Nokea
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.
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A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply.
- A. Risk for Infection Related to Lesions
- B. Impaired Skin Integrity Related to Epidermal Blisters
- C. Disturbed Body Image Related to Presence of Skin Lesions
- D. Acute Pain Related to Disruption in Skin Integrity
- E. Hyperthermia Related to Disruptions in Thermoregulation
Correct Answer: A,B,C,D
Rationale: Pemphigus vulgaris causes blisters, leading to infection risk, impaired skin integrity, pain, and disturbed body image. Hyperthermia is not a concern; hypothermia is more likely.
A nurse educator is teaching a group of medical nurses about Kaposis sarcoma. What would the educator identify as characteristics of endemic Kaposis sarcoma? Select all that apply.
- A. Affects people predominantly in the eastern half of Africa
- B. Affects men more than women
- C. Does not affect children
- D. Cannot infiltrate
- E. Can progress to lymphadenopathic forms
Correct Answer: A,B,E
Rationale: Endemic Kaposis sarcoma is prevalent in eastern Africa, affects men more, and can progress to lymphadenopathic forms. It can affect children and may infiltrate.
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 patient comes to the clinic complaining of a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with herpes zoster?
- A. Grouped vesicles occurring on lips and oral mucous membranes
- B. Grouped vesicles occurring on the genitalia
- C. Rough, fresh, or gray skin protrusions
- D. Grouped vesicles in linear patches along a dermatome
Correct Answer: D
Rationale: Herpes zoster presents as grouped vesicles along a dermatome due to dorsal root ganglia inflammation. Lip vesicles suggest herpes simplex type 1, genital vesicles suggest type 2, and rough protrusions indicate warts.
A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the patient is likely seeking treatment for which of the following?
- A. Wrinkles near the lips and eyes
- B. Removal of acne scars
- C. Vascular lesions on the cheeks
- D. Real or perceived misshaping of the eyes
Correct Answer: A
Rationale: Chemical face peeling is effective for wrinkles around the lips, eyes, and forehead. It does not address acne scars, vascular lesions, or eye shape.