med surg EXAM A+ GRADE ASSURED COMPLETE SOLUTIONS AND VERIFIED ANSWERS

EXAM

Exam Solution ga




Medical Surgical Nursing NCLEX Prep Study Questions 2 ga ga ga ga ga ga ga




026 A+ GRADE ASSURED COMPLETE SOLUTIONS AND V
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ERIFIED ANSWERS (54A5F) ga ga




QUESTION 1 ga




A client sustains a second-
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degree (partial thickness) burn. The nurse would observe for damage to the: 1) epiderm
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is only 2) muscle and bone 3) epidermis and dermis 4) epidermis, dermis, and subcutan
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eous tissue ga




ANSWER

3) epidermis and dermis Rationale: In a second-degree, or partial-
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thickness, burn both the epidermis and dermis are damaged. A first degree, superficial burn, such as su
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nburn, involves only the epidermis (1). A third- or fourth-degree full-
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thickness burn may involve muscle and bone (2). A third-degree, deep, partial- to full-
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thickness burn may include the epidermis, dermis, and subcutaneous tissue
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QUESTION 2 ga




Which nursing intervention would be most effective to improve comfort for a client with
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herpes zoster? 1. Direct sunlight 2. Dry heating pad 3. Cool, wet dressing 4. Warm, mois
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t compress
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ANSWER

3) Cool, wet dressing Rationale: Application of a cool, wet dressing followed by an analgesic is usually e
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ffective in relieving discomforts related to herpes zoster (shingles). The application of any form of war
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mth (1, 2, 4) may increase sensitivity of nerve endings and increase pain.
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QUESTION 3 ga




A client complains of small, red pruritic lesions between the fingers and toes. Upon exa
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mination, the nurse discovers the lesions to appear as a pattern of small linear lines. Wh
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ich of the following conditions do these symptoms most likely represent? 1. Scabies 2. V
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aricella 3. Contusions 4. Herpes zoster ga ga ga ga ga

, ANSWER

1) Scabies Rationale: Scabies are contagious microscopic mites that manifest as linear burrows, frequen
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tly seen between the fingers and toes. Scabies causes intense itching, especially at night. Varicella (2) (c
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hickenpox) is a highly contagious airborne disease that appears as a vesicular skin rash that is itchy. Co
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ntusion (3) Is a bruise that results from blood leakage out of capillary vessels into surrounding tissue.
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Herpes zoster (4) (shingles) is a viral disease seen in older adults and manifests as a painful rash with
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blisters. Herpes zoster may occur as reactivation of the varicella virus, which is dormant in the ganglio
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n after a primary case of chickenpox.
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QUESTION 4 ga




Which description is most accurate regarding a deep partial-
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thickness burn? 1. Painful with weeping blisters 2. Minimal damage to the epidermis 3.
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Necrotic tissue through all layers of the skin 4. Charring visible in the deepest areas
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ANSWER

1) Painful with weeping blisters Rationale: A deep partial-
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thickness burn involves the epidermal and dermal layers of the skin. It is characterized by a wet, shiny;
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weeping surface with blisters and is painful and very sensitive to the touch. Necrosis (3) and charring (
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4) are seen with a full-
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thickness bur. Redness and pain with minimal damage to the epidermis (2) are characteristics of a supe
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rficial, or first-degree, burn.
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QUESTION 5 ga




A nurse is caring for a client who has sustained burns covering the entire surface of bot
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h arms, the anterior trunk, and the right leg. The nurse uses the rule of nines to estimat
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e the percentage of the burn surface area to be: 1. 27%. 2. 36%. 3. 54% 4. 72%.
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ANSWER

3) 54% Rationale: The "Rule of Nines" is a method used to determine the body surface area (BSA) of a
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burn injury. It accounts for 9% for each arm, 9% for the head, 18% for the anterior torso, 18% for the
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posterior torso, 18% for each leg, and 1% for the genitals. The other answer options (1, 2, 4) are incorr
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ect based on the BSA "Rule of Nines" estimate
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QUESTION 6 ga




When a client has psoriasis, which sign would a nurse expect to find? I. Pustules in the s
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kinfolds 2. Itchy, scaly patches on the scalp 3. Macular rash on the trunk area 4. Vesicula
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r rash on the extremities
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ANSWER

2) Itchy, scaly patches on the scalp Rationale: Psoriasis is a noncontagious autoimmune disease. It usual
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ly presents as itchy scales on the scalp, knees, or elbows due to an overproduction of skin cells. Other c
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ommonly affected areas are the joints, fingernails, and toenails. Psoriasis does not present as pustules (
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1), as a macular rash (3), or a vesicular rash
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