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When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what? Select all that apply.
- A. Possible malignancy
- B. Epidermal necrosis
- C. Neurologic involvement
- D. Increased metabolic needs
- E. Possible gastrointestinal mucosal sloughing
Correct Answer: B,D,E
Rationale: High fever, tachycardia, and weakness in TEN indicate epidermal necrosis, increased metabolic needs, and possible GI mucosal sloughing. Malignancy and neurologic involvement are not typical complications.
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A 35-year-old kidney transplant patient comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposis sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposis sarcoma?
- A. Classic
- B. AIDS-related
- C. Immunosuppression-related
- D. Endemic
Correct Answer: C
Rationale: Immunosuppression-related Kaposis sarcoma occurs in transplant recipients due to immunosuppressive therapy. Classic KS affects older Mediterranean or Jewish men, endemic KS is African, and AIDS-related KS occurs in HIV patients.
A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?
- A. Deficient Knowledge about Early Signs of Melanoma
- B. Chronic Pain Related to Surgical Excision and Grafting
- C. Depression Related to Reconstructive Surgery
- D. Anxiety Related to Lack of Social Support
Correct Answer: A
Rationale: Advanced melanoma suggests a lack of early detection, indicating deficient knowledge about melanoma signs. Excision does not cause chronic pain, and depression or anxiety may not be primary concerns.
A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment?
- A. Assessment of the patients stool for evidence of intestinal sloughing
- B. Assessment of the patients apical heart rate for dysrhythmias
- C. Assessment of the patients joints for pain and decreased range of motion
- D. Assessment for cognitive changes resulting from neurologic lesions
Correct Answer: C
Rationale: Psoriasis can lead to psoriatic arthritis in up to 30% of cases, necessitating joint assessment for pain and reduced mobility. It does not affect GI, cardiac, or neurologic function.
A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)?
- A. Teaching participants to improve their overall health through nutrition
- B. Encouraging participants to identify their family history of cancer
- C. Teaching participants to limit their sun exposure
- D. Teaching participants to control exposure to environmental and occupational radiation
Correct Answer: C
Rationale: Limiting sun exposure is the most effective way to reduce BCC risk, as UV radiation is the primary cause. Nutrition, family history, and other radiation exposures are less directly related.
A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply.
- A. Risk for Infection Related to Lesions
- B. Impaired Skin Integrity Related to Epidermal Blisters
- C. Disturbed Body Image Related to Presence of Skin Lesions
- D. Acute Pain Related to Disruption in Skin Integrity
- E. Hyperthermia Related to Disruptions in Thermoregulation
Correct Answer: A,B,C,D
Rationale: Pemphigus vulgaris causes blisters, leading to infection risk, impaired skin integrity, pain, and disturbed body image. Hyperthermia is not a concern; hypothermia is more likely.