Nokea
The nurse is changing a brief for a client that has been incontinent of stool and observes an area over the left trochanter that is reddened and in the center of the area is a shallow skin tear. The nurse takes a picture of the wound for the chart. How will the nurse stage this wound?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: B
Rationale: A stage II pressure sore is red and is accompanied by blistering or a shallow break in the skin, sometimes described as a skin tear. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
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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 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.
The nurse is performing a skin assessment on a client that is admitted to the hospital and observes an area over the left heel that is reddened but intact. How would the nurse stage this pressure sore?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct Answer: A
Rationale: Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage II is the same as stage I but has a blister or shallow break in the skin. Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
A client is having cryosurgery to remove a growth on the leg. How long will the client be informed that healing will take?
- A. 3 to 5 days
- B. Up to 1 week
- C. 2 to 4 weeks
- D. 4 to 6 weeks
Correct Answer: D
Rationale: Cryosurgery is the application of extreme cold to destroy tissue. After application of extreme cold, the area thaws and becomes gelatin-like in appearance. A scab forms at the site. Healing takes approximately 4 to 6 weeks.
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.