Deck 75: Disorders in Fluid and Electrolyte Balance

Question 1

What term is used to identify a soft tissue cut caused by a serrated knife?

A) Abrasion
B) Excoriation
C) Laceration
D) Desquamation

Answer 1

Laceration

Question 2

A client arrives at the healthcare facility to report the presence of a purplish-blue discoloration of the skin on the arm that developed after an auto accident. Which term should the nurse use to document the skin lesion?

A) Purpura
B) Desquamation
C) Laceration
D) Dermatitis

Answer 2

Purpura

Question 3

The nurse examining the skin of a client notices small fluid-filled blisters around the client's mouth and suspects they are caused by the herpesvirus. What test would be performed to confirm this suspicion?

A) Wood light examination
B) Tzanck smear
C) Biopsy
D) Scabies scraping

Answer 3

Tzanck smear

Question 4

Which interventions should be introduced to a client for the treatment and prevention of rashes? Select all that apply.

A) Take hot baths or showers.
B) Do not use make-up.
C) Wear clothing made of wool.
D) Rinse clothes in clear water.
E) Lightly slap the itching area.
F) Keep fingernails short.

Question 5

A client is prescribed the antihistamine fexofenadine for severe seasonal allergies. Which teaching points are appropriate for this client? Select all that apply.

A) Warn the client not to drive or work around machinery.
B) Urge the client to avoid using alcohol and other sedatives.
C) Encourage the client to drink only water when taking the medication.
D) Discontinue the antihistamine for 2 weeks before allergy testing.
E) Use sunscreen to avoid photosensitivity reactions.
F) Warn older adults that a larger dose may be required owing to the effects of aging.

Question 6

The nurse is preparing a therapeutic bath for a client recovering from third-degree burns.Which guideline is recommended for this procedure?

A) Give the bath in a standard tub, not a whirlpool tank.
B) Use water that is as hot as the client can tolerate.
C) Use medicated bath oil instead of soap.
D) Rub the client's skin dry after the therapeutic bath.

Question 7

A client with atopic dermatitis has intense pruritus. Which intervention should the nurse educate the client about in order to prevent pruritus?

A) Do not wash new clothes before wearing them.
B) Apply lotion on dry skin.
C) Wear nylon gloves and socks at night.
D) Avoid activities that cause the body to be chilled.

Question 8

The nurse is applying a moist dressing on the arm of a client with acute dermatitis. Which nursing intervention would be appropriate?

A)
Follow standard precaution procedures.
B) Premoisten the area with alcohol.
C) Use a bed cradle when applying the dressing.
D) Medicate with analgesics following the procedure.

Question 9

The nurse is using wet-to-moist dressing to debride a client's decubitus ulcer. Which type of debridement is the nurse employing?

A) Autolysis
B) Enzymatic debridement
C) Mechanical debridement
D) Surgical debridement

Question 10

Which would be the most likely candidate for a pedicle graft?

A) A client with a stage II decubitus ulcer
B) A client with third-degree burns on his hand
C) A client with severe eczema
D) A client with a keloid behind the ear

Question 11

Which types of diet would be prescribed for a client with a third-degree, full thickness burn on 30% of the body?

A) Low calorie, high carbohydrate
B) High calorie, high carbohydrate
C) Low calorie, high protein
D) High calorie, high protein

Question 12

The nurse performing a physical examination of a client with pruritus suspects the client has urticaria. Which description accurately identifies urticaria?

A) Edematous, raised pink wheals that itch and burn
B) Areas of the skin that are completely lacking in pigmentation
C) Small vesicles with reddened and pruritic skin that is sometimes crusted
D) Small, scaly patches of skin

Question 13

Which locations on the body would the nurse assess to confirm the presence of angioedema? Select all that apply.

A) Lips
B) Eyelids
C) Feet
D) Tongue
E) Ear lobes

Question 14

What is the priority observation of the nurse caring for a client diagnosed with psoriasis?

A) Difficulty breathing
B) Low self-esteem
C) Pigment changes
D) Skin infections

Question 15

A client with a skin disorder is undergoing electrodesiccation. For which disorder is this a common treatment?

A) Warts
B) Impetigo
C) Carbuncle
D) Scabies

Question 16

What makes the eyebrows a common site for seborrheic dermatitis to develop?

A) Thicker dermal tissue
B) Increased number of pigment cells
C) Large number of hair follicles
D) Large concentration of sebaceous glands

Question 17

A client presents with skin that is moist and pinkish with blisters and some blanching. What degree of burns would the nurse document?

A) First degree: superficial, partial thickness
B) Second degree: superficial, partial thickness
C) Second degree: deep dermal, partial thickness
D) Third degree: full thickness

Question 18

The nurse is providing discharge teaching for a client who suffered minor burns using a steam cleaner. Which teaching points should the nurse include?

A) Use ice to cool the area for 10 minutes or until the pain diminishes.
B) If blisters occur, puncture the blisters with a sterile needle.
C) Cover the burn loosely with sterile gauze.
D) Do not use over-the-counter NSAIDs for pain; use only prescribed drugs.

Question 19

How would the nurse classify the source of a sunburn?

A) Thermal
B) Electrical
C) Chemical
D) Radiation

Question 20

What is the extent of tissue damage seen in third-degree burns?

A) Epidermis with minimal dermis involvement
B) Entire epidermis and a portion of dermis
C) Entire epidermis, dermis, and subcutaneous fat
D) Minimal damage of the epidermis

Question 21

What is the nursing goal when caring for the client with 30% full-thickness burns during the resuscitative phase?

A) Achieve physiologic stability.
B) Focus on managing the burn wound.
C) Focus on physical repair of the tissue.
D) Psychological restoration of the individual.

Question 22

What is the priority nursing intervention for a client with minor burns on 20% of his head and neck?

A) Dress the burns with salve.
B) Wrap the burns with sterile bandages.
C) Monitor the client's respiratory status.
D) Insert a feeding tube before edema sets in.

Question 23

The nurse is caring for a client who has third-degree burns on 25% of her body. Which is a goal for this client when managing fluid and electrolyte balance?

A) Urinary output of 1 to 1.5 mL/kg/hour
B) Heart rate less than 120 beats per minute
C) Systolic blood pressure greater than 150 mm Hg
D) Decreased sodium levels

Question 24

What should the nurse use as a topical agent when applying a dressing to a first-degree burn on a client's face?

A) Methotrexate
B) Bacitracin
C) Psoralen
D) Calcipotriene

Question 25

A client with severe burns is undergoing a skin graft made from cadaver skin. What is the term for this type of graft?

A) Homograft
B) Autograft
C) Isograft
D) Xenograft

Question 26

A nurse is caring for a client with full-thickness burns on the entire left side of the body. For which complications should the nurse monitor during the client's recovery period?

A) Asthma
B) Hay fever
C) Anemia
D) Leukemia

Question 27

Which mechanism is involved in the development of a burn induced Curling ulcer?

A) Depletion of hydrogen ions in the gastric mucosa
B) Occurrence of ischemic changes in the gastric mucosa
C) Effect of medication such as cimetidine on gastric mucosa
D) Proliferation of gastric mucosal cells in excess

Question 28

A client diagnosed with basal cell carcinoma arrives at the healthcare facility along with her 16-year-old daughter. The client is worried that her daughter is also susceptible. The client's daughter asks the nurse if skin cancer is preventable. Which intervention should the nurse emphasize with regard to the prevention of basal cell carcinoma cancer?

A) Avoid direct early morning sunlight exposure.
B) Use sunscreen with a sun protective factor (SPF) of 12.
C) Regularly use sunlamps and tanning beds rather than direct sunlight.
D) Consult healthcare provider if changes in moles occur.

Question 29

A nurse is caring for a client with a filiform wart. The nurse understands that filiform warts are nonmalignant. What is an example of a nonmalignant skin tumor?

A) Angioma
B) Wart
C) Ganglion
D) Melanoma
E) Nevi

Question 30

The American Cancer Society has developed a helpful ABCDE rule for evaluating a mole. Which is one of these guidelines?

A) Asymmetry: one-half the mole matches the other half
B) Border: edges are regular and defined
C) Color: color is not uniform and has varying shades
D) Diameter: size is smaller than that of a pencil eraser