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A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?
- A. Vesicle
- B. Macule
- C. Nodule
- D. Wheal
Correct Answer: D
Rationale: A wheal is a primary skin lesion that is elevated and has fluid contained in the dermis. An example of a wheal would be an insect bite or hives.
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A nurse is working with a child who has a chronic skin disorder consisting of many vesicles and pustules. Which nursing assessment indicates that a priority long-term goal has been met?
- A. Child states that he no longer gets teased at school because of his appearance.
- B. Parents and child verbalize acceptance of disease process and need for medication.
- C. Patient participates in sporting events and other after school-activities regularly.
- D. Skin around primary lesions remains free of redness, warmth, swelling, and pain.
Correct Answer: D
Rationale: Physical needs take priority over psychosocial needs, so absence of infection is evidence that a priority goal has been met. Secondary infection can occur due to scratching, picking, and the presence of the lesions themselves.
The school nurse recognizes the signs of scabies when a child presents with:
- A. small fluid-filled blisters that sting when scratched.
- B. dry scaly patches in body creases that itch.
- C. wavy threadlike lines on the body and pruritus.
- D. cluster of papular lesions with pruritus.
Correct Answer: C
Rationale: Scabies is manifested by brown threadlike lines on the body, especially the hands, anus, and body folds. Pruritus is severe.
The nurse finds small, fluid-filled lesions on the margins of the client's surgical dressing. Which statement is the most appropriate scientific rationale for this occurrence?
- A. These were caused by the cautery unit in the operating room.
- B. These are papular wheals from herpes zoster.
- C. These are blisters from the tape used to anchor the dressing.
- D. These macular lesions are from a latex allergy.
Correct Answer: C
Rationale: Blisters from tape are a common reaction due to skin sensitivity or adhesive irritation, fitting the description.
The client is two(2) hours postoperative right ear mastoidectomy. Which assessment data should be reported to the health-care provider?
- A. Complaints of aural fullness.
- B. Hearing loss in the affected ear.
- C. No vertigo.
- D. Facial drooping.
Correct Answer: D
Rationale: Facial drooping indicates potential facial nerve involvement requiring immediate attention.
A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?
- A. Prepare the patient for opening or bivalving of the cast.
- B. Obtain an order for a different analgesic.
- C. Encourage the patient to wiggle and move the fingers.
- D. Petal the edges of the patient's cast.
Correct Answer: A
Rationale: Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Ordering different analgesics does not address the underlying problem. Encouraging the patient to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome.