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The nurse is conducting a session about the principles of first aid and is discussing the
interventions for a snakebite to an extremity. The nurse should inform those attending the
session that the first priority intervention in the event of this occur- rence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
3. Place the extremity in a position so that it is below the level of the heart.
4. Move the victim to a safe area away from the snake and encourage the victim to rest. -
ANSWER 4
Rationale: In the event of a snakebite, the first priority is to move the victim to a safe area
away from the snake and encour- age the victim to rest to decrease venom circulation. Next,
jew- elry and constricting clothing are removed before swelling occurs. Immobilizing the
extremity and maintaining the extremity at the heart level would be done next; these
actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as
alcohol or caffeinated beverages are not given to the victim because these products may
speed the absorption of the venom. The victim should be transported to an emergency
facility as soon as possible.
A client calls the emergency department and tells the nurse that he came directly into
contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the
skin and asks the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rins- ing several times."
1
, 4. "It is not necessary to do anything if you cannot see anything on your skin." -
ANSWER 3
Rationale: When an individual comes in contact with a poison ivy plant, the sap from the
plant forms an invisible film on the human skin. The client should be instructed to cleanse
the area by showering immediately and to lather the skin several times and rinse each time
in running water. Removing the poison ivy sap will decrease the likelihood of irritation.
Calamine lotion may be one product recommended for use if dermatitis develops. The client
does not need to be seen in the emergency department at this time.
A client is being admitted to the hospital for treat- ment of acute cellulitis of the lower left
leg. During the admission assessment, the nurse expects to note which finding?
1. An inflammation of the epidermis only
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. An epidermal and lymphatic infection caused by Staphylococcus - ANSWER 2
Rationale: Cellulitis is an infection of the dermis and underly- ing hypodermis that results in
a deep red erythema without sharp borders and spreads widely throughout tissue spaces.
The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute,
superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not
superficial and extends deeper than the epidermis. Test-Taking Strategy: Eliminate options 3
and 4 because they are comparable or alike and address the lymphatics. Eliminate option 1
because of the closed-ended word only.
The clinic nurse assesses the skin of a client with psoriasis after the client has used a new
topical treatment for 2 months. The nurse identifies which characteristics as improvement in
the manifesta- tions of psoriasis? Select all that apply.
1. Presence of striae
2. Palpable radial pulses
2
The nurse is conducting a session about the principles of first aid and is discussing the
interventions for a snakebite to an extremity. The nurse should inform those attending the
session that the first priority intervention in the event of this occur- rence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
3. Place the extremity in a position so that it is below the level of the heart.
4. Move the victim to a safe area away from the snake and encourage the victim to rest. -
ANSWER 4
Rationale: In the event of a snakebite, the first priority is to move the victim to a safe area
away from the snake and encour- age the victim to rest to decrease venom circulation. Next,
jew- elry and constricting clothing are removed before swelling occurs. Immobilizing the
extremity and maintaining the extremity at the heart level would be done next; these
actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as
alcohol or caffeinated beverages are not given to the victim because these products may
speed the absorption of the venom. The victim should be transported to an emergency
facility as soon as possible.
A client calls the emergency department and tells the nurse that he came directly into
contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the
skin and asks the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rins- ing several times."
1
, 4. "It is not necessary to do anything if you cannot see anything on your skin." -
ANSWER 3
Rationale: When an individual comes in contact with a poison ivy plant, the sap from the
plant forms an invisible film on the human skin. The client should be instructed to cleanse
the area by showering immediately and to lather the skin several times and rinse each time
in running water. Removing the poison ivy sap will decrease the likelihood of irritation.
Calamine lotion may be one product recommended for use if dermatitis develops. The client
does not need to be seen in the emergency department at this time.
A client is being admitted to the hospital for treat- ment of acute cellulitis of the lower left
leg. During the admission assessment, the nurse expects to note which finding?
1. An inflammation of the epidermis only
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. An epidermal and lymphatic infection caused by Staphylococcus - ANSWER 2
Rationale: Cellulitis is an infection of the dermis and underly- ing hypodermis that results in
a deep red erythema without sharp borders and spreads widely throughout tissue spaces.
The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute,
superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not
superficial and extends deeper than the epidermis. Test-Taking Strategy: Eliminate options 3
and 4 because they are comparable or alike and address the lymphatics. Eliminate option 1
because of the closed-ended word only.
The clinic nurse assesses the skin of a client with psoriasis after the client has used a new
topical treatment for 2 months. The nurse identifies which characteristics as improvement in
the manifesta- tions of psoriasis? Select all that apply.
1. Presence of striae
2. Palpable radial pulses
2
