Nokea
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.
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Plantar warts may be treated with what method?
- A. Photochemotherapy
- B. Radiation
- C. Electrodesiccation
- D. Cryosurgery
Correct Answer: C
Rationale: Electrodesiccation is the use of electrical energy converted to heat, which destroys the tissue. Photochemotherapy involves a combination of psoralen methoxsalen and type A ultraviolet light. Radiation therapy is used to treat malignant skin lesions. Cryosurgery is the application of extreme cold to destroy tissue.
Which stage of a pressure injury is exhibited by deeply ulcerated tissue, exposing muscle and bone?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: D
Rationale: Stage IV occurs when the tissue is deeply ulcerated, exposing muscle and bones. Stage III pressure sores are those in which the superficial impairment progresses to a shallow crater that extends to the subcutaneous tissue. Stage I pressure sores are characterized by redness of the skin. Stage II pressure sores are red and accompanied by blistering and a shallow break in the skin.
The nurse is assessing a client who is hospitalized for dehydration from persistent vomiting. How would the nurse assess that the client's skin turgor is related to the state of dehydration?
- A. When the nurse pinches up skin of the hand, there is rapid recoil.
- B. The client has wrinkles of the chest.
- C. The nurse grasps the skin over the sternum between the thumb and forefinger with slow recoil observed.
- D. The nurse grasps the skin over the sternum between the thumb and forefinger with rapid recoil observed.
Correct Answer: C
Rationale: Poor skin turgor, indicated by slow recoil when the skin over the sternum is pinched, suggests dehydration. Rapid recoil indicates normal hydration. Wrinkles on the chest are not a specific indicator of dehydration.
A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?
- A. Macule
- B. Vesicle
- C. Pustule
- D. Cyst
Correct Answer: C
Rationale: A pustule has an elevated, raised border, filled with pus. A macule is a flat, round, colored lesion such as a freckle or rash. A vesicle is a lesion that is elevated, round, and filled with serum. A cyst is an encapsulated, round, fluid-filled or solid mass beneath the skin.
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?
- A. Concave
- B. Brittle
- C. Discolored
- D. Clubbing
Correct Answer: D
Rationale: Clubbing of the nails is evidenced by an angle greater than 160?° and suggests long-standing cardiopulmonary disease and chronic hypoxic states. Concave or 'spooning' may indicate iron-deficiency anemia. Discolored or brittle nails may result from other disorders or smoking.