What is the most common profile of a client with malignant melanoma?
- A. An African American client with dark skin and dark hair
- B. A Scandinavian client with freckles and blue eyes
- C. A Mexican client with tan skin and dark brown hair
- D. A Caucasian client with brown hair and brown eyes
Correct Answer: B
Rationale: Fair-skinned individuals with freckles are at higher risk for melanoma.
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The client experiences local burning and stinging when mafenide cream is applied to treat a burn injury. Which action should be taken by the nurse?
- A. Remove any mafenide that has been applied.
- B. Immediately notify the health care provider.
- C. Double-check the concentration of mafenide.
- D. Inform the client that this is a normal response.
Correct Answer: D
Rationale: Burning or stinging with application of mafenide (Sulfamylon) is a normal response. Mafenide is bacteriostatic and used to reduce gram-negative and gram-positive organisms present in burned tissues. Removal of mafenide or notifying the HCP is unnecessary. Mafenide cream is supplied in 11.2% cream; there are no other concentrations available.
Aside from blood on the anterior end of the packing, what other sign or symptom would suggest that the client is bleeding from the operative area?
- A. Frequent swallowing
- B. Impaired appetite
- C. Slight hoarseness
- D. Diminished hearing
Correct Answer: A
Rationale: Frequent swallowing may indicate blood trickling down the throat.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with a stage IV pressure ulcer. Which action by the UAP warrants intervention by the nurse?
- A. The UAP turns the client every two (2) hours.
- B. The UAP keeps the sheets wrinkle free.
- C. The UAP encourages the client to drink high-protein drinks.
- D. The UAP places multiple diapers on the client.
Correct Answer: D
Rationale: Multiple diapers increase moisture and pressure, worsening stage IV ulcers. Turning, wrinkle-free sheets, and protein drinks are appropriate.
The nurse is explaining facelift (rhytidectomy) surgery to the client and describing the site where the incision is most commonly made. Place an X on the site where the incision most commonly used for rhytidectomy is made.
- A. An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face.
Correct Answer: A
Rationale: An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face. Incisions in the forehead and periorbital area are for blepharoplasty and browlift. Head and neck reconstruction utilizes the chin site.
Which question is most appropriate for the nurse to ask at this time?
- A. What childhood diseases have you had?
- B. What's your present occupation?
- C. Do you eat a well-balanced diet?
- D. How much aspirin do you take?
Correct Answer: D
Rationale: Excessive aspirin use can cause tinnitus, making it the most relevant question.
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