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The nurse arrives to the scene of a house fire. A victim is running out of the house, with flames on the arms. Which is the nurse's first action?
- A. Transport victim to hospital.
- B. Cover victim with clean cloth or sheet.
- C. Stop, drop, and roll.
- D. Remove all nonadherent clothing and jewelry.
Correct Answer: C
Rationale: The primary concern is to stop the burning process, arrest skin damage, provide an open airway, control any bleeding, prevent infection by covering with a clean cloth, and obtain medical help by transporting to the nearest hospital.
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A resident of an assisted living center reports having sharp pain on one side of the body, with patches of 'blisters'. The nurse notices vesicles on one side of the thorax, which follow a peripheral nerve pathway. Suspecting herpes zoster, the nurse immediately contacts the health care provider. Which is the reason for the prompt notification?
- A. Early recognition is essential to treat the disorder.
- B. Prompt notification prevents sexual transmission.
- C. Oral ulcers could prevent intake of adequate fluids.
- D. Early administration of the varicella vaccine is needed.
Correct Answer: A
Rationale: Early recognition of herpes zoster (shingles) will allow administration of antiviral agents, prevention of secondary infections and pain relief. Acyclovir, when given within 72 hours of the onset of symptoms, reduces pain and the duration of the outbreak. Herpes zoster is not transmitted sexually. Oral lesions are associated with Herpes simplex 1. Varicella vaccine will not be effective against this current outbreak.
A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for which most common cause of burn-related deaths?
- A. shock.
- B. respiratory arrest.
- C. hemorrhage.
- D. infection.
Correct Answer: D
Rationale: Infection is the most common complication and cause of death after the first 72 hours. Shock, due to hypovolemia is most common during the emergent phase of the burn injury. Respiratory arrest and hemorrhage are not common causes of death.
A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction will be helpful in managing the pruritus?
- A. Use cool, wet dressings and baths to promote vasoconstriction.
- B. Trim the fingernails short to prevent skin damage from scratching.
- C. Expose the areas to the sun to promote drying and healing of the lesions.
- D. Wear cotton gloves and cover all other affected areas with clothing to prevent environmental irritation.
Correct Answer: A
Rationale: Wet dressings and using Burow's solution help promote the healing process. Cold compresses may be applied to decrease circulation to the area (vasoconstriction). Short nails prevent skin damage, but not pruritus. Exposing the areas to the sun will not manage pruritus. Wearing cotton gloves may prevent environmental irritation, but will not help the existing pruritis.
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.
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.