Nokea
The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?
- A. Severity of the symptoms
- B. Site of the lesions
- C. Symptomatology of the lesions
- D. Surface area of the lesions
Correct Answer: A
Rationale: The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present). In this mnemonic, S does not stand for site, symptomology or surface area of the lesion.
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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%.
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.
Which will the nurse dressing a necrotic pressure injury with a minimal exudate most likely use?
- A. Hydrocolloid dressing
- B. Alginate dressing
- C. Hydrofiber dressing
- D. Transparent film
Correct Answer: A
Rationale: Hydrocolloid dressings are useful in necrotic wounds with little exudate. Alginate and hydrofiber dressings are used for wounds with copious exudate. Transparent film is not absorbent.
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.
Which is the greatest concern during the emergent phase of a burn injury?
- A. joint contractures
- B. Fluid overload
- C. hypovolemic shock.
- D. adrenal failure.
Correct Answer: C
Rationale: Hypovolemic shock is frequently lethal in the emergent period of a severe burn because of the transfer of fluids into the interstitial tissue from the circulating volume. Joint contractures and fluid overload occur during later phases of the burn injury. Adrenal failure is not associated with the emergent period of a severe burn.