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During primary survey of a patient who sustained a burn injury, the nurse checks for which as an early signs of carbon monoxide poisoning?
- A. Dizziness
- B. Urticaria
- C. Vomiting
- D. Headache
- E. Vertigo
- F. Unsteady gait
Correct Answer: C,D,F
Rationale: Early signs of carbon monoxide poisoning include headache, nausea, vomiting, and unsteady gait. Urticaria is a skin reaction seen in allergic responses. Dizziness and vertigo are not signs of carbon monoxide poisoning.
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A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?
- A. Angioma
- B. Keloid
- C. Melanoma
- D. Nevus
Correct Answer: B
Rationale: Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than in Whites. An angiomas resembles a birthmark. A melanoma is a serious form of skin cancer. A nevus is commonly referred to as a mole.
Which action will the nurse take when administering a therapeutic bath to a patient who has severe pruritus from contact dermatitis?
- A. Use Burow's solution to help promote healing.
- B. Rub the skin briskly to decrease pruritus.
- C. Limit bathing to three times a week.
- D. Ensure that bath area is at least 85 degrees and dehumidified.
Correct Answer: A
Rationale: Pruritus is responsible for most of the discomfort. Wet dressings and using Burow's solution help promote the healing process. Rubbing the skin would increase pruritis. Give daily baths with an application to cleanse the skin. A cool environment with increased humidity decreases the pruritus.
Which patient instruction will the nurse reinforce relative to the management of systemic lupus erythematosus (SLE)?
- A. Maintain a balance between rest and activity.
- B. Increase activity to promote mobility.
- C. Increase exposure to the sun to increase vitamin D absorption.
- D. Increase sodium consumption.
Correct Answer: A
Rationale: Balanced rest, activity, and diet will support medication management. It is not necessary to increase activity to promote mobility. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium.
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.
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.