Nokea
A patient, age 46, reports to the health care provider's office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, 'It itches like crazy.' Which type of lesion would the nurse include in the documentation?
- A. Macules
- B. Plaques
- C. Wheals
- D. Vesicles
Correct Answer: C
Rationale: Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border. Macules are small, flat blemishes flush with the skin surface. Plaques are elevated, firm, rough lesions with a flat topped surface. A vesicle is a circumscribed elevation of skin filled with serous fluid.
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A patient has been admitted to the hospital with burns to the upper chest. The nurse notes singed nasal hairs. The nurse needs to assess this patient frequently for which condition?
- A. Decreased activity
- B. Bradycardia
- C. Respiratory complications
- D. Hypertension
Correct Answer: C
Rationale: Signs and symptoms of inhalation injury include singed nasal hairs. Breathing difficulties may take several hours to occur.
The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
- A. Increase the IV rate and monitor for burn shock.
- B. Monitor for signs of seizure activity.
- C. Assess for signs of fluid overload.
- D. Raise the foot of the bed and apply blankets.
Correct Answer: C
Rationale: As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. Burn shock occurs from hypovolemia in the first 72 hours of a burn injury. Seizures are not associated with the burn injury. Raising the foot of the bed would not be of value in this situation.
Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where can the melanocytes be found?
- A. Dermis
- B. Superficial fascia
- C. Epidermis
- D. Loose connective tissue
Correct Answer: C
Rationale: A layer in the epidermis contains highly specialized cells called melanocytes.
A resident of an assisted living center reports having sharp pain on one side of the body, with patches of 'blisters'. The nurse notices vesicles on one side of the thorax, which follow a peripheral nerve pathway. Suspecting herpes zoster, the nurse immediately contacts the health care provider. Which is the reason for the prompt notification?
- A. Early recognition is essential to treat the disorder.
- B. Prompt notification prevents sexual transmission.
- C. Oral ulcers could prevent intake of adequate fluids.
- D. Early administration of the varicella vaccine is needed.
Correct Answer: A
Rationale: Early recognition of herpes zoster (shingles) will allow administration of antiviral agents, prevention of secondary infections and pain relief. Acyclovir, when given within 72 hours of the onset of symptoms, reduces pain and the duration of the outbreak. Herpes zoster is not transmitted sexually. Oral lesions are associated with Herpes simplex 1. Varicella vaccine will not be effective against this current outbreak.
What is the last intervention for a hospitalized severely burned victim during the emergent phase?
- A. Tetanus prophylaxis.
- B. Insert Foley catheter.
- C. Insert nasogastric tube.
- D. Establish airway.
- E. Administer analgesics.
- F. Initiate fluid therapy.
Correct Answer: A,
Rationale: The priority of care should proceed from the establishment of an airway,initiation of fluid therapy,insertion of Foley and NG tube administration of analgesics and tetanus prophylaxis."