Nokea
An older adult client is being seen in the dermatology clinic for lesions on the hands and forearm. The client is concerned about the possibility of having melanoma and wants to be evaluated. The nurse documents the lesions as small, brown lesions of the hands and forearms. What type of benign lesions are these characteristic of?
- A. Senile keratoses
- B. Senile lentigines
- C. Melanoma
- D. Freckles
Correct Answer: B
Rationale: Small, brown, pigmented, benign lesions, known as liver spots or senile lentigines, form on the hands and forearms of older people. Small, yellow or brown, raised lesions called senile keratoses may appear on the face and trunk and are precancerous and require close observation. Melanoma is diagnosed by biopsy and generally has irregular borders and is dark in color.
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The nurse is changing a brief for a client that has been incontinent of stool and observes an area over the left trochanter that is reddened and in the center of the area is a shallow skin tear. The nurse takes a picture of the wound for the chart. How will the nurse stage this wound?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: B
Rationale: A stage II pressure sore is red and is accompanied by blistering or a shallow break in the skin, sometimes described as a skin tear. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
Which medication classification is prescribed when allergy is a factor causing the skin disorder?
- A. Corticosteroids
- B. Antihistamines
- C. Antibiotics
- D. Local anesthetics
Correct Answer: B
Rationale: Antihistamines are frequently prescribed when an allergy is a factor in causing the skin disorder. They relieve itching and shorten the duration of allergic reaction. Corticosteroids are used to relieve inflammatory or allergic symptoms. Antibiotics are used to treat infectious disorders. Local anesthetics are used to relieve minor skin pain and itching.
A client is having cryosurgery to remove a growth on the leg. How long will the client be informed that healing will take?
- A. 3 to 5 days
- B. Up to 1 week
- C. 2 to 4 weeks
- D. 4 to 6 weeks
Correct Answer: D
Rationale: Cryosurgery is the application of extreme cold to destroy tissue. After application of extreme cold, the area thaws and becomes gelatin-like in appearance. A scab forms at the site. Healing takes approximately 4 to 6 weeks.
Which stage of a pressure injury is exhibited by deeply ulcerated tissue, exposing muscle and bone?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: D
Rationale: Stage IV occurs when the tissue is deeply ulcerated, exposing muscle and bones. Stage III pressure sores are those in which the superficial impairment progresses to a shallow crater that extends to the subcutaneous tissue. Stage I pressure sores are characterized by redness of the skin. Stage II pressure sores are red and accompanied by blistering and a shallow break in the skin.
The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?
- A. Radiation
- B. Evaporation
- C. Conduction
- D. Convection
Correct Answer: C
Rationale: Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water. Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body.