Medical Surgical Nursing NCLEX Prep Study
Questions with Accurate Answers
15. A nurse is planning care for a client with a 30% body surface area burn injury.
Which statement is true regarding the nutritional status of this client?
1. Decreased protein intake will decrease renal complicatons.
2. Maintaining a hypermetabolic state decreases the client's risk for infection.
3. A hypermetabolic state results in poor healing and increased needs.
4. Controlling the temperature of the environment decreases caloric
requirements. correct answer 3. A hypermetabolic state results in poor healing
and increased needs.
Rationale: A burn injury causes a hypermetabolic state, resulting in protein and
lipid catabolism that can inhibit wound healing.
Therefore the client with a burn injury requires increased calories and protein to
enable the healing process. Protein intake (1) in the burn client should be
increased to promote wound healing. Renal function is monitored for
complications, which is low risk with burns, because the need for protein is
increased. A hypermetabolic state (2) is not desired and is a complication of a
burn injury. Controlling the temperature of the environment (4) has no effect on
caloric requirements.
A client believes he was bitten by a brown recluse spider. Which assessment data
obtained characteristic of this type of bite?
1. Bull's-eye rash
2. Tender, itchy oval rash
3. Painful rash surrounded by an area of bluish/purple necrosis
4. Line of papules and vesicles appearing 1 to 3 days after the suspected bite
correct answer 3. Painful rash surrounded by an area of bluish/purple necrosis
, Rationale: A necrotic, painful, non-bull's-eye rash is associated with the bite of a
brown recluse spider. It can take from 7 days to 6 months for the wound to
ulcerate and necrose. A bull's-eye rash (1) is characteristic of Lyme disease, and
tender, itchy oval rash (2) is characteristic of a fungal infection such as ringworm.
A line of papules and vesicles (4) is characteristic of scabies.
A client complains of small, red pruritic lesions between the fingers and toes.
Upon examination, the nurse discovers the lesions to appear as a pattern of small
linear lines. Which of the following conditions do these symptoms most likely
represent?
1. Scabies
2. Varicella
3. Contusions
4. Herpes zoster correct answer 1) Scabies
Rationale: Scabies are contagious microscopic mites that manifest as linear
burrows, frequently seen between the fingers and toes. Scabies causes intense
itching, especially at night. Varicella (2) (chickenpox) is a highly contagious
airborne disease that appears as a vesicular skin rash that is itchy. Contusion (3) Is
a bruise that results from blood leakage out of capillary vessels into surrounding
tissue. Herpes zoster (4) (shingles) is a viral disease seen in older adults and
manifests as a painful rash with blisters. Herpes zoster may occur as reactivation
of the varicella virus, which is dormant in the ganglion after a primary case of
chickenpox.
A client has a sacral pressure ulcer that is receiving wet-to-dry dressings. Which
statement is most accurate regarding the rationale for this type of dressing?
1. An occlusive dressing should cover the wet dressing.
Questions with Accurate Answers
15. A nurse is planning care for a client with a 30% body surface area burn injury.
Which statement is true regarding the nutritional status of this client?
1. Decreased protein intake will decrease renal complicatons.
2. Maintaining a hypermetabolic state decreases the client's risk for infection.
3. A hypermetabolic state results in poor healing and increased needs.
4. Controlling the temperature of the environment decreases caloric
requirements. correct answer 3. A hypermetabolic state results in poor healing
and increased needs.
Rationale: A burn injury causes a hypermetabolic state, resulting in protein and
lipid catabolism that can inhibit wound healing.
Therefore the client with a burn injury requires increased calories and protein to
enable the healing process. Protein intake (1) in the burn client should be
increased to promote wound healing. Renal function is monitored for
complications, which is low risk with burns, because the need for protein is
increased. A hypermetabolic state (2) is not desired and is a complication of a
burn injury. Controlling the temperature of the environment (4) has no effect on
caloric requirements.
A client believes he was bitten by a brown recluse spider. Which assessment data
obtained characteristic of this type of bite?
1. Bull's-eye rash
2. Tender, itchy oval rash
3. Painful rash surrounded by an area of bluish/purple necrosis
4. Line of papules and vesicles appearing 1 to 3 days after the suspected bite
correct answer 3. Painful rash surrounded by an area of bluish/purple necrosis
, Rationale: A necrotic, painful, non-bull's-eye rash is associated with the bite of a
brown recluse spider. It can take from 7 days to 6 months for the wound to
ulcerate and necrose. A bull's-eye rash (1) is characteristic of Lyme disease, and
tender, itchy oval rash (2) is characteristic of a fungal infection such as ringworm.
A line of papules and vesicles (4) is characteristic of scabies.
A client complains of small, red pruritic lesions between the fingers and toes.
Upon examination, the nurse discovers the lesions to appear as a pattern of small
linear lines. Which of the following conditions do these symptoms most likely
represent?
1. Scabies
2. Varicella
3. Contusions
4. Herpes zoster correct answer 1) Scabies
Rationale: Scabies are contagious microscopic mites that manifest as linear
burrows, frequently seen between the fingers and toes. Scabies causes intense
itching, especially at night. Varicella (2) (chickenpox) is a highly contagious
airborne disease that appears as a vesicular skin rash that is itchy. Contusion (3) Is
a bruise that results from blood leakage out of capillary vessels into surrounding
tissue. Herpes zoster (4) (shingles) is a viral disease seen in older adults and
manifests as a painful rash with blisters. Herpes zoster may occur as reactivation
of the varicella virus, which is dormant in the ganglion after a primary case of
chickenpox.
A client has a sacral pressure ulcer that is receiving wet-to-dry dressings. Which
statement is most accurate regarding the rationale for this type of dressing?
1. An occlusive dressing should cover the wet dressing.
