Nokea
What is the best instruction by the nurse 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. Sun lamps are just as damaging as the sun.
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The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
- A. Use a pillow to keep the heels off the bed when supine
- B. Order a low air-loss therapy bed immediately
- C. Prepare to insert a nasogastric feeding tube
- D. Order an occupational therapy consult for strength training
Correct Answer: A
Rationale: Keeping heels off the bed prevents pressure ulcers, a key intervention for a paralyzed client.
When assessing for primary skin lesions on children, what does the nurse specifically look for?
- A. Crusts
- B. Keloids
- C. Scales
- D. Wheals
Correct Answer: D
Rationale: Primary skin lesions are initial lesions that arise from previously normal skin. Wheals (e.g., hives) are primary lesions, characterized by transient, edematous, itchy areas. Crusts, keloids, and scales are secondary lesions that result from changes to primary lesions or healing processes.
A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion?
- A. Crust
- B. Keloid
- C. Pustule
- D. Ulcer
Correct Answer: C
Rationale: A pustule is an example of a primary skin lesion. Primary skin lesions are original lesions arising from previously normal skin.
The nurse describes common complications that burn patients may experience. Which description best fits hyperkalemia?
- A. Potassium released from damaged cells
- B. Increased viscosity of blood slowing blood flow to small vessels
- C. Negative nitrogen balance
- D. Inflammatory response causing fluid shift
Correct Answer: A
Rationale: Hyperkalemia occurs in burns due to potassium release from damaged cells.
In evaluating the adequacy of fluid resuscitation in a burn client, which assessment provides the most reliable indicator?
- A. Vital signs
- B. Urine output
- C. Mental status
- D. Peripheral pulses
Correct Answer: B
Rationale: Urine output is the most reliable indicator of fluid resuscitation adequacy as it reflects renal perfusion.