SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX THREE

SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX THREE. The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is expected from the chemotherapeutic agent. Which statement made by the client indicates a need for further teaching? "I can't believe my hair loss will be permanent." 6) The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? High pressure alarm keeps sounding on the ventilator 7) A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem? Blotchy brown macules across the cheeks and forehead 8) The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? Hypertrophy of collagen fibers 9) The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure. View Figure Stage IV pressure ulcer 10) A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply. Hepatitis Infection 11) The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions? "I need to assess my skin for lesions that appear net-like." 12) A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply. Fever Vasodilation Inflammation Excessively high environmental temperature 13) An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions? Spider angioma 14) An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? Greater trochanter 15) In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? Altered body image 16) The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first? Nails 17) A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? Ecchymosis 18) A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? Autograft 19) The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? "You will need to wear dark eye goggles during the treatment." 20) The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy of a client's skin lesion. Which interventions should be included in the preprocedure plan of care? Select all that apply. Obtain an informed consent. Prepare to apply direct pressure to the biopsy site after the procedure. Tell the client that a small piece of tissue will be removed for examination. 21) The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply. The exact cause of acne is unknown. Acne requires active treatment for control until it resolves. Oily skin and a genetic predisposition may be contributing factors for acne. The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules.