Nokea
A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment?
- A. Chemotherapy
- B. Immunotherapy
- C. Wide excision
- D. Radiation therapy
Correct Answer: C
Rationale: Wide excision is the primary treatment for malignant melanoma to remove the lesion and assess staging. Chemotherapy, immunotherapy, and radiation are secondary or palliative options.
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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.
A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?
- A. The childs scalp should be monitored for 48 to 72 hours before starting treatment.
- B. Nits may have to be manually removed from the childs hair shafts.
- C. The disease is self-limiting and symptoms will abate within 1 week.
- D. Efforts should be made to improve the childs level of hygiene.
Correct Answer: B
Rationale: Manual removal of nits is often necessary after medicated shampoo for pediculosis capitis. The condition is not self-limiting, requires prompt treatment, and is not caused by poor hygiene.
When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what?
- A. Impaired Skin Integrity Related to Scaly Lesions
- B. Acute Pain Related to Blistering and Erosions of the Oral Cavity
- C. Impaired Tissue Integrity Related to Epidermal Shedding
- D. Anxiety Related to Risk for Melanoma
Correct Answer: A
Rationale: Psoriasis causes scaly lesions, leading to impaired skin integrity. It does not typically affect the oral cavity, cause epidermal shedding, or increase melanoma risk.
When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what? Select all that apply.
- A. Possible malignancy
- B. Epidermal necrosis
- C. Neurologic involvement
- D. Increased metabolic needs
- E. Possible gastrointestinal mucosal sloughing
Correct Answer: B,D,E
Rationale: High fever, tachycardia, and weakness in TEN indicate epidermal necrosis, increased metabolic needs, and possible GI mucosal sloughing. Malignancy and neurologic involvement are not typical complications.
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.