ATI MED SURG PROCTORED EXAM 2019-STUDY GUIDE
1)A nurse is caring for a client diagnosed with a skin infection who is receiving tobramycin sulfate (Nebcin) intravenously every 8 hours. Which of the following would indicate to the nurse that the client is experiencing an adverse reaction related to the medication?Options:A)A blood urea nitrogen (BUN) of 30 mg/dLB)A white blood cell count (WBC) of 6000/ulC)A sedimentation rate of 15 mm/hourD)A total bilirubin of 0.5 mg/dL
Correct Answer is: AExplanation : Adverse reactions or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy tremors, and visual disturbances. A normal WBC is 4500 to 11,000/ul. The normal sedimentation rate is 0 to 30 mm/hour. The normal total bilirubin level is less than 1.5 mg/dL. The normal BUN is 5 to 20 mg/dL.
2)A nurse is caring for a client with a diagnosis of pemphigus. On assessment of the client, the nurse looks for which hallmark sign characteristic of this condition?Options:A)Homans’ signB)Chvostek’s signC)Tousseau’s signD)Nikolsky’s sign
Correct Answer is: DExplanation : A hallmark sign of lpemphigus is Nikolsky’s sign, which is when the epidermis can be rubbed off by slight friction or injury. Other characteristics include flaccid bullae that rupture easily and emit a foul-smelling drainage leaving crusted, denuded skin. The lesions are common on theface, back, chest, and umbilicus. Even slight pressureon an intact blister may cause spread to adjacent skin. Trousseau’s sign is a sign for tetany, in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Homans’ sign, a sign of thrombosis in the leg, is discomfort in the calf on forced dorsiflexion of the foot.
3)The temperature of water for a tepid bath should be approximately,Options:A)92 to94 FB)95 to 97 FC)98 to 100 FD) 101 to 103 F
Correct Answer is: CExplanation : The temperature range for tepid applications is approximately as body temperature. 1. This temperature is too cool for a tepid bath. 2. Same as answer 1. 4. This temperature is too hot for a tepid bath temperature
4)A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse assesses the infant closely for which early sign of CHF?Options:A)CoughB)TachycardiaC)Slow and shallow breathingD)Pallor
Correct Answer is: BExplanation : The early signs of congestive heart failure (CHF) include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation but is not an early sign. Pallor may be noted in the infant with CHF but is also not an early sign.Use the process of elimination and note the key word “early.” Think about the physiology and the effects on the heart when fluid overload occurs. These concepts will assist in directing you to option . 2. If you had difficulty with this question, review the early signs of CHF in an infant.
5)Cholesterol is important in the human body for,Options:A)Blood clottingB)Bone formationC)Muscle contractionD)Cellular membrane structure
Correct Answer is: DExplanation : 4. Cholesterol is an essential structural and functional component of most cellular membranes. That it is associated with atherosclerotic plaques does not detract from its essential functions. 1. Cholesterol is not necessary for blood clotting; calcium and vitamin K are. 2. Cholesterol is not essential for bone formation; calcium, phosphorus, and calciferol are. 3. Cholesterol is not involved in muscle contraction; potassium, sodium, and calcium are
6)The client with unresolved edema will most likely develop,Options:A)ProteinemiaB)ContracturesC)Tissue ischemiaD)Thrombus formation Correct Answer is: CExplanation : 3.Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia. 1. This is not a complication resulting from long- term edema. 2. Same as answer 1. 4. Same as answer 1
7)The darkening of tissue seen in chronic venous insufficiency results from the breakdown of hemoglobin with subsequent formation of,Options:A)HemeB)Ferric chlorideC)Ferrous sulfateD)Insoluble amino acids
Correct Answer is: CExplanation : 3. The release of iron from hemoglobin as erythrocytes disintegrate in tissue results in ferrous sulfate formation, causing darkening of the tissues. 1. Heme constitutes the pigment portion of the hemoglobin molecule, which gives blood its red color; it is not associated with chronic venous insufficiency. 2. Ferric chloride is used as a reagent, topically as an antiseptic, and as an astringent; it is not related to chronic venous insufficiency. 4. All amino acids are soluble.
8)The nurse realizes that sink faucets in a client’s room are considered contaminated because,Options:A)They are not in sterile areasB)They are opened with dirty handsC)Large numbers of people use themD)Water encourages bacterial growth
Correct Answer is: BExplanation : 2. Unwashed hands are considered contaminated and are used to turn on sink faucets. The use of foot pedals or a paper towel barrier prevents recontamination of washed hands. 1. They are not considered contaminated for this reason; areas cannot be sterile. 3. It is unrelated to the number of people, but rather to being touched by contaminated hands. 4. Although bacterial growth is facilitated in moist environments, this is not why sink faucets are considered contaminated.
9)The most important aspect of handwashing is,Options:A)TimeB)SoapC)WaterD)Friction
Correct Answer is: DExplanation : 4. Soap helps by reducing the surface tension of water, but friction is necessary for the removal of microorganisms. 1. Although this aspect of handwashing is important, without friction it has minimal value. 2. Although soap reduces surface tension, without friction it has minimal value. 3. Although water flushes some microorganisms from the skin, without friction it has minimal value.
10)A moist sterile dressing placed on a cloth sterile field will be contaminated because of the principle of,Options:A)DialysisB)OsmosisC)DiffusionD)Capillarity
Correct Answer is: DExplanation : 4. The absorption of fluids by gauze results from the adhesion of water to the gauze threads. The surface tension of water causes contraction of the fiber, pulling fluid up the threads. 1. This is separation of substances in solution utilizing their differing rates of diffusion through a membrane. 2. This refers to movement of water through a semipermeable membrane. 3. This is movement of molecules from high to low concentration.
11)When changing a client’s postoperative dressing, the nurse is careful not to introduce microorganisms into the surgical incision. This is an example of,Options:A)Wound asepsisB)Medical asepsisC)Surgical asepsisD)Concurrent asepsis
Correct Answer is: CExplanation : 3. Intact skin is the first line of defense against entry of microorganisms. A surgical incision is a portal of entry, so a technique that requires the absence of all microorganisms (surgical asepsis) is essential. 1. Wound asepsis is incorrect terminology. 2. Medical asepsis utilizes clean technique to minimize the spread of microorganisms; when there is a break in the skin, this is insufficient. 4. Concurrent disinfection refers to measures initiated to control the spread of infection while an infection is present; concurrent asepsis is incorrect terminology
12)The nurse is preparing to change a client’s dressing. The statement that best explains the basis of surgical asepsis that the nurse will follow in this procedure is,Options: A)Keep the area free of microorganismsB)Protect self from microorganisms in the woundC)Confine the microorganisms to the surgical site.D)Keep the number of opportunistic microorganisms to a minimum
Correct Answer is: AExplanation : 1. Surgical asepsis means that the defined area contains no microorganisms. 2. This would apply to personal protective equipment and medical asepsis. 3. Same as answer 2. 4. This would apply to medical asepsis.
13)When assessing an obese client who has had abdominal surgery, the nurse identifies dehisence and evisceration. After placing this client in the supine position, the nurse’s next intervention should be to,Options:A)Notify the physicianB)Obtain the client’s vital signsC)Reinsert the protruding organsD)Cover the wound with a sterile towel moistened with saline
Correct Answer is: DExplanation : 4. This covering will not adhere to the wound and it will protect the area until the physician arrives. 1. This is not the priority; the client has needs that must be met first. 2. Although this would eventually he has done, it is not the priority. 3. This is contraindicated because it could injure delicate tissues and organs
14)After emptying a client’s portable wound drainage system, it is important for the nurse to,Options:A)Irrigate the suction tube with sterile salineB)Encircle the drainage present on the dressingC)Clean the drainage port with an alcohol wipeD)Compress the container before closing the port
Correct Answer is: DExplanation : 4. The Jackson-Pratt or Hemovac is compressed to maintain suction; this must be done with the port open to avoid reintroduction of drainage into the surgical site by positive pressure. 1. Irrigation usually is not required and would necessitate a doctor’s order. 2. This does not need to be done when emptying the device; a portable wound drainage system usually removes excess drainage before it leaks onto the dressing. 3. The nurse should avoid touching the port because it is sterile.
15)To promote healing of a large surgical incision, a client’s physician would most likely order daily doses of,Options:A)Vitamin AB)MephytonC)Ascorbic acidD)Vitamin B12 complex
Correct Answer is: CExplanation : 3. Vitamin C (ascorbic acid) plays a major role in wound healing. It is necessary for the maintenance and formation of strong collagen, the major protein of most connective tissues. 1. Vitamin A is important for the healing process; however, vitamin C cements the ground substance of supportive tissue. 2. Phytonadione (Mephyton) is vitamin K, which plays a major role in blood coagulation. 4. Vitamin B12 is needed for RBC synthesis and a healthy nervous system.
16)A disease produced when a Clostridium organism enters wounds and produces a toxin causing crepitus is,Options:A)TetanusB)AnthraxC)BotulismD)Gangrene
Correct Answer is: DExplanation : 4. Clostridium welchii (C. perfringens) is a spore- forming bacterium that produces a toxin that decays muscle, releasing a gas; it is one of the major causative agents for gas gangrene. 1. Clostridium tetani enters the body via puncture of the skin and affects the nervous system; gas gangrene does not occur with this organism. 2. This disease is caused by Bacillus anthracis, not Clostridium. 3. Clostridium botulinum contaminates food that is then ingested, causing botulism.
17)The nurse should assess a client with psoriasis for,Options:A)Pruritic lesionsB)Multiple petechiaeC)Shiny, scaly lesionsD)Erythematous macules
Correct Answer is: CExplanation : 3. Psoriasis is characterized by dry, scaly lesions that occur most frequently on the elbows. knees, scalp, and torso. 1. Pruritus, if present at all, is generally mild. 2. Petechiae are not characteristic. 4. Macules are erythematous flat spots on the skin as in measles; no scales are present. 18)The nurse should explain to the client with psoriasis that treatment usually involves,Options:A)Avoiding exposure to the sunB)Topical application of steroidsC)Potassium permanganate bathsD)Debridement of necrotic plaques
Correct Answer is: BExplanation : 2. Steroids are applied locally and the lesions are usually covered with plastic (or Saran Wrap) at night to reverse the inflammatory process. 1. Solar rays maybe used for treatment; other forms of ultraviolet light are preferred. 3. Potassium permanganate is an antiseptic astringent used on infected, draining, or vesicular lesions. 4.The plaques are not necrotic and therefore do not require debriding.
19)When caring for a client with scabies, the nurse should be aware that scabies is,Options:A)Highly contagiousB)A chronic problemC)Caused by a fungusD)Associated with other allergies
Correct Answer is: AExplanation : 1. Scabies is caused by the itch mite (Sarcoptes scabiei), the female of which burrows under the skin to deposit eggs. It is intensely pruritic and is transmitted by direct contact or in a limited way by soiled sheets or undergarments. 2. Scabies is an acute infection. 3. It is caused by the itch mite, a parasite. 4. It is an infectious disease unrelated to allergies.
20)The nurse must help the client with pemphigus vulgaris deal with the resulting,Options:A)InfertilityB)ParalysisC)Skin lesionsD)Impaired digestion
Correct Answer is: CExplanation : 3. Pemphigus is primarily a serious disease characterized by large vesicles called bullae. Although potentially fatal, it can be relatively controlled by steroid therapy.1. Pemphigus is a disease of the skin. 2. Same as answer 1. 4. Same as answer 1.
21)The assessment that is most indicative of systemic lupus erythematosus (SLE) is,Options:A)A butterfly rashB)Firm skin fixed to tissueC)Muscle mass degenerationD)An inflammation of small arteries
Correct Answer is: AExplanation : 1. The connective tissue degeneration of SLE leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the malar region. 2. This occurs in scleroderma; in an advanced stage the client has the appearance of a living mummy. 3. This occurs in muscular dystrophy; it is characterized by muscle wasting and weakness. 4. This occurs in polyarteritis nodosa, a collagen disease affecting the arteries and nervous system.
22)Although no cause has been determined for scleroderma, it is thought to be the result of,Options:A)AutoimmunityB)Ocular motilityC)Increased amino acid metabolismD)Defective sebaceous gland formation
Correct Answer is: AExplanation : 1. Scleroderma is an immunologic disorder characterized by inflammatory, fibrotic, and degenerative changes. 2. This is not involved in the development of scleroderma. 3. Same as answer 2. 4. Same as answer 2.
23)An older adult is admitted to the surgical unit from a nursing home for treatment of a pressure ulcer. During the initial physical assessment, the nurse notes that the client is dehydrated and the skin is dry and scaly. The nurse immediately applies emollients to the client’s skin and reinforces the dressing on the pressure ulcer. Legally,Options:A)The nurse should have instituted a plan to increase activityB)The nurse provided supportive nursing care for the well-being of the clientC)No treatment should have been instituted for the client until the physician’s orders were receivedD)Debridement of the pressure ulcer should have been done by the nurse before the dressing was applied
Correct Answer is: BExplanation : 2. According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. 1. Activity is prescribed by the
1)A nurse is caring for a client diagnosed with a skin infection who is receiving tobramycin sulfate (Nebcin) intravenously every 8 hours. Which of the following would indicate to the nurse that the client is experiencing an adverse reaction related to the medication?Options:A)A blood urea nitrogen (BUN) of 30 mg/dLB)A white blood cell count (WBC) of 6000/ulC)A sedimentation rate of 15 mm/hourD)A total bilirubin of 0.5 mg/dL
Correct Answer is: AExplanation : Adverse reactions or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy tremors, and visual disturbances. A normal WBC is 4500 to 11,000/ul. The normal sedimentation rate is 0 to 30 mm/hour. The normal total bilirubin level is less than 1.5 mg/dL. The normal BUN is 5 to 20 mg/dL.
2)A nurse is caring for a client with a diagnosis of pemphigus. On assessment of the client, the nurse looks for which hallmark sign characteristic of this condition?Options:A)Homans’ signB)Chvostek’s signC)Tousseau’s signD)Nikolsky’s sign
Correct Answer is: DExplanation : A hallmark sign of lpemphigus is Nikolsky’s sign, which is when the epidermis can be rubbed off by slight friction or injury. Other characteristics include flaccid bullae that rupture easily and emit a foul-smelling drainage leaving crusted, denuded skin. The lesions are common on theface, back, chest, and umbilicus. Even slight pressureon an intact blister may cause spread to adjacent skin. Trousseau’s sign is a sign for tetany, in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Homans’ sign, a sign of thrombosis in the leg, is discomfort in the calf on forced dorsiflexion of the foot.
3)The temperature of water for a tepid bath should be approximately,Options:A)92 to94 FB)95 to 97 FC)98 to 100 FD) 101 to 103 F
Correct Answer is: CExplanation : The temperature range for tepid applications is approximately as body temperature. 1. This temperature is too cool for a tepid bath. 2. Same as answer 1. 4. This temperature is too hot for a tepid bath temperature
4)A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse assesses the infant closely for which early sign of CHF?Options:A)CoughB)TachycardiaC)Slow and shallow breathingD)Pallor
Correct Answer is: BExplanation : The early signs of congestive heart failure (CHF) include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation but is not an early sign. Pallor may be noted in the infant with CHF but is also not an early sign.Use the process of elimination and note the key word “early.” Think about the physiology and the effects on the heart when fluid overload occurs. These concepts will assist in directing you to option . 2. If you had difficulty with this question, review the early signs of CHF in an infant.
5)Cholesterol is important in the human body for,Options:A)Blood clottingB)Bone formationC)Muscle contractionD)Cellular membrane structure
Correct Answer is: DExplanation : 4. Cholesterol is an essential structural and functional component of most cellular membranes. That it is associated with atherosclerotic plaques does not detract from its essential functions. 1. Cholesterol is not necessary for blood clotting; calcium and vitamin K are. 2. Cholesterol is not essential for bone formation; calcium, phosphorus, and calciferol are. 3. Cholesterol is not involved in muscle contraction; potassium, sodium, and calcium are
6)The client with unresolved edema will most likely develop,Options:A)ProteinemiaB)ContracturesC)Tissue ischemiaD)Thrombus formation Correct Answer is: CExplanation : 3.Oxygen perfusion is impaired during prolonged edema, leading to tissue ischemia. 1. This is not a complication resulting from long- term edema. 2. Same as answer 1. 4. Same as answer 1
7)The darkening of tissue seen in chronic venous insufficiency results from the breakdown of hemoglobin with subsequent formation of,Options:A)HemeB)Ferric chlorideC)Ferrous sulfateD)Insoluble amino acids
Correct Answer is: CExplanation : 3. The release of iron from hemoglobin as erythrocytes disintegrate in tissue results in ferrous sulfate formation, causing darkening of the tissues. 1. Heme constitutes the pigment portion of the hemoglobin molecule, which gives blood its red color; it is not associated with chronic venous insufficiency. 2. Ferric chloride is used as a reagent, topically as an antiseptic, and as an astringent; it is not related to chronic venous insufficiency. 4. All amino acids are soluble.
8)The nurse realizes that sink faucets in a client’s room are considered contaminated because,Options:A)They are not in sterile areasB)They are opened with dirty handsC)Large numbers of people use themD)Water encourages bacterial growth
Correct Answer is: BExplanation : 2. Unwashed hands are considered contaminated and are used to turn on sink faucets. The use of foot pedals or a paper towel barrier prevents recontamination of washed hands. 1. They are not considered contaminated for this reason; areas cannot be sterile. 3. It is unrelated to the number of people, but rather to being touched by contaminated hands. 4. Although bacterial growth is facilitated in moist environments, this is not why sink faucets are considered contaminated.
9)The most important aspect of handwashing is,Options:A)TimeB)SoapC)WaterD)Friction
Correct Answer is: DExplanation : 4. Soap helps by reducing the surface tension of water, but friction is necessary for the removal of microorganisms. 1. Although this aspect of handwashing is important, without friction it has minimal value. 2. Although soap reduces surface tension, without friction it has minimal value. 3. Although water flushes some microorganisms from the skin, without friction it has minimal value.
10)A moist sterile dressing placed on a cloth sterile field will be contaminated because of the principle of,Options:A)DialysisB)OsmosisC)DiffusionD)Capillarity
Correct Answer is: DExplanation : 4. The absorption of fluids by gauze results from the adhesion of water to the gauze threads. The surface tension of water causes contraction of the fiber, pulling fluid up the threads. 1. This is separation of substances in solution utilizing their differing rates of diffusion through a membrane. 2. This refers to movement of water through a semipermeable membrane. 3. This is movement of molecules from high to low concentration.
11)When changing a client’s postoperative dressing, the nurse is careful not to introduce microorganisms into the surgical incision. This is an example of,Options:A)Wound asepsisB)Medical asepsisC)Surgical asepsisD)Concurrent asepsis
Correct Answer is: CExplanation : 3. Intact skin is the first line of defense against entry of microorganisms. A surgical incision is a portal of entry, so a technique that requires the absence of all microorganisms (surgical asepsis) is essential. 1. Wound asepsis is incorrect terminology. 2. Medical asepsis utilizes clean technique to minimize the spread of microorganisms; when there is a break in the skin, this is insufficient. 4. Concurrent disinfection refers to measures initiated to control the spread of infection while an infection is present; concurrent asepsis is incorrect terminology
12)The nurse is preparing to change a client’s dressing. The statement that best explains the basis of surgical asepsis that the nurse will follow in this procedure is,Options: A)Keep the area free of microorganismsB)Protect self from microorganisms in the woundC)Confine the microorganisms to the surgical site.D)Keep the number of opportunistic microorganisms to a minimum
Correct Answer is: AExplanation : 1. Surgical asepsis means that the defined area contains no microorganisms. 2. This would apply to personal protective equipment and medical asepsis. 3. Same as answer 2. 4. This would apply to medical asepsis.
13)When assessing an obese client who has had abdominal surgery, the nurse identifies dehisence and evisceration. After placing this client in the supine position, the nurse’s next intervention should be to,Options:A)Notify the physicianB)Obtain the client’s vital signsC)Reinsert the protruding organsD)Cover the wound with a sterile towel moistened with saline
Correct Answer is: DExplanation : 4. This covering will not adhere to the wound and it will protect the area until the physician arrives. 1. This is not the priority; the client has needs that must be met first. 2. Although this would eventually he has done, it is not the priority. 3. This is contraindicated because it could injure delicate tissues and organs
14)After emptying a client’s portable wound drainage system, it is important for the nurse to,Options:A)Irrigate the suction tube with sterile salineB)Encircle the drainage present on the dressingC)Clean the drainage port with an alcohol wipeD)Compress the container before closing the port
Correct Answer is: DExplanation : 4. The Jackson-Pratt or Hemovac is compressed to maintain suction; this must be done with the port open to avoid reintroduction of drainage into the surgical site by positive pressure. 1. Irrigation usually is not required and would necessitate a doctor’s order. 2. This does not need to be done when emptying the device; a portable wound drainage system usually removes excess drainage before it leaks onto the dressing. 3. The nurse should avoid touching the port because it is sterile.
15)To promote healing of a large surgical incision, a client’s physician would most likely order daily doses of,Options:A)Vitamin AB)MephytonC)Ascorbic acidD)Vitamin B12 complex
Correct Answer is: CExplanation : 3. Vitamin C (ascorbic acid) plays a major role in wound healing. It is necessary for the maintenance and formation of strong collagen, the major protein of most connective tissues. 1. Vitamin A is important for the healing process; however, vitamin C cements the ground substance of supportive tissue. 2. Phytonadione (Mephyton) is vitamin K, which plays a major role in blood coagulation. 4. Vitamin B12 is needed for RBC synthesis and a healthy nervous system.
16)A disease produced when a Clostridium organism enters wounds and produces a toxin causing crepitus is,Options:A)TetanusB)AnthraxC)BotulismD)Gangrene
Correct Answer is: DExplanation : 4. Clostridium welchii (C. perfringens) is a spore- forming bacterium that produces a toxin that decays muscle, releasing a gas; it is one of the major causative agents for gas gangrene. 1. Clostridium tetani enters the body via puncture of the skin and affects the nervous system; gas gangrene does not occur with this organism. 2. This disease is caused by Bacillus anthracis, not Clostridium. 3. Clostridium botulinum contaminates food that is then ingested, causing botulism.
17)The nurse should assess a client with psoriasis for,Options:A)Pruritic lesionsB)Multiple petechiaeC)Shiny, scaly lesionsD)Erythematous macules
Correct Answer is: CExplanation : 3. Psoriasis is characterized by dry, scaly lesions that occur most frequently on the elbows. knees, scalp, and torso. 1. Pruritus, if present at all, is generally mild. 2. Petechiae are not characteristic. 4. Macules are erythematous flat spots on the skin as in measles; no scales are present. 18)The nurse should explain to the client with psoriasis that treatment usually involves,Options:A)Avoiding exposure to the sunB)Topical application of steroidsC)Potassium permanganate bathsD)Debridement of necrotic plaques
Correct Answer is: BExplanation : 2. Steroids are applied locally and the lesions are usually covered with plastic (or Saran Wrap) at night to reverse the inflammatory process. 1. Solar rays maybe used for treatment; other forms of ultraviolet light are preferred. 3. Potassium permanganate is an antiseptic astringent used on infected, draining, or vesicular lesions. 4.The plaques are not necrotic and therefore do not require debriding.
19)When caring for a client with scabies, the nurse should be aware that scabies is,Options:A)Highly contagiousB)A chronic problemC)Caused by a fungusD)Associated with other allergies
Correct Answer is: AExplanation : 1. Scabies is caused by the itch mite (Sarcoptes scabiei), the female of which burrows under the skin to deposit eggs. It is intensely pruritic and is transmitted by direct contact or in a limited way by soiled sheets or undergarments. 2. Scabies is an acute infection. 3. It is caused by the itch mite, a parasite. 4. It is an infectious disease unrelated to allergies.
20)The nurse must help the client with pemphigus vulgaris deal with the resulting,Options:A)InfertilityB)ParalysisC)Skin lesionsD)Impaired digestion
Correct Answer is: CExplanation : 3. Pemphigus is primarily a serious disease characterized by large vesicles called bullae. Although potentially fatal, it can be relatively controlled by steroid therapy.1. Pemphigus is a disease of the skin. 2. Same as answer 1. 4. Same as answer 1.
21)The assessment that is most indicative of systemic lupus erythematosus (SLE) is,Options:A)A butterfly rashB)Firm skin fixed to tissueC)Muscle mass degenerationD)An inflammation of small arteries
Correct Answer is: AExplanation : 1. The connective tissue degeneration of SLE leads to involvement of the basal cell layer, producing a butterfly rash over the bridge of the nose and in the malar region. 2. This occurs in scleroderma; in an advanced stage the client has the appearance of a living mummy. 3. This occurs in muscular dystrophy; it is characterized by muscle wasting and weakness. 4. This occurs in polyarteritis nodosa, a collagen disease affecting the arteries and nervous system.
22)Although no cause has been determined for scleroderma, it is thought to be the result of,Options:A)AutoimmunityB)Ocular motilityC)Increased amino acid metabolismD)Defective sebaceous gland formation
Correct Answer is: AExplanation : 1. Scleroderma is an immunologic disorder characterized by inflammatory, fibrotic, and degenerative changes. 2. This is not involved in the development of scleroderma. 3. Same as answer 2. 4. Same as answer 2.
23)An older adult is admitted to the surgical unit from a nursing home for treatment of a pressure ulcer. During the initial physical assessment, the nurse notes that the client is dehydrated and the skin is dry and scaly. The nurse immediately applies emollients to the client’s skin and reinforces the dressing on the pressure ulcer. Legally,Options:A)The nurse should have instituted a plan to increase activityB)The nurse provided supportive nursing care for the well-being of the clientC)No treatment should have been instituted for the client until the physician’s orders were receivedD)Debridement of the pressure ulcer should have been done by the nurse before the dressing was applied
Correct Answer is: BExplanation : 2. According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. 1. Activity is prescribed by the
