness grafts prioritizes matching the color and texture of the surgical site to minimize scarring and ensure aesthetic compatibility.
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 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 patient with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction should the nurse include in home care instructions?
- A. Gently massage the graft site daily to promote perfusion.
- B. Protect the graft from direct sunlight and temperature extremes.
- C. Protect the graft site from any form of moisture for at least 12 weeks.
- D. Apply antibiotic ointment to the graft site and donor site daily.
Correct Answer: B
Rationale: Protecting the graft from sunlight and temperature extremes prevents thermal injury and promotes healing. Massage and antibiotics are not standard, and avoiding all moisture for 12 weeks is impractical.
A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions?
- A. Cataract development is possible.
- B. The ointment is likely to cause weeping.
- C. Corticosteroid use is contraindicated on these lesions.
- D. The patient may develop glaucoma.
Correct Answer: A
Rationale: Repeated use of topical corticosteroids near the eyes can lead to cataract development. Weeping and glaucoma are not typical risks, and corticosteroids are not contraindicated for periorbital psoriasis.