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The nurse is assessing a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which of the following assessment data is a priority?
- A. The patient complains of incisional pain.
- B. The patient 's heart rate is 110 beats/minute.
- C. The patient is unable to detect when the eyelids are touched
- D. The skin around the incision is pale and cold when palpated.
Correct Answer: D
Rationale: Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. Warm, pink skin that blanches with pressure indicates that adequate circulation is present in the surgical area. The other assessment data indicate a need for ongoing assessment or nursing action. A heart rate of 110 may be related to the stress associated with surgery, assessment of other vital signs and continued monitoring are appropriate. Because local anaesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.
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The nurse is assessing a new patient at the outpatient clinic and notes dry, scaly skin; thin hair; and thick, brittle nails. Which of the following actions is best for the nurse to take at this time?
- A. Instruct the patient about the importance of nutrition in skin heath.
- B. Make a referral to a podiatrist so that the nails can be safely trimmed.
- C. Consult with the health care provider about the need for further diagnostic testing.
- D. Teach the patient about using moisturizing creams and lotions to decrease dry skin.
Correct Answer: C
Rationale: The patient has clinical manifestations that could be caused by systemic problems or interferences with nutrition (e.g. protein deficiency) so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, and referral to a podiatrist also may be needed, but the priority is to rule out underlying disease that may be causing these manifestations.
The nurse is teaching the patient how to use wet compresses at home for treatment of poison ivy. Which of the following instructions would the nurse include in the teaching plan?
- A. Use only sterile water as the solution for the dressing.
- B. The material for the compress is to be 4-8 layers thick.
- C. The compress should meet the edge of the area that is to be treated.
- D. Use abdominal pads (gauze sponges) when covering odd-shaped body parts.
Correct Answer: B
Rationale: The material for wet compresses should be 4-8 layers thick and slightly larger than the area that is being treated. Abdominal pads are to be avoided as they hold too much fluid as well as fibres may be left in the wound if the skin is not intact. It is not necessary to use sterile water; tap water at room temperature is acceptable.
To decrease the risk for sun damage to the skin, which information should the nurse include when teaching patients?
- A. Waterproof sunscreens will provide good protection when swimming.
- B. Use a sunscreen with an SPF of at least 8-10 for adequate protection.
- C. Try to stay out of the sun between the hours of 10:00 and 16:00.
- D. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
Correct Answer: C
Rationale: The risk for skin damage from the sun is highest with exposure between 10:00 and 15:00 during regular time and 11:00-16:00 during daylight savings time. The term waterproof is misleading; no sunscreen is completely waterproof. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased.
A patient who has severe refractory psoriasis on the face, neck, and extremities has quit working and withdrawn from social activities because of the appearance of the lesions. Which of the following actions should the nurse take first?
- A. Discuss the possibility of enrolling in a worker-retraining program.
- B. Encourage the patient to volunteer to work on community projects.
- C. Suggest that the patient use cosmetics to cover the psoriatic lesions
- D. Ask the patient to describe the impact of psoriasis on quality of life.
Correct Answer: D
Rationale: The nurse's initial actions should be to assess the impact of the disease on the patient's life and to allow the patient to verbalize feelings about the psoriasis. Depending on the assessment findings, other actions may be appropriate.
After the nurse determines that a patient has the following risk factors for melanoma, which risk factor should be the focus of patient teaching related to prevention?
- A. The patient has multiple dyplastic nevi.
- B. The patient is fair-skinned and has blue eyes.
- C. The patient s mother died of a malignant melanoma.
- D. The patient uses a tanning booth throughout the winter.
Correct Answer: D
Rationale: Since the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk.