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When providing the open method of treatment for a patient who is 52 years old with burns to the lower extremities, which does the nurse expect to see included in the nursing plan?
- A. Change the dressing using good medical asepsis.
- B. Provide an analgesic immediately after the dressing change.
- C. Perform circulation checks every 2 to 4 hours.
- D. Keep the room temperature at 85°F (29.4°C) to prevent chilling.
Correct Answer: D
Rationale: Chilling may be controlled by keeping the room temperature at 85°F (29.4°C). The open method of burn injury treatment does not involve dressings; the wound is left undressed. Strict surgical protocol is observed and analgesia should be given before the treatment. Circulation is not restricted if the wound area is left open.
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A patient, age 46, reports to the health care provider's office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, 'It itches like crazy.' Which type of lesion would the nurse include in the documentation?
- A. Macules
- B. Plaques
- C. Wheals
- D. Vesicles
Correct Answer: C
Rationale: Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold. The lesions are elevated with a white center and a pale red border. Macules are small, flat blemishes flush with the skin surface. Plaques are elevated, firm, rough lesions with a flat topped surface. A vesicle is a circumscribed elevation of skin filled with serous fluid.
A patient has been admitted to the hospital with burns to the upper chest. The nurse notes singed nasal hairs. The nurse needs to assess this patient frequently for which condition?
- A. Decreased activity
- B. Bradycardia
- C. Respiratory complications
- D. Hypertension
Correct Answer: C
Rationale: Signs and symptoms of inhalation injury include singed nasal hairs. Breathing difficulties may take several hours to occur.
Which patient instruction will the nurse reinforce relative to the management of systemic lupus erythematosus (SLE)?
- A. Maintain a balance between rest and activity.
- B. Increase activity to promote mobility.
- C. Increase exposure to the sun to increase vitamin D absorption.
- D. Increase sodium consumption.
Correct Answer: A
Rationale: Balanced rest, activity, and diet will support medication management. It is not necessary to increase activity to promote mobility. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium.
Several residents in a long term care facility have been diagnosed with herpes zoster. Which resident will require the closest observation for development of complications?
- A. A resident who is sexually active
- B. A resident recovering from a hip fracture
- C. A resident with dementia who requires assistance eating.
- D. A resident who is undergoing chemotherapy for breast cancer
Correct Answer: D
Rationale: The resident who is undergoing chemotherapy is likely to develop a low white blood cell count, and is at the highest risk of complications such as disseminated herpes zoster or severe skin infection from the irritated skin at the lesion sites. A resident who is sexually active is not necessarily at high risk of complications of herpes zoster, (shingles). Neither the resident recovering from a hip fracture or the resident with dementia are as high a risk as the resident undergoing chemotherapy.
Which is a major function of the skin?
- A. Excretion of wastes
- B. Protection
- C. Vitamin C synthesis
- D. Temperature regulation
- E. Prevention of dehydration
Correct Answer: A,B,D,E
Rationale: Functions of the skin include protection from the environment (pathogenic organisms, foreign substances, natural barrier against infection), temperature regulation, prevention of dehydration, excretion of waste products, and vitamin D synthesis.