Chapter 56

27問 • 1年前

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Displaying her hands, a patient asks, “Do you think my liver is OK? Look at all these liver spots!” Which is the most appropriate nursing response?

“The spots are normal aging changes and have nothing to do with your liver.”

A confused patient has been restrained because of combativeness and hyperactivity. Which skin assessment may occur as a result of the restraints?

Senile purpura

Which information should a nurse ask about when taking the functional assessment of a patient with a skin disorder?

Exposure to chemicals or irritants

A daughter of an older adult patient who has just returned from surgery is distressed about her father’s pale, cold hands and feet. Which is the best response by the nurse after covering the patient with an extra blanket? a. b. c. d.

“When patients have blood loss during surgery, superficial vessels close off temporarily, resulting in cold extremities.”

Which information should a nurse provide to a patient with vitiligo receiving phototherapy?

“Wear protective clothing.”

A nurse is screening patients that the plastic surgeon is considering for phototherapy. Which patient should the nurse exclude?

A 34-year-old woman with lupus erythematosus

Which age-related skin changes should a nurse anticipate when performing a physical assessment on an 80-year-old man? (Select all that apply.)

Increased nasal hair, Flattened nails, Increased hair on the helix of the ear, Presence of seborrheic keratosis

Which conditions can be improved with negative pressure therapy? (Select all that apply.)

Pressure ulcers, Skin grafts, Eczema

The client is brought to the emergency department with partial-thickness and full-thickness burns. What immediate nursing interventions are indicated for this client? Select all that apply.

Administer oxygen therapy., Begin an infusion of crystalloid solution., Administer a tetanus injection., Administer pain medication.

In the emergency department, it is necessary to estimate the total body surface that is burned. When the nurse estimates the percentage of burns, what characteristic is associated with full-thickness burns?

Full-thickness burns appear white and leathery

If the nurse uses the rule of nines to estimate the total body surface that has been burned, what percentage is used if the chest and torso are burned?

18%

What is the primary reason the nurse estimates the percentage of the burn?

It is used to calculate fluid replacement.

What nursing assessment is the best evidence of a successful response to the initial burn treatment?

Adequate urine output

If the open method of burn wound management is used when caring for the client, what potential problem is most important for the nurse to monitor to detect?

Infection

What is the chief disadvantage when the nurse applies mafenide acetate cream to the burn wound?

Pain on application

Before each periodic debridement of the burn wound using hydrotherapy, what nursing intervention is essential?

Administering a prescribed analgesic

The health care team is informed that skin autografting is planned for the burn client. Following an autograft of skin, what is most appropriate to include in the care plan?

Minimize movement to prevent graft disruption.

Before discharge, the client is fitted for an elasticized pressure garment that covers the burned areas of skin. What statement is the best indication to the nurse that the client understands the purpose of wearing the pressure garment?

It reduces the severity of scar formation.

During the nurse's initial physical assessment of an older client who was just transferred from a nursing home, the nurse notes that the client has a pressure ulcer on the left hip and sacrum. Based on the etiology of pressure ulcers, what nursing intervention is best for promoting the client's skin integrity?

Reposition the client every 2 hours.

A home health nurse visits the home of a family being treated for pediculosis (head lice). Which of the parent's statements indicates that the nurse should provide more teaching?

"Lice are gone if I don't see any one day after treatment."

What health teaching is appropriate for the nurse to provide to prevent skin cancer? Select all that apply.

Avoid direct sunlight from midmorning to midafternoon., Wear a hat with a wide brim when outdoors., Avoid commercial tanning beds.

What area of health teaching from the nurse is essential when a female client is prescribed isotretinoin for treating acne vulgaris?

Techniques for avoiding pregnancy

What is the best nursing advice for individuals who have frequent outbreaks of tinea pedis?

Wear different shoes each day.

When examining the skin of a client with psoriasis, what finding would the nurse expect to observe?

Red skin patches covered with silvery scales

When an unlicensed assistive personnel with an allergy to latex asks the nurse for advice on carrying out standard precautions, what is the best advice the nurse can offer?

Wear two pairs of vinyl gloves when there's a potential for contact with body fluids

When a client reports pruritus from dry skin, what nursing suggestion is most appropriate for relieving the client's discomfort?

Use hypoallergenic or glycerin soap for bathing.

When a client presents with a skin rash, what questions are appropriate for the nurse to ask to determine its etiology? Select all that apply.

"Have you acquired any new pets?", "Have you eaten foods that are different from usual?", "Have you changed your laundry detergent?", "Have you taken any new medications?"

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ユーザ名非公開 · 61問 · 1年前

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