MED-SURG Exam 1

What are the ABCDE's to identify skin cancer? - correct answer A: Asymmetry of shape B: Border irregularity C: Color variation within one lesion D: Diameter 6mm E: Evolving/changing features What are some psychosocial assessments for skin integrity? - correct answer Body Image Body Language Social Isolation The nurse is assessing a patient's skin. Which lesion finding requires further nursing intervention? A- Symmetry B- Consistent color C- Diameter of 8mm D- Regular border - correct answer Answer is C Which of the following is not a safe and effective care environment? A- Assist patients to change positions at least every 2 hours; noting any areas of comprised tissue integrity B Use lift sheets when moving pts with fragile skin to avoid sheering C- Use standard precautions when providing care to pts who have skin integrity D- Make sure to wash your hands after touching any areas of impaired skin integiry E- Position pts who are confined to bed to promote air circulation to skinfold areas to minimize pressure over bony prominences - correct answer D- you should wash your hands BEFORE and AFTER What is an important aspect of physiological integrity? - correct answer Ask any pt who has started taking a new prescription or OTC drug whether he or she has noticed any skin changes that occurred since taking the drug What are some ways for a nurse to promote health and maintenance with adults to prevent damage and cancer development? - correct answer -Teach them to reduce sun exposure -To regularly use sunscreen -To examine their skin on a monthly basis for new changes and lesions -Teach pts to bathe, shampoo hair, and keep fingernails clean and trimmed What does red indicate for pressure mapping? What about blue? - correct answer Areas of greater heat production and increased pressure loads. Blue indicates cooler areas under lower pressure What does a positive nitrogen balance require? - correct answer An intake of 30 to 35 calories per kg of body weight with a protein intake of 1.25 to 1.5g/kg/day. Up to 2g/kg/day of protein may be needed when nutritional deficits are severe or protein loss is ongoing. So if a patient weighs 68kg they need at least 85g of protein daily. What are 3 things that are important to remember with skin care? - correct answer 1. Do not massage bony prominences 2. Document and report any manifestations of skin infection 3. Use moisturizers daily on dry skin and apply when skin is damp Explain a stage 1 pressure ulcer... - correct answer -The skin is intact -Area usually over bony prominence, does not blanch (lighten/turn white) with external pressure which indicates absence of capillary blood flow and early tissue damage -Observable pressure-related alterations of intact skin Explain stage 2 pressure ulcer - correct answer -Skin is not intact -Partial-thickness skin loss of epidermis or dermis -Ulcer is superficial, may appear as abrasion, blister, or shallow crater -Bruising not present Explain stage 3 pressure ulcer - correct answer -Full-thickness skin loss -Subcutaneous tissue and underlying fascia may be damaged or necrotic -Bone, tendon, muscle NOT exposed -May have undermining and tunneling Explain stage 4 pressure ulcer - correct answer -Full-thickness with exposed or palpable muscle, tendon, or bone -Undermining and tunneling common with sinus tracts possible -Slough and eschar often present (dead tissue) Nurses canNOT delegate this assessment to UAP because it is beyond their scope of practice - correct answer Nurses should also inspect the ENTIRE body for location, size, color, extent of tissue involvement and surrounding tissue, cell types in wound base and margins, exudate, and foreign bodies. Nurses should always clean before they assess is, then they can dress it. Document what you see, feel, and smell Explain sanguineous/bloody exudate - correct answer Bright red and thin in consistency Explain serosanguineous exudate - correct answer Light red to pink and is thin in consistency Explain serous exudate - correct answer Clear or light in color and thin in consistency Explain seropurulent exudate - correct answer Cloudy, yellow to tan, and thin in consistency Explain purulent exudate - correct answer Yellow, tan or green, opaque, and thick in consistency Infection is diagnosed based on clinical indicators, systemic signs such as?.... - correct answer Ulcer size or dpeth, changes in the quantity and quality of exudate and systemic signs of bacteremia (fever, elevated WBC count) What is a normal range for serum potassium? - correct answer 3.5-5 g/dL What are the 3 different approaches to therapy for psoriasis - correct answer 1. Based on the extent of disease 2. The patients distress 3. The response of the psoriasis to treatment. Pts must understand that no cure for psoriasis exists yet, therapy is aimed at reducing cell proliferation and inflammation What is the treatment for herpes zoster (Shingles) - correct answer Contact isolation with PPE. Pain management. Avoid allowing staff who are immunosuppressed to care for patient. Assess if staff has had the chicken pox vaccine First intention wound healing - correct answer edges brought together with skin lined up in correct anatomical position -A clean laceration or a surgical incision can be closed with sutures, staples, or adhesives Second intention would healing - correct answer Requires gradual filling in of dead space with connective tissue, -A chronic pressure injury or venous stasis ulcer Third intention wound healing - correct answer Delayed closure; high risk for injection with resulting scar. -Wounds at high risk for infection, such as surgical incisions into a non-sterile body cavity or contaminated traumatic wounds. What is an excision? - correct answer Total surgical removal of small lesions What is a wide excision? - correct answer Deep skin resection often involving removal of full-thickness skin in the area of the lesion What is interferon used for? - correct answer It is a nonsurgical option for skin cancer - antineoplastic, antiviral, and antiproliferation Used for melanomas that are at stage III or higher. They are protein capable of modifying the immune response and have anitproliferative action against tumor cells The patient has reddened scratch marks on the right forearm. Which is a Priority medical surgical concept for the patient? A- Cellular regulation B- Perfusion C- Immunity D- Tissue integrity - correct answer D-tissue integrity A dark-skinned patient is admitted for pneumonia. What is the MOST accurate method to asses for cyanosis in this patient? A- Observe for shallow- rapid respiration's B- Check the tongue and lips for a gray color C- Auscultate for decreased breath sounds in lung fields D- Inspect the palms and soles for a yellow-tinged color - correct answer B-Check the tongue and lips for a gray color A patient is at risk for hypovolemia. The nurse assess this patient's skin using which assessment technique? A- Brush the skin surface and observe for flaking B- Push on the skin and obServe for blanching C- gently pinch the skin on the chest and observe for tinting D- Push on the skin over the tibia and observe for depth of indentation - correct answer B or C A patient with a history of HF goes to the outpatient clinic for a follow-up appt. How does the nurses asses for dependent edema in the pt? A- Palpate the dorsum of the foot or the medial ankle B- Weigh the pt and compare to the baseline weight C- Check the pt's buttocks or lower back D- Ask the pt about Intake and output - correct answer A-palpate the dorsum of the foot or the medial ankle The nurse is preparing patient education material about healthy skin. What is the single most important preventive health behavior the nurse promotes? A- Limit continuous skin exposure B- Drink plenty of water C-Practice good skin hygience D- Eat a well balanced meal - correct answer A-Limit sun exposure What are normal lab values for hematocrit? - correct answer 37%-47%(WOMEN) 42%-52%)MEN) What are normal lab values for hemoglobin? - correct answer 12-16 g/dL(women) 14-18 g/dL(men) What are the three most important nursing care for the pts with burns during the resuscitation, acute, and rehabilitation stages - correct answer 1. Tissue integrity 2- Fluid and electrolyte balance 3- Gas exchange What is hypovolemic shock? - correct answer Common cause of death in early phase in patients with serious injuries. It is a great loss of fluid or blood What are the priorities for management for an early phase burn victim? - correct answer 1- SECURE THE AIRWAY 2- Support circulation and organ perfusion by fluid replacement 3-Keep the patients comfortable with analgesics 4- Prevent infection through careful wound care 5- Maintain body temp 6- Provide emotional support This continues for about 24-48 hours until diuresis occurs A change in respiratory pattern may indicate a pulmonary injury. This patient may do 4 things which could mean they are about to lose their airway - correct answer 1- Become progressively hoarse 2- Develop brassy cough 3- Drool or have difficulty swallowing 4- Produce sounds on exhalation that include audible wheezes, crowing, and stridor Explain the rules of nines - correct answer uses multiples of 9% of total BSA. The most rapid method for calculating the size of a burn injury