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The nurse has staged a pressure injury that has a shallow crater with a dry pink wound bed in which way?
- A. stage 1.
- B. stage 2.
- C. stage 3.
- D. stage 4.
Correct Answer: B
Rationale: Stage 2 pressure injuries appear as a shallow open injury, usually shiny or dry, with a red-pink wound bed without slough. Stage 1 involves intact skin with non-blanchable redness. A stage 3 pressure injury involves full-thickness tissue loss and sometimes subcutaneous fat is visible. At stage 4, there is a full thickness tissue loss with exposed bone, tendon, cartilage or muscle.
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Which is a nursing intervention and patient teaching item for the treatment of head lice and scabies?
- A. Clothing, linens, and bath articles thoroughly cleaned in hot water
- B. Stress nature and transmission of the disease
- C. Special carbohydrate diet to promote healing
- D. Complete isolation from the public
- E. removal of pets from the home
Correct Answer: A,B
Rationale: Identify involved contacts while stressing importance of preventing transmission of disease. Washable and clothing items should be cleaned in hot water to prevent reinfection. No special diet is required. Isolation is not necessary once medical management is completed. It is not necessary to remove pets from the home.
The nurse will provide which instruction regarding reducing the risk factors for melanoma?
- A. Avoid exposure to the sun and use protective measures when exposure occurs.
- B. Have all nevi removed.
- C. Watch for changes in moles, especially on the back.
- D. Use a sun lamp for tanning.
Correct Answer: A
Rationale: Encourage the patient to protect skin from the sun by wearing protective clothing, including a hat with 4-in brim, applying sunscreen all over the body, and avoiding the midday sun from 10 a.m. to 4 p.m. Having all nevi removed is impractical. Watching for changes in moles does not reduce risk factors; it allows for early detection. Sun lamps are just as damaging as the sun.
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.
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%.
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.