Nokea
The nurse receives a client who has just returned from a circular skin punch biopsy to confirm a skin cancer diagnosis. The nurse should prioritize observing the site for:
- A. Dehiscence
- B. Infection
- C. Bleeding
- D. Swelling
Correct Answer: C
Rationale: Bleeding is the priority concern post-punch biopsy due to the risk of hemorrhage from the procedure site.
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The nurse is performing a physical assessment on a client who has a round, non-tender nodule on the left wrist. It would be appropriate for the nurse to identify this as a
- A. janeway lesion
- B. bouchard node
- C. ganglion cyst
- D. pilar cyst
Correct Answer: C
Rationale: A round, non-tender nodule on the wrist is characteristic of a ganglion cyst, a benign fluid-filled sac.
The nurse is providing discharge instructions to a client with a skin abscess that has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following instructions should the nurse include?
- A. Avoid using alcohol-based hand sanitizer
- B. Use disposable dishes and utensils for all meals
- C. Wear a surgical mask when you are out in public
- D. Keep the wound covered with a dry bandage
Correct Answer: D
Rationale: Keeping the wound covered with a dry bandage prevents the spread of MRSA and protects the wound from further contamination.
The nurse is conducting a community health class on skin changes for older adults. It would be appropriate for the nurse to state which of the following are normal age-related changes? Select all that apply.
- A. Decreased dermal blood flow
- B. Development of actinic lentigo
- C. Degeneration of elastic fibers
- D. Loss of subcutaneous fat
- E. Increased epidermal thickness
Correct Answer: A, B, C, D
Rationale: Normal age-related skin changes include decreased dermal blood flow, actinic lentigo (age spots), degeneration of elastic fibers (leading to wrinkles), and loss of subcutaneous fat (thinner skin). Increased epidermal thickness is not typical; the epidermis thins with age.
The nurse is preparing to perform a dressing change on a client with deep partial-thickness and full-thickness burns. Which of the following actions would be inappropriate when caring for this client?
- A. Administer an oral cyclooxygenase-2 (COX-2) inhibitor 30 minutes before the dressing change
- B. Provide a clear explanation to the client about the procedure and how it will be performed
- C. Changing the client's dressing carefully and handling burned areas gently
- D. Let the client watch their favorite television show while dressing change is being performed
Correct Answer: D
Rationale: Watching TV may distract the client but is inappropriate during a painful procedure like a dressing change, as it does not address pain or procedural needs.
The nurse reviews the pathophysiology of burns with students. It would be correct to state which hormone alterations occur during a major burn. Select all that apply.
- A. Increased secretion of epinephrine
- B. Increased secretion of antidiuretic hormone (ADH)
- C. Increased secretion of aldosterone
- D. Decreased levels of glucose
- E. Increased secretion of norepinephrine
Correct Answer: A, B, C, E
Rationale: Major burns cause a stress response, increasing epinephrine, ADH, aldosterone, and norepinephrine to compensate for fluid loss and maintain homeostasis. Glucose levels increase, not decrease, due to stress-induced hyperglycemia.