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A patient age 28, is admitted with a suspected malignant melanoma on his left shoulder.
When performing the physical assessment, the nurse would expect to find which of the
following?
A. A brown birthmark that has lightened in color
B. An area of petechiae
C. A brown or black mole with red, white, or blue areas
D. A red birthmark that has recently become darker
ANSWER✓
⬛
C. Melanomas have an irregular shape and lack uniformity in color. They may appear brown
or black with red, white, or blue areas. Opt A,B, and D contain inaccurate information.
Prevention and early treatment of Lyme's disease are crucial because late complications of
this disease include:
A. Sterility
B. Renal failure
C. Lung abscess
D. Arthritis
ANSWER⬛
✓
D. Arthritis
If Lyme disease goes untreated, arthritis, neurological problems, and cardiac abnormalities
may arise as a late complications. The first sign of Lyme disease is typically a skin lesion that
enlarges and has a characteristic red border. However, not all pt develop this lesion. Opt
A,B,C are incorrect because they arent complications of Lyme disease.
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,A pt, age 32, is admitted with a tentative diagnosis of acquired immunodeficiency syndrome
(AIDS). The practitioner orders biopsy of his facial lesions; the preliminary biopsy report indi-
cates Kaposi's sarcoma. Which of the following would be the nurse's best approach?
A. Tell the patient that Kaposi's sarcoma is common in people with AIDS.
B. Pretend not to notice the lesions on the patient's face.
C. Inform the patient of biopsy results, and support him emotionally
D. Explore the patient's feeling about his facial disfigurement
ANSWER✓
⬛
D. Facial lesions can contribute to situational low self-esteem and a disturbed body image.
Kaposi's sarcoma is among the many psychosocial and physical traumas that may confront
the patient with AIDS; anxiety , anger, grief, and depression are common emotional re-
sponses. The nurse who works with patients who have AIDS must develop excellent listening
skills. The pt. maybe especially concerned that others will realize he has Kaposis Sarcoma.
OPT A. doesn't provide emotional support. OPT B. ignores the patient's concerns. OPT C is
incorrect because the practitioner should inform the patient of the biopsy results, not the
nurse.
A pt. who is human immunodeficiency virus (HIV) positive begins zidovudine therapy. Which
statement best describes the actions of this drug?
A. It eliminates the virus that causes AIDS.
B. It interferes with viral replications
C. It stimulates the immune system
D. It clears up skin lessions
ANSWER⬛
✓
B. Ziduvudine inhibits deoxyribonucleic acid synthesis within the virus that causes AIDS. in-
terfering with viral replications.
During routine hygiene care for a patient with AIDS, a nurse following standard precautions
would take which actions?
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,A. Use reverse isolation
B. Place the pt. in a private room
C. Put on mask, gloves, and a gown
D. Wear gloves when giving mouth care
ANSWER⬛
✓
D. Standard precautions stipulate that a health care worker who anticipates coming into con-
tact with a pt. blood or body fluid must wear gloves; this protects the health care worker.
OPT A is incorrect because reverse isolation is used to protect the patient from the health
care worker. OPT B is incorrect because a private room doesn't provide a method of barrier
protections, which is needed for a standard precautions. OPT C is incorrect because a mask
and gloves are needed only for anticipated contact with airborne droplets of blood or body
fluids; a gown is needed only for anticipated contact with splashes or blood or body fluid.
When assessing the skin of a pt. with deep partial-thickness burns, what would the nurse ex-
pect to find?
A. Dry, pale areas with no blister formation
B. Blister of varying sizes, with areas of charred tissue
C. Cherry-red areas with weeping blister
D. Pearly-white areas with charred tissue
ANSWER⬛
✓
C. In partial-thickness burns, skin color varies from pink to cherry-red. Deep second-degree
burns appear cherry-red and may have blisters that ooze fluid. OPT A and D are incorrect be-
cause they describe full-thickness burns. Opt B is incorrect because it describes superficial
partial-thickness burns.
A pt, age 72, has otosclerosis and is scheduled for stapedectomy. During preoperative teach-
ing, the nurse should give him which instructions.
A. "Cough and sneeze with your mouth closed."
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, B. "Try to get up and walk around as soon as you return from the operating room."
C. "Lie on the bed with your operative ear facing up."
D. "Turn your head rapidly to prevent dizziness."
ANSWER⬛
⬛
✓
C. To prevent pressure on the graf t site, which may cause graft displacement, the nurse
should instruct the pt. to lie on the nonoperative side. OPT A is incorrect because the pt.
should cough or sneeze with his mouth open, not closed, to prevent increased pressure
through the eustachian tube into the middle ear (which could displace the graft). OPT B. is
incorrect because the patient should remain in bed for 24 hours after surgery to prevent
graf t displacement. OPT D is incorrect because rapid head movement could cause vertigo.
A pt, age 23, underwent a rhinoplasty 6 hours ago. After administering his pain medications,
the nurse notes that he is swallowing frequently. What is the most likely cause of the swal-
lowing?
A. Oral dryness caused by nasal packing
B. Bleeding posterior to the nasal packing
C. An adverse reactions to the analgesic
D. A normal response to the analgesic
ANSWER⬛
✓
B. In a pt who has nasal packing in place, frequent swallowing may indicate bleeding in the
posterior pharynx. OPT A. is incorrect because mouth dryness causes thirst, not frequent
swallowing. OPT C and D are incorrect because frequent swallowing isn't a response to anal-
gesic.
During an eye assessment, a pt. complains that "a curtain seems to be coming down in front
of my eye." This complaint suggest which condition?
A. Glaucoma
B. Retinal detachment
C. Cataract
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