Nokea
A patient has sustained a burn injury following a house fire. Which finding indicates the need to observe the patient for airway complications?
- A. Bradypnea
- B. Singed nasal hairs
- C. Burns to the upper arms
- D. Intercostal retractions
- E. Grunting noted with respiration
Correct Answer: B,D,E
Rationale: A patient who has sustained a burn injury should be monitored for airway complications if the patient has singed nasal hairs, intercostal retractions or grunting respirations. Tachypnea, not bradypnea, is a finding suggestive of potential airway complications. A patient with burns to the face, neck and upper chest requires further observation.
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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.
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."
Which instruction will the nurse give the patient taking isotretinoin to treat acne?
- A. Do not take acetaminophen when using this medication.
- B. This medication may cause dry skin or eczema to develop
- C. Wear heavy makeup to cover up the acne until this medication takes effect
- D. Stay away from school or your friends until this medication begins to take effect.
Correct Answer: B
Rationale: Isotretinoin may cause dry skin or eczema to develop. There is no reason to avoid acetaminophen when using this medication. Heavy makeup is not advised. The nurse should provide emotional support to the patient with acne so the patient can continue their lifestyle.
Which is a common diagnostic criterion for identifying systemic lupus erythematosus (SLE)?
- A. Butterfly rash over nose and cheeks
- B. Photosensitivity
- C. Severe abdominal pain
- D. Skin ulcers
- E. Polyarthralgias and polyarthritis
- F. Immobility
Correct Answer: A,B,E
Rationale: Butterfly rash on face, sensitivity to sunlight, polyarthralgias, and polyarthritis are some of the main criteria leading to the diagnosis of SLE. Abdominal pain, skin ulcers and immobility are not associated with SLE.
A patient with severe eczema is starting a coal tar derivative treatment. Which will the nurse include in the teaching plan for the patient relative to this treatment?
- A. Drink at least 1000 mL of fluid daily.
- B. Avoid exposure to sunlight for 72 hours after use.
- C. Bathe with an astringent soap.
- D. Reduce intake of high calcium foods.
Correct Answer: B
Rationale: Persons using coal tar derivatives should avoid exposure to sunlight for 72 hours after use. The product stains clothes and bathroom fixtures. There is no need to drink additional fluids, bathe with astringent soaps or reduce calcium rich foods.