Nokea
The nurse is caring for a client in the long-term care facility who had been living at home and being cared for by a family member. The family member states having had a difficult time getting the client to eat or drink and that the client developed a 'bed sore.' The nurse observes a serous drainage covering the dressing and a 2x2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure sore as?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: C
Rationale: Stage III pressure sores involve superficial skin impairment that progresses to a shallow crater extending to the subcutaneous tissue, often with serous drainage. Stage I is characterized by redness of intact skin. Stage II includes a blister or shallow break in the skin. Stage IV involves deep ulceration exposing muscle or bone.
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A client has joined a rowing team and has been enjoying the activity for approximately 1 month. The client comes to the clinic for a routine physical examination and shows the nurse the hands, which are observed to have thickened areas in several areas. What does the nurse recognize these are in response to the repeated friction of the oars?
- A. Calluses
- B. Senile keratosis
- C. Senile lentigines
- D. Rheumatoid nodules
Correct Answer: A
Rationale: Areas of skin subjected to friction, such as where a pencil is held repeatedly, have accelerated rates of epidermal cell production. A callus, which is a thick layer of epidermal cells, forms in response to recurring friction on an area of skin. Senile keratosis is small, yellow or brown raised lesions that appear on the face and trunk in an older adult client. Senile lentigines are also known as liver spots and are found on the hands and forearms of older people. Rheumatoid nodules affect those clients with rheumatoid arthritis.
Which of the following pigments influences hair color?
- A. Pheromones
- B. Keratin
- C. Seburin
- D. Melanin
Correct Answer: D
Rationale: Melanin, produced by the melanocytes in the hair roots, influences hair color. Pheromones are hormone-like chemicals that communicate reproductive and social information among the lower animal species. Seburin is a lubricant that prevents drying and cracking of the skin and hair. Keratin is a tough protective protein.
The nurse is applying a cool compress to the forehead of a client with an elevated temperature. This is an example of what type of heat loss?
- A. Radiation
- B. Evaporation
- C. Conduction
- D. Convection
Correct Answer: C
Rationale: Conduction is the transfer of heat through direct contact. Radiation is the transfer of surface heat in the environment. Evaporation is the loss of moisture or water. Convection is the transfer of heat by means of currents of liquids or gases in which warm air molecules move away from the body.
A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination using ultraviolet light can be used to determine if the rash is a fungal rash?
- A. Skin biopsy
- B. Fungal culture
- C. Potassium hydroxide test
- D. A Wood light examination
Correct Answer: D
Rationale: A Wood light is also known as a black light and is a handheld device that can identify certain fungal infections that fluoresce under long-wave ultraviolet light. In a darkened room, when a physician or nurse aims the light at a lesion caused by a fungus that fluoresces, the lesion emits a blue-green color. It is the only test that uses a light; the others use skin scrapings.
An older adult client is brought to the emergency department reporting having become overheated while sitting in the sun. The client states, 'But I wasn't even perspiring.' What occurs in older adults that decreases spontaneous sweating and makes them vulnerable to heat?
- A. Decrease in the number of eccrine glands
- B. Increase in the number of eccrine glands
- C. Decreased number of apocrine glands
- D. Increased number of apocrine glands
Correct Answer: A
Rationale: A decline in the number of eccrine glands, along with decreased cutaneous vascularity, causes a decrease in spontaneous sweating with age, this makes older persons more vulnerable to heat. Apocrine glands are found around the nipples, in the anogenital region, in the eyelids, in the mammary glands of the breast, and in the external ear canals where the secretion is referred to as cerumen.