Nokea
The nurse is obtaining a preoperative health history on the client scheduled for revision of facial scars. Which client comment indicates an increased risk for a poor cosmetic outcome?
- A. I haven't had anything to eat or drink since 10 pm last night.
- B. I'm nervous about surgery; what if the surgery doesn't work?
- C. My high blood pressure is controlled with lisinopril.
- D. I plan to continue taking diclofenac for pain control.
Correct Answer: D
Rationale: Diclofenac (Voltaren) is an NSAID; increased bleeding tendency and increased sensitivity to sunlight are side effects that may inhibit achieving optimal cosmetic outcomes. Fasting is standard practice. Nervousness does not affect cosmetic outcomes. Controlled hypertension poses no significant risk.
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Before the examination can be completed, which type of eye medication would the nurse instill in the client's eye to dilate the pupil and temporarily paralyze the ciliary muscle?
- A. Pilocarpine (Pilocar)
- B. Dipivefrin (Propine)
- C. Gentamicin (Genoptic)
- D. Cyclopentolate solution (Cyclogyl)
Correct Answer: D
Rationale: Cyclopentolate is a cycloplegic agent that dilates the pupil and paralyzes the ciliary muscle for retinoscopy.
When assessing a burn victim's skin the nurse notices the entire right and left upper extremities are red, moist, weeping, and blistered. How should the nurse document the degree and total body surface area (TBSA) burned?
- A. First-degree burn on 9% TBSA
- B. Partial-thickness burn on 18% TBSA
- C. Partial-thickness burn on 27% TBSA
- D. Full-thickness burn on 36% TBSA
Correct Answer: B
Rationale: Partial-thickness burns damage the dermis and epidermis, often resulting in loss of epidermis and/or blistering. Each entire upper extremity is blistered. Approximately 18% of the TBSA has a partial-thickness burn (9% TBSA per each upper extremity). This is not a first-degree burn—In a first-degree burn the skin may appear red but intact, no weeping, and no blistering. With full-thickness burns there would be loss of tissue and a black or white charred/waxy appearance to the remaining tissues.
Which individual would most likely experience the skin disorder pseudofolliculitis barbae (shaving bumps)?
- A. A male African American soldier.
- B. A female Caucasian hairdresser.
- C. A male Asian food server.
- D. A female Hispanic schoolteacher.
Correct Answer: A
Rationale: Pseudofolliculitis barbae is common in African American males due to curly hair causing ingrown hairs post-shaving. Other groups are less affected.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.
- A. Perform meticulous hand hygiene.
- B. Use sterile gloves for wound care.
- C. Wear gown and mask during procedures.
- D. Change central lines once a week.
- E. Administer antibiotics as prescribed.
Correct Answer: A,B,C,E
Rationale: Hand hygiene, sterile gloves, gown/mask, and antibiotics prevent infection in extensive burns. Weekly central line changes are not standard; daily assessment is preferred.
The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma?
- A. The lesion is asymmetrical and has irregular borders.
- B. The lesion has a waxy appearance with pearlike borders.
- C. The lesion has a thickened and scaly appearance.
- D. The lesion appeared as a thickened area after an injury.
Correct Answer: A
Rationale: Asymmetry and irregular borders (ABCD criteria) characterize malignant melanoma. Waxy, scaly, or post-injury lesions suggest other conditions.