Nokea
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.
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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.
The three major glands of the skin are sudoriferous, ceruminous, and
- A. sebaceous
Correct Answer: sebaceous
Rationale: Sudoriferous glands-sweat glands open into pores on the skin surface and excrete sweat. Ceruminous glands-secrete a waxlike substance called cerumen and are located in the external ear canal. Sebaceous glands-secrete their substance, sebum (an oily secretion), through the hair follicles distributed on the body.
Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?
- A. Curling ulcer
- B. Paralytic ileus
- C. Ruptured colon
- D. Gastritis
Correct Answer: A
Rationale: Curling ulcer is a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body. The first sign is usually vomiting of bright red blood. Paralytic ileus involves the small intestine becoming immobile, characterized by absent bowel sounds. A ruptured colon would cause internal bleeding, and possibly rectal bleeding. Gastritis would not cause bright red bleeding.
The nurse assisting with data collection of a burned patient upon arrival in the emergency room observes that the entire right arm (anterior and posterior), right anterior leg, chest, and abdomen are covered with reddened skin and blisters. Using the Rule of Nines, the nurse estimates the percentage of burn to be %.
- A. 36
Correct Answer: 36
Rationale: Anterior and posterior are 9%, anterior leg = 9%, chest = 9%, abdomen = 9%. Total 36%.
A nurse can assess cyanosis in a dark-skinned patient by assessing the color of which body part?
- A. abdomen
- B. sclera.
- C. lips and mucous membranes.
- D. soles of the feet.
Correct Answer: C
Rationale: Assessment of color is more easily made in areas where the epidermis is thin, such as the lips and mucous membranes. Assessing the abdomen, sclera or soles of the feet will not be as accurate as the lips and mucous membranes.