Nokea
The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review?
- A. Hemoglobin and hematocrit
- B. Arterial blood gases
- C. BUN and creatinine
- D. Glucose level
Correct Answer: A
Rationale: Normal nails appear slightly convex with a 160?° angle between the nail base and the skin. Concave-shaped nails, referred to as 'spooning' because of their characteristic appearance, are a sign of iron-deficiency anemia. ABGs, BUN and creatinine, and glucose levels are not related to this shape of nail.
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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.
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 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.
A client is coming to the office to have a growth removed by the doctor. The client asks 'What does cryosurgery do to the growth?' What is the correct response by the nurse?
- A. Removes the entire growth
- B. Through the application of extreme cold, the tissue is destroyed.
- C. Freezes the growth, so the physician can remove it at the next appointment
- D. Lasers the growth off
Correct Answer: B
Rationale: Cryosurgery is the application of extreme cold to destroy tissue. The other statements are false.