Nokea
The nurse will provide which instruction regarding reducing the risk factors for melanoma?
- A. Avoid exposure to the sun and use protective measures when exposure occurs.
- B. Have all nevi removed.
- C. Watch for changes in moles, especially on the back.
- D. Use a sun lamp for tanning.
Correct Answer: A
Rationale: Encourage the patient to protect skin from the sun by wearing protective clothing, including a hat with 4-in brim, applying sunscreen all over the body, and avoiding the midday sun from 10 a.m. to 4 p.m. Having all nevi removed is impractical. Watching for changes in moles does not reduce risk factors; it allows for early detection. Sun lamps are just as damaging as the sun.
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The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?
- A. Severity of the symptoms
- B. Site of the lesions
- C. Symptomatology of the lesions
- D. Surface area of the lesions
Correct Answer: A
Rationale: The mnemonic PQRST stands for Provocative factors (causes), Quantity, Region of the body, Severity of the symptoms, Time (length of time the disorder has been present). In this mnemonic, S does not stand for site, symptomology or surface area of the lesion.
The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
- A. Increase the IV rate and monitor for burn shock.
- B. Monitor for signs of seizure activity.
- C. Assess for signs of fluid overload.
- D. Raise the foot of the bed and apply blankets.
Correct Answer: C
Rationale: As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. Burn shock occurs from hypovolemia in the first 72 hours of a burn injury. Seizures are not associated with the burn injury. Raising the foot of the bed would not be of value in this situation.
The three major glands of the skin are sudoriferous, ceruminous, and
- A. sebaceous
Correct Answer: sebaceous
Rationale: Sudoriferous glands-sweat glands open into pores on the skin surface and excrete sweat. Ceruminous glands-secrete a waxlike substance called cerumen and are located in the external ear canal. Sebaceous glands-secrete their substance, sebum (an oily secretion), through the hair follicles distributed on the body.
Which may indicate a malignant melanoma in a nevus on a patient's arm?
- A. Even coloring of the mole
- B. Decrease in size of the mole
- C. Irregular border of the mole
- D. Symmetry of the mole
Correct Answer: C
Rationale: Any change in color, size, or texture and any bleeding or pruritus of a nevus deserves investigation. A malignant melanoma is a cancerous neoplasm in which pigment cells or melanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue.
Which action will the nurse take when administering a therapeutic bath to a patient who has severe pruritus from contact dermatitis?
- A. Use Burow's solution to help promote healing.
- B. Rub the skin briskly to decrease pruritus.
- C. Limit bathing to three times a week.
- D. Ensure that bath area is at least 85 degrees and dehumidified.
Correct Answer: A
Rationale: Pruritus is responsible for most of the discomfort. Wet dressings and using Burow's solution help promote the healing process. Rubbing the skin would increase pruritis. Give daily baths with an application to cleanse the skin. A cool environment with increased humidity decreases the pruritus.