Summary Med Surg Final Exam Bank.

Med Surg Final Exam Bank. Chapter 20 Visual problems 1. The client is diagnosed with glaucoma. Which symptom should the nurse expect the client to report? 1. Loss of peripheral vision. 2. Floating spots in the vision. 3. A yellow haze around everything. 4. A curtain coming across vision. 2. The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client? 1. Administer dilating drops to both eyes for 72 hours prior to surgery. 2. Prior to surgery do not lift or push any objects heavier than 15 pounds. 3. Make arrangements for being in the hospital for at least three (3) days. 4. Avoid taking any type of medication which may cause bleeding, such as aspirin. 3. The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first? 1. Teach the signs of increased intraocular pressure. 2. Position the client as prescribed by the surgeon. 3. Assess the eye for signs/symptoms of complications. 4. Explain the importance of follow-up visits. 4. The 65-year-old client is diagnosed with macular degeneration. Which statement by the client indicates the client needs more discharge teaching? 1. “I should use magnification devices as much as possible.” 2. “I will look at my Amsler grid at least twice a week.” 3. “I need to use low-watt light bulbs in my house.” 4. “I am going to contact a low-vision center to evaluate my home.” 5. The nurse who is at a local park sees a young man on the ground who has fallen and has a stick lodged in his eye. Which intervention should the nurse implement at the scene? 1. Carefully remove the stick from the eye. 2. Stabilize the stick as best as possible. 3. Flush the eye with water if available. 4. Place the young man in a high-Fowler’s position. 6. The employee health nurse is teaching a class on “Preventing Eye Injury.” Which information should be discussed in the class? 1. Read instructions thoroughly before using tools and working with chemicals. 2. Wear some type of glasses when working around flying fragments. 3. Always wear a protective helmet with eye shield around dust particles. 4. Pay close attention to the surroundings so eye injuries will be prevented. 7. The 65-year-old male client who is complaining of blurred vision reports he thinks his glasses need to be cleaned all the time, and he denies any type of eye pain. Which eye disorder should the nurse suspect the client has? 1. Corneal dystrophy. 2. Conjunctivitis. 3. Diabetic retinopathy. 4. Cataracts. 8. The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply. 1. Do not touch the tip of the medication container to the eye. 2. Apply gentle pressure on the outer canthus of the eye. 3. Apply sterile gloves prior to instilling eyedrops. 4. Hold the lower lid down and instill drops into the conjunctiva. 5. Gently pat the skin to absorb excess eyedrops on the cheek. , 4, 5 9. The client has had an enucleation of the left eye. Which intervention should the nurse implement? 1. Discuss the need for special eyeglasses. 2. Refer the client for an ocular prosthesis. 3. Help the client obtain a seeing-eye dog. 4. Teach the client how to instill eyedrops. 10. The client diagnosed with glaucoma is prescribed a miotic cholinergic medication. Which data indicate the medication has been effective? 1. No redness or irritation of the eyes. 2. A decrease in intraocular pressure. 3. The pupil reacts briskly to light. 4. The client denies any type of floaters. 11. The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instruction should the nurse discuss prior to the client’s discharge from day surgery? 1. Wear bilateral eye patches for three (3) days. 2. Wear corrective lenses until the follow-up visit. 3. Do not read any material for at least one (1) week. 4. Teach the client how to instill corticosteroid ophthalmic drops. 12. The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first? 1. Have the client move the eyes in all directions. 2. Administer a broad-spectrum antibiotic. 3. Irrigate the eyes with normal saline solution. 4. Determine when the client had a tetanus shot. Chapter 21 Ear Disorders 13. Which statement indicates to the nurse the client is experiencing some hearing loss? 1. “I clean my ears every day after I take a shower.” 2. “I keep turning up the sound on my television.” 3. “My ears hurt, especially when I yawn.” 4. “I get dizzy when I get up from the chair.” 14. Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply. 1. Perforation of the tympanic membrane. 2. Chronic exposure to loud noises. 3. Recurrent ear infections. 4. Use of nephrotoxic medications. 5. Multiple piercings in the auricle. ,2,3 15. The nurse is caring for a client diagnosed with acute otitis media. Which signs/symptoms support this medical diagnosis? 1. Unilateral pain in the ear. 2. Green, foul-smelling drainage. 3. Sensation of congestion in the ear. 4. Reports of hearing loss. 16. The client diagnosed with chronic otitis media is scheduled for a mastoidectomy. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to blow the nose with the mouth closed. 2. Explain the client will never be able to hear from the ear. 3. Instill ophthalmic drops in both ears and then insert a cotton ball. 4. Do not allow water to enter the ear for six (6) weeks. 17. The client is diagnosed with Ménière’s disease. Which statement indicates the client understands the medical management for this disease? 1. “After intravenous antibiotic therapy, I will be cured.” 2. “I will have to use a hearing aid for the rest of my life.” 3. “I must adhere to a low-sodium diet, 2,000 mg/day.” 4. “I should sleep with the head of my bed elevated.” 18. The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client’s chart? 1. Complaints of vertigo. 2. Complaints of otorrhea. 3. Complaints of tinnitus. 4. Complaints presbycusis. 19. Which statement best describes the scientific rationale for the nurse holding the otoscope with the hand in a pencil-hold position when examining the client’s ear? 1. It is usually the most comfortable position to hold the otoscope. 2. This allows the best visualization of the tympanic membrane. 3. This prevents inserting the otoscope too far into the external ear. 4. It ensures the nurse will not cause pain when examining the ear. 20. The nurse is preparing to administer otic drops into an adult client’s right ear. Which intervention should the nurse implement? 1. Grasp the earlobe and pull back and out when putting drops in the ear. 2. Insert the eardrops without touching the outside of the ear. 3. Instruct the client to close the mouth and blow prior to instilling drops. 4. Pull the auricle down and back prior to instilling drops. 21. Which ototoxic medication should the nurse recognize as potentially life altering or threatening to the client? 1. An oral calcium channel blocker. 2. An intravenous aminoglycoside antibiotic. 3. An intravenous glucocorticoid. 4. An oral loop diuretic. 22. Which teaching instruction should the nurse discuss with students who are on the high school swim team when discussing how to prevent external otitis? 1. Do not wear tight-fitting swim caps. 2. Avoid using silicone ear plugs while swimming. 3. Use a drying agent in the ear after swimming. 4. Insert a bulb syringe into each ear to remove excess water. 23. The client comes to the clinic and is diagnosed with otitis media. Which intervention should the clinic nurse include in the discharge teaching? 1. Instruct the client not to take any over-the counter pain medication. 2. Encourage the client to apply cold packs to the affected ear. 3. Tell the client to call the HCP if an abrupt relief of ear pain occurs. 4. Wear a protective ear plug in the affected ear. 24. The client is scheduled for ear surgery. Which statement indicates the client needs more preoperative teaching concerning the surgery? 1. “If I have to sneeze or blow my nose, I will do it with my mouth open.” 2. “I may get dizzy after the surgery, so I must be careful when walking.” 3. “I will probably have some hearing loss after surgery, but hearing will return.” 4. “I can shampoo my hair the day after surgery as long as I am careful.” 25. The nurse is observing the client administer the prescribed eyedrops. Which intervention should the nurse implement? 1. Praise the client for instilling the eyedrops as recommended. 2. Remind the client to instill the eyedrops from 0.4 to 0.8 inch above the eye. 3. Ask the client if the eyedrops have been warmed to room temperature. 4. Teach the client to instill the eyedrops in the upper conjunctival sac. 26. The nurse is administering eardrops to a six (6)-year-old client. Which indicates the nurse is aware of the correct method for instilling eardrops to a child? 1. Pull the pinna upward only to instill the eardrops. 2. Pull the pinna to a neutral position to instill the eardrops. 3. Pull the pinna upward and backward prior to instilling the drops. 4. Pull the pinna downward and forward to instill the drops. 27. The nurse is instilling eye ointment. Which should the nurse perform prior to instilling the medication depicted in the image? 1. Have the client close the eye tightly to rid the eye of tears. 2. Place the nurse’s nondominant hand on the client’s eyebrow. 3. Discard the first bead of ointment, then instill the ointment. 4. Ask the client to look down toward the floor. 28. The nurse is assessing a client and performs a whisper test. Which should the nurse implement? Rank in order of performance. 1. Have the client cover the ear not being tested. 2. Stand 12 to 24 inches to the side of the client. 3. Explain to the client to repeat what the nurse says. 4. Repeat the test for the opposite ear. 5. Ask the client if he/she is willing to participate in the test. Answer 5,3,1,2,4 29. The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment information should the nurse determine first when placing the client in the assigned room? 1. Determine if the client has loss of vision in the same half of each visual field. 2. Find out if the client prefers the bed by the window or by the bathroom. 3. Request dietary to place the meat at 1200 on each plate and vegetables at 0900 and 1500. 4. Request a physical therapy consult to assess the client’s mobility issues. 30. The elderly client has undergone a right-eye cataract removal with an intraocular implant. Which discharge instructions should the nurse teach the client? 1. Have the client demonstrate placing the otic drops in the ear. 2. Teach the client to instill the eyedrops as prescribed. 3. Remind the client to keep the lights in the home low at all times. 4. Encourage the client to sleep on two pillows at night. 31. The nurse is assessing a client who has a “pinpoint” pupil reaction bilaterally and the pupils do not constrict when the light is shown on the eye. Which should the nurse document? 1. Pupillary response poor. 2. Pupils one (1) mm, equal and nonreactive to light. 3. Pupils two (2) to three (3) mm and nonconstrictive to light. 4. Pupils are barely open and don’t constrict to light. 32. The emergency department nurse is assessing a client who has a needle in the sclera of the right eyeball just below the iris. Which should the nurse implement first? 1. Remove the needle with tweezers. 2. Notify an ophthalmologist to care for the client. 3. Stabilize the right eye and place a patch over the left eye. 4. Irrigate the right eye to wash the needle out of the eye. Comprehensive examination Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs? 1. Suggest installing multiple smoke alarms in the home. 2. Recommend using a night-light in the hallway and bathroom. 3. Discuss keeping a high-humidity atmosphere in the bedroom. 4. Encourage the client to smell food prior to eating it. 2. The elderly male client tells the nurse, “My wife says her cooking hasn’t changed, but it is bland and tasteless.” Which response by the nurse is most appropriate? 1. “Would you like me to talk to your wife about her cooking?” 2. “Taste buds change with age, which may be why the food seems bland.” 3. “This happens because the medications sometimes cause a change in taste.” 4. “Why don’t you barbecue food on a grill if you don’t like your wife’s cooking?” 3. The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement? 1. Ensure the client’s room temperature is cool. 2. Talk louder to make sure the client hears clearly. 3. Complete the admission as fast as possible. 4. Provide extra orientation to the surroundings. 4. Which assessment technique should the nurse implement when assessing the client’s cranial nerves for vibration? 1. Move the big toe up and down and ask in which direction the vibration is felt. 2. Place a tuning fork on the big toe and ask if the vibrations are felt. 3. Tap the client’s cheek with the finger and determine if vibrations are felt. 4. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt. 5. Which intervention should the nurse include when conducting an in-service to the ancillary nursing staff on caring for elderly clients addressing normal developmental sensory changes? 1. Ensure curtains are open when having the client read written material. 2. Provide a variety of written material when discussing a procedure. 3. Assist the client when getting out of the bed and sitting in the chair. 4. Request a telephone for the hearing impaired for all elderly clients. 6. Which situation makes the nurse suspect the client has glaucoma? 1. An automobile accident because the client did not see the car in the next lane. 2. The cake tasted funny because the client could not read the recipe. 3. The client has been wearing mismatched clothes and socks. 4. The client ran a stoplight and hit a pedestrian walking in the crosswalk. 7. The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching? 1. The client must lie flat with the face down. 2. The head of the bed must be elevated 45 degrees. 3. The client should wear sunglasses when outside. 4. The client should avoid reading for three (3) weeks. 8. The nurse is conducting a Weber test on the client who is suspected of having conductive hearing loss in the left ear. Where should the nurse place the tuning fork when conducting this test? 1. A 2. B 3. C 4. D 9. The student nurse asks the nurse, “Which type of hearing loss involves damage to the cochlea or vestibulocochlear nerve?” Which statement is the best response of the nurse? 1. “It is called conductive hearing loss.” 2. “It is called a functional hearing loss.” 3. “It is called a mixed hearing loss.” 4. “It is called sensorineural hearing loss.” 10. The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse? 1. The client is ambulating without assistance. 2. The client is sneezing with the mouth open. 3. There is some slight serosanguineous drainage. 4. The client reports hearing popping in the affected ear. 11. The female client tells the clinic nurse she is going on a seven- (7)-day cruise and is worried about getting motion sickness. Which information should the nurse discuss with the client? 1. Make an appointment for the client to see the health-care provider. 2. Recommend getting an over-the-counter scopolamine patch. 3. Discourage the client from taking the trip because she is worried. 4. Instruct the client to lie down and the motion sickness will go away. 12. The nurse writes the diagnosis “risk for injury related to impaired balance” for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care? 1. Provide information about vertigo and its treatment. 2. Assess for level and type of diversional activity. 3. Assess for visual acuity and proprioceptive deficits. 4. Refer the client to a support group and counseling. 13. The nurse is assessing the client’s cranial nerves. Which assessment data indicate cranial nerve I is intact? 1. The client can identify cold and hot on the face. 2. The client does not have any tongue tremor. 3. The client has no ptosis of the eyelids. 4. The client is able to identify a peppermint smell. 14. The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client’s perception of pain? 1. Elderly clients react to pain the same way any other age group does. 2. The elderly client usually requires more pain medication. 3. Reaction to painful stimuli may be decreased with age. 4. The elderly client should use the Wong scale to assess pain. 15. Which instruction should the nurse discuss with the client when completing a sensory assessment regarding proprioception? 1. Instruct the client to lie flat without a pillow during the assessment. 2. Instruct the client to keep both eyes shut during the assessment. 3. During the assessment the client must be in a treatment room. 4. Keep the lights off during the client’s sensory assessment. 16. Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma? 1. Incapacitating vertigo and otorrhea. 2. Nystagmus and complaints of dizziness. 3. Nausea and vomiting. 4. Unilateral hearing loss and tinnitus. 17. Which assessment technique should the nurse use to assess the client’s optic nerve? 1. Have the client identify different smells. 2. Have the client discriminate between sugar and salt. 3. Have the client read the Snellen chart. 4. Have the client say “ah” to assess the rise of the uvula. 18. Which referral is most important for the nurse to implement for the client with permanent hearing loss? 1. Aural rehabilitation. 2. Speech therapist. 3. Social worker. 4. Vocational rehabilitation. 19. Which instruction should the nurse discuss with the female client with viral conjunctivitis? 1. Contact the HCP if pain occurs. 2. Do not share towels or linens. 3. Apply warm compresses to the eyes. 4. Apply makeup very lightly. 20. The client is two (2) hours postoperative right ear mastoidectomy. Which assessment data should be reported to the health-care provider? 1. Complaints of aural fullness. 2. Hearing loss in the affected ear. 3. No vertigo. 4. Facial drooping. 21. Which behavior by the male client should make the nurse suspect the client has a hearing loss? Select all that apply. 1. The client reports hearing voices in his head. 2. The client becomes irritable very easily. 3. The client has difficulty making decisions. 4. The client’s wife reports he ignores her. 5. The client does not dominate a conversation. 22. The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client? 1. Do not push or pull objects heavier than 50 pounds. 2. Lie on the affected eye with two pillows at night. 3. Wear glasses or metal eye shields at all times. 4. Bend and stoop carefully for the rest of your life. 23. The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test? 1. The client is unable to identify which way the toe is being moved. 2. The client cannot discriminate between sharp and dull objects. 3. The toes contract and draw together when the sole of the foot is stroked. 4. The client is unable to identify a key in the hand with both eyes closed. 24. Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse? 1. “I put a night-light in my mother’s bedroom.” 2. “I got carbon monoxide detectors for my mother’s house.” 3. “I changed my mother’s furniture around.” 4. “I got my mother large-print books.” 25. The 72-year-old client tells the nurse food does not taste good anymore and he has lost a little weight. Which information should the nurse discuss with the client? 1. Suggest using extra seasoning when cooking. 2. Instruct the client to keep a seven (7)-day food diary. 3. Refer the client to a dietitian immediately. 4. Recommend eating three (3) meals a day. 26. The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority. 1. Notify the health-care provider. 2. Check the client’s hemoglobin A1c. 3. Assess the client’s vision using the Amsler grid. 4. Teach the client about controlling blood glucose levels. 5. Determine where the spots appear to be in the client’s field of vision. Answer 5,3,2,1,4 Chapter 23 Integumentary disorder 1. The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree. 2. The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Ensure adequate peripheral circulation to both feet. 3. The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy. 4. The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client’s lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client’s ABGs are pH 7.34, Pao2 98, Paco2 38, and HCO3 20. 4. The client is able to perform active range-of motion exercises. 5. The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, “What is a xenograft?” Which statement by the nurse would be the best response? 1. “The doctor will graft skin from your back to your leg.” 2. “The skin from a donor will be used to cover your burn.” 3. “The graft will come from an animal, probably a pig.” 4. “I think you should ask your doctor about the graft.” 6. The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe fullthickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit. 7. The nurse writes the nursing diagnosis “impaired skin integrity related to open burn wounds.” Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client’s wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers. 8. Which nursing interventions should be included for the client who has full-thickness and deep partialthickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change central lines once a week. 5. Administer antibiotics as prescribed. 9. The nurse is caring for a client with deep partial thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client’s pulse oximeter reading is 95%. 3. The client has T 100.4o F, P 100, R 24, and BP 102/60. 4. The client’s urinary output is 50 mL in two (2) hours. 10. The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client’s nutritional status. Which intervention should the nurse implement? 1. Encourage the client’s family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client’s weight weekly in the same clothes. 4. Make a referral to the hospital social worker. 11. The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor’s office. 12. The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client’s mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist. Pressure Ulcers 13. The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize? 1. Keep the skin moist by leaving the skin damp after the bath. 2. Do not rub any lotion into the skin. 3. Turn clients who are immobile at least every two (2) hours. 4. Only the licensed nursing staff may care for the client’s skin. 14. The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority? 1. Impaired cognition. 2. Altered nutrition. 3. Self-care deficit. 4. Altered coping. 15. The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers? 1. Constant perineal moisture. 2. Ability of the clients to reposition themselves. 3. Decreased elasticity of the skin. 4. Impaired cardiovascular perfusion of the periphery. 16. What is the scientific rationale for placing lift pads under an immobile client? 1. The pads will absorb any urinary incontinence and contain stool. 2. The pads will prevent the client from being diaphoretic. 3. The pads will keep the staff from workplace injuries such as a pulled muscle. 4. The pads will help prevent friction shearing when repositioning the client. 17. The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital? 1. Complete the Braden Scale. 2. Monitor the client on a Glasgow Coma Scale. 3. Assess for Babinski’s sign. 4. Initiate a Brudzinski flow sheet. 18. The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse? 1. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch. 2. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally. 3. The skin covering the coccyx is intact but the client complains of pain in the area. 4. The coccyx wound extends to the subcutaneous layer and there is drainage. 19. The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance. 2. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit. 3. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift. 4. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing. 20. The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first? 1. The 34-year-old client who is quadriplegic and cannot move his arms. 2. The elderly client diagnosed with a CVA who is weak on the right side. 3. The 78-year-old client with pressure ulcers who has a temperature of 102.3o F. 4. The young adult who is unhappy with the care that was provided last shift. 21. The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions? 1. Use a pillow to keep the heels off the bed when supine. 2. Order a low air-loss therapy bed immediately. 3. Prepare to insert a nasogastric feeding tube. 4. Order an occupational therapy consult for strength training. 22. The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is “tired of it all.” Which is the nurse’s best therapeutic response? 1. “These wounds can heal if we get enough protein into you.” 2. “Are you tired of the treatments and needing to be cared for?” 3. “Why would you say that? We are doing our best.” 4. “Have you made out an advance directive to let the HCP know your wishes?” 23. The nurse writes the problem “impaired skin integrity” for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply. 1. Turn the client every three (3) to four (4) hours. 2. Ask the dietitian to consult. 3. Have the client sign a consent for pictures of the wounds. 4. Obtain an order for a low air-loss bed. 5. Elevate the head of the bed at all times. 24. The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement? 1. “This surgery will create a skin flap to cover my wounds.” 2. “This surgery will get all the old black tissue out of the wound so it can heal.” 3. “The surgery is important to allow oxygen to get to the tissue for healing to occur.” 4. “Stool will come out an opening in my abdomen so it won’t get in the sore.” Skin Cancer 25. The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching? 1. Wear a sunscreen with a protection factor of 10 or less when in the sun. 2. Try to stay out of the sun between 0300 and 0500 daily. 3. Perform a thorough skin check monthly. 4. Remember caps and long sleeves do not help prevent skin cancer. 26. The female client admitted for an unrelated diagnosis asks the nurse to check her back because “it itches all the time in that one spot.” When the nurse assesses the client’s back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first? 1. Notify the HCP to check the lesion on rounds. 2. Measure the lesion and note the color. 3. Apply lotion to the lesion. 4. Instruct the client to make sure the HCP checks the lesion. 27. The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first? 1. The client scheduled for a skin biopsy who is crying. 2. The client who had surgery three (3) hours ago and is sleeping. 3. The client who needs to void prior to discharge. 4. The client who has received discharge instructions and is ready to go home. 28. Which client is at the greatest risk for the development of skin cancer? 1. The African American male who lives in the northeast. 2. The elderly Hispanic female who moved from Mexico as a child. 3. The client who has a family history of basal cell carcinoma. 4. The client with fair complexion who cannot get a tan. 29. The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include? 1. Teach the client that there is no more risk for cancer. 2. Refer the client to a prosthesis specialist for prosthesis. 3. Instruct the client how to apply sunscreen to the area. 4. Demonstrate care of the surgical site. 30. The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychosocial problem of “fear.” Which nursing interventions should be included in the plan of care? 1. Explain to the client that the fears are unfounded. 2. Encourage the client to verbalize the feeling of being afraid. 3. Have the HCP discuss the client’s fear with the client. 4. Instruct the client regarding all planned procedures. 31. The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP? 1. Stock the rooms with the equipment needed. 2. Weigh the clients and position the clients for the examination. 3. Discuss problems the client has experienced since the previous visit. 4. Take the biopsy specimens to the laboratory. 32. The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma? 1. The lesion is asymmetrical and has irregular borders. 2. The lesion has a waxy appearance with pearl like borders. 3. The lesion has a thickened and scaly appearance. 4. The lesion appeared as a thickened area after an injury. 33. The client has had a squamous cell carcinoma removed from the lip. Which discharge instructions should the nurse provide? 1. Notify the HCP if a nonhealing lesion develops around the mouth. 2. Squamous cell carcinoma tumors do not metastasize. 3. Limit foods to liquid or soft consistency for one (1) month. 4. Apply heat to the area for 20 minutes every four (4) hours. 34. Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion? 1. The client will express feelings of fear. 2. The client will ask questions about the diagnosis. 3. The client will state a diminished level of pain. 4. The client will demonstrate care of the operative site. 35. The male client diagnosed with acquired immunodeficiency syndrome (AIDS) states that he has developed a purple-brown spot on his calf. Which action should the nurse do first? 1. Refer the client to an HCP for a biopsy of the area. 2. Assess the lesion for size, color, and symmetry. 3. Discuss end-of-life decisions with the client. 4. Report the sexually transmitted illness to the health department. 36. The nurse participating in a health fair is discussing malignant melanoma with a group of clients. Which information regarding the use of sunscreen is important to include? 1. Sunscreen is only needed during the hottest hours of the day. 2. Toddlers should not have sunscreen applied to their skin. 3. Sunscreen does not help prevent skin cancer. 4. The higher the number of the sunscreen, the more it blocks UV rays. Bacterial Skin Infection 37. The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100.8o F. Which condition would the nurse suspect the client is experiencing? 1. Cellulitis. 2. Lyme disease. 3. Impetigo. 4. Deep vein thrombosis. 38. The client comes to the clinic complaining of sudden onset of high fever, chills, and a headache. The nurse assesses a patchy macular rash on the trunk and a circular type of rash that looks like an insect bite. Which question would be most appropriate for the nurse to ask during the interview? 1. “Do you live in an area where animals roam the street?” 2. “Have you been working in your garden lately?” 3. “Have you been deer hunting in the last week?” 4. “Do you use sunscreen when you are outside?” 39. The school nurse is discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, “How can I prevent getting impetigo?” Which statement would be the most appropriate response? 1. “Wash your hands after using the bathroom.” 2. “Do not touch any affected areas without gloves.” 3. “Apply a topical antibiotic to your hands.” 4. “Keep the child with impetigo isolated in the room.” 40. The client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse? 1. The client has bilaterally weak radial pulses. 2. The client is able to move the left fingers. 3. The client has a CRT less than three (3) seconds. 4. The client is unable to remove the wedding ring. 41. The nurse writes the client problem of “acute pain and itching secondary to bacterial skin lesions.” Which interventions should be included in the care plan? Select all that apply. 1. Keep humidity at less than 20%. 2. Maintain a cool environment. 3. Use a mild soap for sensitive skin. 4. Keep lesions covered at all times. 5. Apply skin lotion after bathing. 42. The nurse observes the unlicensed assistive personnel (UAP) squeezing the “blackheads” on an elderly client. Which action should the nurse implement first? 1. Notify the unit manager of witnessing this activity. 2. Instruct the assistant to stop this behavior. 3. Demonstrate the correct way to care for the skin. 4. Complete an incident report regarding the action. 43. The client is diagnosed with acne vulgaris. Which psychosocial problem is priority? 1. Impaired skin integrity. 2. Ineffective grieving. 3. Body image disturbance. 4. Knowledge deficit. 44. Which individual would most likely experience the skin disorder pseudo folliculitis barbae (shaving bumps)? 1. A male African American soldier. 2. A female Caucasian hairdresser. 3. A male Asian food server. 4. A female Hispanic school teacher. 45. The female client calls the clinic and tells the nurse that she has a really big “boil” in the perineal area that is causing a lot of pain. Which intervention should the nurse implement? 1. Schedule an emergency appointment for the client. 2. Instruct the client to apply warm, moist compresses to the area. 3. Determine if someone can squeeze the boil. 4. Explain that this will resolve on its own. 46. Which client would most likely be at risk for the development of a carbuncle? 1. The young male who is just beginning to shave. 2. The female with a fair complexion. 3. The male who works out in the gym daily. 4. The female diagnosed with diabetes mellitus. 47. The female teacher comes to the school nurse’s office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement? 1. Instruct the teacher to go to her HCP today. 2. Tell the teacher to wash her hands with soap and water. 3. Encourage the teacher to rub vitamin E oil on the lesions. 4. Explain that the rash will go away in a few days. 48. The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion? 1. Instruct the clients to wear dark clothes when hunting. 2. Use a sunscreen of at least SPF 30 when outside. 3. Avoid dense undergrowth when in a wooded area. 4. Do not use any type of insect repellant when deer hunting. Viral Skin Infection 49. The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client? 1. Encourage the client to get the chickenpox immunization. 2. Do not engage in oral sex if you have a cold sore on the mouth. 3. Wear nonsterile gloves when cleaning the genital area. 4. Do not share any type of towel or washcloth with another person. 50. The client is complaining of burning, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement? 1. Transfer the client to the ED for a cardiac work-up. 2. Inform the client that the nurse can’t see anything. 3. Administer a nonnarcotic analgesic to the client. 4. Ask the client if he or she has ever had chickenpox. 51. The client is diagnosed with herpes simplex 2 and prescribed the antiviral medication valacyclovir (Valtrex). Which instructions should the nurse teach? 1. This medication will prevent pregnancy and treat the virus. 2. This medication must be tapered when discontinuing the medication. 3. This medication will suppress symptoms but does not cure the disease. 4. This medication may cause the client’s urine to turn orange. 52. The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain decreased to a “5” on a 1- to-10 scale. Which intervention should the nurse implement? 1. Turn on soft music and shut the blinds. 2. Apply warm, moist heat to the lesions. 3. Notify the HCP for more pain medication. 4. Encourage the client to ambulate with assistance. 53. The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which interventions should the nurse implement? Select all that apply. 1. Place the client in contact isolation. 2. Administer a corticosteroid IVP. 3. Assess the client’s pain on a 1-to-10 scale. 4. Request that the client not have any visitors. 5. Ensure that only nurses who have had chickenpox care for this client. 54. Which statement by the client diagnosed with chickenpox indicates that the client understands the teaching? 1. “I should put rubbing alcohol on the lesions twice a day.” 2. “I should not scratch myself if at all possible. It might lead to scarring.” 3. “I can go to work when my lesions have all disappeared.” 4. “I need to take all my antibiotics no matter how I feel.” 55. The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal? 1. The client will refrain from scratching the skin. 2. The client will maintain intact skin integrity. 3. The client will have relief from itching. 4. The client will not develop a secondary bacterial infection. 56. The nurse is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the unlicensed assistive personnel? 1. Measure and document the client’s skin lesions. 2. Apply the antihistamine cream to the lesions. 3. Set up the isolation equipment for the client. 4. Determine if the client has prepared an advance directive. 57. The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220 pounds and the order reads 10 mg per kilogram per day to be administered in equally divided doses every six (6) hours. How many milligrams will be administered in one dose? 250mg 58. The 55-year-old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox? 1. Deep vein thrombosis. 2. Varicella pneumonia. 3. Pericarditis. 4. Scarring of the skin. 59. The nurse is assessing a young mother who came to the clinic complaining of sores on her skin. Which assessment data would support that the client has chickenpox? 1. Crops of lesions that have pus and reddened base. 2. Oval scaling lesions that occur on the legs and arms. 3. Severe itching of the scalp with tiny eggs visible. 4. Ringed red lesions on the face, neck, trunk, and extremities. 60. The long-term care nurse has received the report. Which client should the nurse assess first? 1. The client who has not had a bowel movement today. 2. The client who needs the indwelling catheter changed. 3. The client with periorbital skin lesions. 4. The client with a stage I pressure ulcer. Fungal/Parasitic Skin Infection 61. The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children? 1. “I used the comb to remove all the nits.” 2. “I washed my hair with Kwell shampoo.” 3. “I removed all the sheets from my bed.” 4. “I had to fix my daughter’s hair with my brush.” 62. The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement? 1. Instruct the football players to wear tight, snug-fitting jock straps. 2. Explain the importance of wearing white socks. 3. Teach the football players to not share brushes or combs. 4. Discuss the need to dry the groin area thoroughly after bathing. 63. The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client’s fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data? 1. Tinea capitis. 2. Herpes simplex 2. 3. Scabies. 4. Psoriasis. 64. The HCP prescribed Kewell lotion to be applied to the entire body. Which instructions should the nurse teach the client concerning this medication? 1. Leave the lotion on for two (2) hours after applying it to the body. 2. Make sure that the skin is completely dry before applying the lotion. 3. Repeat total body lotion application daily for at least one (1) week. 4. Put the lotion in the bathwater and soak for at least 20 minutes. 65. The nurse in the long-term care facility must delegate a nursing task to an unlicensed assistive personnel. Which nursing task would be most appropriate to delegate? 1. Comb the nits out of the client’s hair. 2. Massage the reddened area on the hip. 3. Scrape the burrows to remove the scabies mite. 4. Apply antifungal lotion to the groin area. 66. The client has tinea pedis. Which intervention should the nurse teach to the client? 1. Soak feet in a vinegar-and-water solution. 2. Wear shoes without any type of socks. 3. Alternate shoes on a monthly basis. 4. Cut toenails straight across. 67. The client with thick, crusty, yellow toenails is diagnosed with tinea unguium (onychomycosis) and asks the clinic nurse what happens if he can’t afford to take the medication the physician prescribed. The nurse’s response will be based on which scientific rationale? 1. The toes will become gangrenous and may have to be amputated. 2. Over-the-counter antifungal creams can be substituted for the oral medication. 3. The toenail plate will separate and the entire toenail may be destroyed. 4. Take all the prescribed antibiotics or the infection may return. 68. There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection? 1. Use only hand-washing foam when caring for clients with scabies. 2. Wear gloves when providing hands-on care for a client with scabies. 3. Wash all linen and clothes in cold water and dry them outside in the sun. 4. Instruct clients to use plastic eating utensils for meals. 69. The nurse in a dermatology clinic is taking the history of a client. Which questions should the dermatology nurse ask the client? Select all that apply. 1. When did you first notice the skin problem? 2. What cosmetics or skin products do you use? 3. Have you experienced any loss of sensation? 4. What is your current and previous occupation? 5. Do you experience any itching, burning, or tingling? 70. The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate? 1. Gently palpate the affected area using sterile gloves. 2. Apply vinegar to the affected area to identify the scabies. 3. Use a magnifying glass and a penlight to visualize the skin. 4. Obtain a Doppler to assess the movement of the mites. 71. The public health nurse is providing a class on skin disorders in the African American community. Which information should the nurse include in the presentation? 1. People with dark skin suffer the same skin conditions as people with light skin. 2. African American men are more likely to have skin cancer than women. 3. Dark-skinned individuals are less likely to form keloids after any type of surgery. 4. Buccal mucosa of dark-skinned individuals is usually a bluish-tinged color. 72. Which skin condition would most likely occur in the highlighted areas? 1. Contact dermatitis. 2. Herpes zoster. 3. Seborrheic dermatitis. 4. Scabies. 73. The nurse is staging a pressure ulcer on a newly admitted client. Which would the nurse document for this client? 1. Stage I. 2. Stage II. 3. Stage III. 4. Stage IV. 74. The nurse has written the concept of impaired skin integrity for a client diagnosed with diabetes mellitus type 2 who has an infected wound on the left heel. Which interventions should the nurse implement? Select all that apply. 1. Administer antibiotics via IVPB method. 2. Perform wound dressing changes using unsterile gloves. 3. Monitor blood glucose levels. 4. Assess the client’s culture daily. 5. Encourage the client to comply with the recommended diet. 75. The nurse is assessing a client’s skin form melanoma. The example below illustrates which of the A, B, C, D, Es of skin cancer detection? Select all that apply. 1. Asymmetry. 2. Borders. 3. Color. 4. Diameter. 5. Evolving 76. The nurse is admitting a male client who states that he has been having a lot of pain in his right chest and side. The nurse observes the client’s side and chest area and notes the vesicles seen below. Which should the nurse implement? 1. Allow the client’s preschool-aged grandchildren to visit if they have not had the varicella vaccine. 2. Do not assign a nurse to care for the client if the nurse has never had chickenpox or the varicella vaccine. 3. Place the client in airborne precautions and have nuclear medicine decontaminate the trays before sending them to be washed. 4. Request a prescription for vancomycin, an aminoglycoside antibiotic, so the client’s infection will heal faster. Chapter 23 Integumentary Disorders 77. The nurse is presenting an in-service to participants in a local health fair. Which information regarding the development of skin cancers should the nurse teach? 1. The fairer the skin, the less the risk of developing skin cancer. 2. Eating a diet high in fiber helps to minimize the risk of skin cancer development. 3. Sun exposure at a beach is less dangerous than at a stadium. 4. The participants should avoid sun exposure in the afternoon hours. 78. The nurse identifies the concept of impaired skin integrity for a pediatric client diagnosed with impetigo on the arms. Which interventions should the nurse implement? 1. Teach the parents to ensure the child takes all the prescribed antibiotics. 2. Give the parents a written excuse so the child can go back to school. 3. Encourage the parents to bathe the child in an oatmeal bath for the itching. 4. Apply topical lidocaine before debriding the crusts from the lesions. 79. The nurse admitting a client to a medical surgical unit notes the lesion below. Which intervention should the nurse implement first? 1. Measure the lesion with a ruler. 2. Document the finding in the client’s medical record. 3. Determine if the client has noticed the lesion before. 4. Notify the health-care provider (HCP) of the lesion. 80. The clinic nurse is preparing to administer medications. Which safety precautions should the nurse employ when administering the client’s medications? 1. Keep the head of the bed/chair elevated for 30 minutes after the application. 2. Teach the client not to eat solid foods for 24 hours after the medication is applied. 3. Have the client expose the area to sunlight for 30 minutes after the application. 4. Wear unsterile gloves when applying the 5-fluorouracil to the client’s lip. Comprehensive exam 1. The nurse is caring for a client with complaints of a rash and itching on the face for one (1) week. Which intervention should the nurse implement first? 1. Check for the presence of hirsutism on the face. 2. Use the Wood’s light to visualize the rash under the black light. 3. Determine what OTC medications the client has used on the rash. 4. Ask the client to describe when the rash first appeared. 2. The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis? 1. Appearance of red, elevated plaques with silvery white scales. 2. A burning, prickling row of vesicles located along the torso. 3. Raised, flesh-colored papules with a rough surface area. 4. An overgrowth of tissue with an excessive amount of collagen. 3. The nurse is preparing the plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care? 1. Apply a thin dusting with Myostatin, an antifungal powder, over the area. 2. Cover the area with an occlusive dressing after applying a steroid cream. 3. Administer acyclovir, an antiviral medication, to the affected areas six (6) times a day. 4. Teach the client the risks and hazards of implanted radiation therapy. 4. The nurse has completed the teaching plan for the client diagnosed with psoriasis. Which statement indicates the need for further teaching? 1. “I will check my skin every day for redness with tenderness.” 2. “I must take my psoralen medication two (2) hours before my treatment.” 3. “I will wear dark glasses during my treatment and the rest of the day.” 4. “The coal-tar ointments and lotions will not stain my clothes.” 5. The nurse is planning the care of a client diagnosed with psoriasis. Which psychosocial problem should be included in the plan? 1. Alteration in comfort. 2. Altered body image. 3. Anxiety. 4. Altered family processes. 6. The elderly client diagnosed with poison ivy is prescribed a Solu-Medrol (a steroid) dose pack. Which intervention should the nurse teach the client? 1. Tell the client to return to the office in one (1) week for blood levels. 2. Instruct the client to take the medication exactly as prescribed. 3. Explain the medication should be taken on an empty stomach. 4. Teach to stop the medication immediately if side effects occur. 7. The nurse is teaching clients at a community center about skin diseases. Which information about pruritus should the nurse include? Select all that apply. 1. Cool environments increase itching. 2. Use of soap increases itching. 3. Use hot water to rinse off soap. 4. Apply mild skin lotion for hydration. 5. Blot gently, but completely dry the skin. 8. Which laboratory test should the nurse monitor to identify an allergic reaction for the client diagnosed with contact dermatitis? 1. IgA. 2. IgD. 3. IgE. 4. IgG. 9. Which client signs and symptoms indicate contact dermatitis to the nurse? 1. Erythema and oozing vesicles. 2. Pustules and nodule formation. 3. Varicosities and edema. 4. Telangiectasia and flushing. 10. The nurse is caring for the client diagnosed with contact dermatitis. Which collaborative intervention should the nurse implement? 1. Encourage the use of support stockings. 2. Administer a topical anti-inflammatory cream. 3. Remove scales frequently by shampooing. 4. Shampoo with lindane 1%, an antiparasitic, weekly. 11. The client had an allergic reaction to poison oak two (2) weeks ago. He has returned to the clinic with severe itching and weeping vesicles on the arms and legs. Which intervention should the nurse implement? 1. Obtain a sample of the drainage for culture and sensitivities. 2. Determine any allergic reactions to any medications taken recently. 3. Inquire how the poison ivy/oak plants were destroyed. 4. Assess for any temperature elevation since the last visit to the clinic. 12. The client is complaining of severe itching following a course of antibiotics. Which independent nursing action should the nurse implement? 1. Refer to an allergy specialist to begin desensitization. 2. Use a tar-preparation gel after each shower or bath. 3. Keep the covers tightly around the client at night. 4. Take baths with an OTC colloidal oatmeal preparation. 13. The home health nurse is visiting an elderly client who shows the nurse an area of rough skin with a greasy feel and multiple papules. Which information should the nurse provide the client? 1. Contact the health-care provider immediately for an appointment. 2. Tell the client this is a normal aging change and no action should be taken. 3. Tell the client to discuss this with the HCP at the next appointment. 4. Have the client buy a wart remover kit at the store. 14. The nurse is preparing the plan of care for a client diagnosed with Stevens-Johnson syndrome. Which interventions should the nurse include? Select all that apply. 1. Monitor intake and output every eight (8) hours. 2. Assess breath sounds and rate every four (4) hours. 3. Assess vesicles, erosions, and crusts frequently. 4. Perform the whisper test for auditory changes daily. 5. Assess orientation to person, place, and time every shift. ,2,3 15. Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis? 1. The client will have no further outbreaks. 2. The client will follow medical protocol. 3. The client will shampoo three (3) times a week. 4. The client will apply bacitracin twice daily. 16. The public health nurse is caring for a client diagnosed with leprosy (Hansen’s disease). Which intervention should the nurse implement? 1. Explain the need for admission to the hospital. 2. Administer dapsone, a sulfone, for one (1) month only. 3. Instruct to use skin moisturizing lotion to control the symptoms. 4. Discuss the ways leprosy is transmitted to other individuals. 17. The health department nurse is caring for the client who has leprosy (Hansen’s disease). Which assessment data indicate the client is experiencing a complication of the disease? 1. Elevated temperature at night. 2. Brownish-black discoloration to the skin. 3. Reduced skin sensation in the lesions. 4. A high count of mycobacteria in the culture. 18. Which problem should the nurse identify for the client recently diagnosed with leprosy (Hansen’s disease)? 1. Social isolation. 2. Altered body image. 3. Potential for infection. 4. Alteration in comfort. 19. The nurse is teaching the client diagnosed with atopic dermatitis. Which information should the nurse include in the teaching? 1. Discuss skin care using hydrating lotions and minimal soap. 2. Tell the client the methods of treating secondary infection. 3. Explain there are no adverse effects to using topical corticosteroids daily. 4. Warn the client inhaled allergens have been linked to exacerbations. 20. The nurse is working with clients in an aesthetic surgery center. Which intervention should the nurse implement for a client undergoing a chemical peel? 1. Teach the client to expect extreme swelling after the procedure. 2. Apply the chemical mixture directly to skin after the face is cleansed. 3. Administer general anesthesia to the client prior to the procedure. 4. Explain that there will be no pain or discomfort during the procedure. 21. The nurse is preparing the client scheduled for a dermabrasion. Which information should the nurse include while teaching the client? 1. Erythema will go away within 24 hours. 2. Do not change the dressing until seen by the HCP. 3. Stay out of extreme cold or heat situations. 4. Avoid direct sunlight for three (3) days. 22. The nurse is caring for an elderly female client preoperative for facial reconstruction. Which client problem should the nurse include in the preoperative plan of care? 1. Loss of self-esteem. 2. Alteration in comfort. 3. Ineffective airway clearance. 4. Impaired communication. 23. The nurse is caring for a client one (1) day postoperative for facial reconstruction. Which intervention should the nurse implement? 1. Provide all activities of daily living. 2. Allow the client to voice fears and concerns. 3. Monitor nutritional food and fluid intake. 4. Assess signs and symptoms of infection. 24. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with a stage IV pressure ulcer. Which action by the UAP warrants intervention by the nurse? 1. The UAP turns the client every two (2) hours. 2. The UAP keeps the sheets wrinkle free. 3. The UAP encourages the client to drink high-protein drinks. 4. The UAP places multiple diapers on the client. 25. The nurse is caring for a male client diagnosed with folliculitis barbae. Which information should the nurse teach to prevent a reoccurrence? 1. Tell the client to not shave the face. 2. Instruct the client to rub on astringent aftershave lotion. 3. Recommend the client apply hot packs for 20 minutes before shaving. 4. Teach the client to use an antibacterial soap on the face. 26. The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full thickness burns. Which interventions should the nurse implement? List in order of priority. 1. Estimate the amount of burned area using the rule of nines. 2. Insert two (2) 18-gauge catheters and begin fluid replacement. 3. Apply sterile saline dressings to the burned areas. 4. Determine the client’s airway status. 5. Administer morphine sulfate, IV. ,2,3,1,5 Chapter 29, 30 Hematologic disorder 1. The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? 1. Hold all venipuncture sites for at least five (5) minutes. 2. Limit fresh fruits and flowers. 3. Place all clients in reverse isolation. 4. Have the clients use a soft-bristle toothbrush. 2. The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? 1. Fever and infections. 2. Nausea and vomiting. 3. Excessive energy and high platelet counts. 4. Cervical lymph node enlargement and positive acid-fast bacillus. 3. The client diagnosed with leukemia has central nervous system involvement. Which instruction should the nurse teach? 1. Sleep with the HOB elevated to prevent increased intracranial pressure. 2. Take an analgesic medication for pain only when the pain becomes severe. 3. Explain radiation therapy to the head may result in permanent hair loss. 4. Discuss end-of-life decisions prior to cognitive deterioration. 4. The client diagnosed with leukemia is scheduled for bone marrow transplantation. Which interventions should be implemented to prepare the client for this procedure? Select all that apply. 1. Administer high-dose chemotherapy. 2. Teach the client about autologous transfusions. 3. Have the family members’ HLA typed. 4. Monitor the complete blood cell count daily. 5. Provide central line care per protocol. ,3,4,5 5. The client is diagnosed with chronic lymphocytic leukemia (CLL) after routine laboratory tests during a yearly physical. Which