Nokea
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.
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Which patient statement indicates that more teaching is needed regarding antibiotic therapy for the treatment of cellulitis?
- A. My skin is cleared up. I don't think I need the medication anymore.'
- B. Cellulitis can come back at any time.'
- C. If I had washed that scratch with soap and water, I probably would not have gotten cellulitis.'
- D. Cellulitis is contagious.'
Correct Answer: A
Rationale: The entire amount of antibiotic medication should be completed even if the symptoms have abated to ensure the eradication of the infectious agent. Cellulitis can return if untreated or undertreated. Washing wounds with soap and water can prevent many infections, but this is not related to the discussion of antibiotics. Cellulitis can spread, however this is not related to the discussion of antibiotics.
Which may indicate a malignant melanoma in a nevus on a patient's arm?
- A. Even coloring of the mole
- B. Decrease in size of the mole
- C. Irregular border of the mole
- D. Symmetry of the mole
Correct Answer: C
Rationale: Any change in color, size, or texture and any bleeding or pruritus of a nevus deserves investigation. A malignant melanoma is a cancerous neoplasm in which pigment cells or melanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue.
Several residents in a long term care facility have been diagnosed with herpes zoster. Which resident will require the closest observation for development of complications?
- A. A resident who is sexually active
- B. A resident recovering from a hip fracture
- C. A resident with dementia who requires assistance eating.
- D. A resident who is undergoing chemotherapy for breast cancer
Correct Answer: D
Rationale: The resident who is undergoing chemotherapy is likely to develop a low white blood cell count, and is at the highest risk of complications such as disseminated herpes zoster or severe skin infection from the irritated skin at the lesion sites. A resident who is sexually active is not necessarily at high risk of complications of herpes zoster, (shingles). Neither the resident recovering from a hip fracture or the resident with dementia are as high a risk as the resident undergoing chemotherapy.
A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower lip and chin. The nurse believes these lesions most likely are caused by which condition?
- A. chickenpox.
- B. impetigo.
- C. shingles.
- D. herpes simplex type I.
Correct Answer: B
Rationale: Impetigo is seen at all ages but is particularly common in children. The crust is honey-colored and easily removed and is associated with pruritus. The disease is highly contagious and spreads by contact. Chickenpox and shingles are characterized by vesicles and are not honey-colored. Herpes simplex type I is also known as 'cold sores' or 'fever blisters'. Lesions are generally located around and in the mouth.
A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction will be helpful in managing the pruritus?
- A. Use cool, wet dressings and baths to promote vasoconstriction.
- B. Trim the fingernails short to prevent skin damage from scratching.
- C. Expose the areas to the sun to promote drying and healing of the lesions.
- D. Wear cotton gloves and cover all other affected areas with clothing to prevent environmental irritation.
Correct Answer: A
Rationale: Wet dressings and using Burow's solution help promote the healing process. Cold compresses may be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skin damage, but not pruritus. Exposing the areas to the sun will not manage pruritus. Wearing cotton gloves may prevent environmental irritation, but will not help the existing pruritis.