Question 1

The nurse read in the patient's chart that the patient has a stage III pressure ulcer.Which assessment findings are consistent with this stage of ulcer?

Accepted Answer

A stage III pressure ulcer presents as a crater-like ulcer.The underlying subcutaneous tissue is involved in the destructive process.The ulcer may or may not be infected.Bacterial infection is almost always present at this stage.Unblanching skin and mottled skin are consistent with a stage I pressure ulcer.Damage to the epidermis is noted with a stage II pressure ulcer.

Question 2

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it.

-Inflammatory response causing fluid shift

Accepted Answer

The inflammatory response from a burn injury can cause edema by causing fluid to shift from blood vessels into the surrounding tissues.

Answer: C
 Hypovolemia can occur in burn patients due to fluid loss from the burned area and/or the inflammatory response causing fluid shift.

Answer: D
 Tissue hypoxia may occur in burn patients if the burned area is large enough to compromise blood flow to surrounding tissues, leading to decreased oxygen delivery.

Answer: E
 Burn patients often experience hypermetabolism, which is an increase in metabolic rate and energy expenditure, potentially leading to weight loss and muscle wasting. It is not directly related to the inflammatory response or fluid shifts.

There is no match for hyperkalemia as it is not a common complication of burn patients.

Question 3

The nurse is providing education about dietary selections that will promote wound healing.The selection of which menu options should be included? (Select all that apply.)

Accepted Answer

Protein,zinc,and vitamins A,C,and E are shown to reduce pressure ulcers in high-risk patients.Tofu and lean beef are sources of protein.Citrus fruits are high sources of vitamin C.Leafy green vegetables are sources of vitamin A.

Question 4

Matching
The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.)

-Mast cell-stimulated release of histamine

Accepted Answer

Atopic dermatitis is characterized by an immune response that includes mast cell-stimulated release of histamine, leading to inflammation and itching.

Question 5

An 86-year-old resident struck her forearm on a table,causing a category I L-shaped skin tear 6 cm ´ 2 cm.The nurse should: (Select all that apply.)

Accepted Answer

Alcohol would act as an irritant to the skin tear and should be avoided.Cleansing with normal saline is recommended.The remaining options are appropriate for the management of the skin tear.

Question 6

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it.

-Potassium released from damaged cells

Accepted Answer

Potassium is released from damaged cells and can lead to hyperkalemia, which can cause cardiac arrhythmias or even cardiac arrest in burn patients.

Answer: A
 Edema, or the accumulation of fluid in interstitial spaces, is a common complication of burn injuries due to the increased permeability of blood vessels and lymphatic channels.

Answer: C
 Hypovolemia, or decreased blood volume, can occur in burn patients due to loss of fluid and electrolytes through the burn wound. This can lead to decreased perfusion to vital organs and contribute to shock.

Answer: D
 Tissue hypoxia can occur in burn patients due to decreased blood flow to the affected area or as a result of smoke inhalation injury.

Answer: E
 Hypermetabolism is a common complication of burns where the body has an increased energy expenditure and requires more calories to maintain vital functions. This can lead to malnutrition and delayed wound healing if not properly managed.

Question 7

Matching
The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.)

-Cell-mediated immunity resulting in inflammatory response

Accepted Answer

Contact dermatitis is characterized by a cell-mediated immune response resulting in an inflammatory reaction, which can be caused by exposure to irritants or allergens.

Answer: B
 Atopic dermatitis is a chronic, relapsing, and pruritic dermatitis that is associated with allergies and a family history of atopy, and is often caused or aggravated by environmental triggers.

Answer: C
 Stasis dermatitis is a dermatitis that occurs as a result of impaired circulation and a buildup of fluid in the legs, leading to inflammation and skin changes.

Answer: D
 Seborrheic dermatitis is a chronic dermatitis that affects the sebaceous glands and is characterized by scaling and erythema, particularly in areas with a high concentration of sebaceous glands, such as the face, scalp, and chest.

Question 8

Matching
The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.)

-Rash associated with poison ivy

Accepted Answer

Contact dermatitis is a type of dermatitis that occurs when the skin comes into contact with an irritant or allergen. Poison ivy is a common example of an irritant that can cause contact dermatitis.

Question 9

Matching
The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.)

-Lesions may become ulcerated

Accepted Answer

Stasis dermatitis often involves the lower legs and can lead to skin ulceration due to poor circulation and venous stasis.

Question 10

Matching
The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.)

-Erythema and pruritus with scaling associated with phlebitis

Accepted Answer

The erythema and pruritus with scaling associated with phlebitis is characteristic of stasis dermatitis, which develops due to venous insufficiency and can commonly be seen in the lower legs.

Answer: D
 Seborrheic dermatitis is characterized by erythematous, scaly patches or plaques on the scalp, face, and other oily areas of the body. It is typically worse in areas with high sebaceous gland activity and can be associated with pruritus.

Option A (Contact dermatitis) is characterized by a rash at the site of contact with an allergen or irritant.

Option B (Atopic dermatitis) is characterized by intense pruritus, erythematous, and scaly lesions typically located on the flexural areas.

Question 11

An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg,front of the right arm,and one half of the front torso.The nurse,using the "rule of nines," assesses the burn as ____%.

Accepted Answer

The answer of An adult male patient enters the emergency...

Question 12

Matching
The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.)

-Scaly lesions on scalp,ear canals,and eyebrows

Accepted Answer

Seborrheic dermatitis is characterized by scaly lesions on the scalp, ear canals, and eyebrows.

Question 13

The interventions for a burn patient newly admitted to the emergency department include: (Select all that apply.)

Accepted Answer

Clothing stuck to a burned area should not be removed.

Question 14

Matching
The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.)

-Appearance of vesicular lesions following inflammatory response

Accepted Answer

Contact dermatitis is characterized by the appearance of vesicular lesions following an inflammatory response, often in response to contact with an irritant or allergen.

Answer: B 
 Atopic dermatitis typically presents with red, itchy, scaly patches on the skin, and is often associated with allergies or other immune system disorders.

Answer: C 
 Stasis dermatitis is associated with poor circulation in the legs and may present with lesions, discoloration, or ulcers.

Answer: D 
 Seborrheic dermatitis is a chronic skin condition that causes red, scaly patches on the scalp, face, and other areas of the body.

Question 15

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it.

-Negative nitrogen balance

Accepted Answer

Hypermetabolism is a common complication in burn patients due to increased energy demands and protein breakdown, which can result in a negative nitrogen balance.

Answer: A
 Edema is a common complication in burn patients due to increased capillary permeability and fluid shift, which can lead to tissue swelling and impaired circulation.

Answer: C
 Hypovolemia is a common complication in burn patients due to fluid loss from damaged tissue, which can result in decreased blood volume and decreased cardiac output.

Answer: D
 Tissue hypoxia is a common complication in burn patients due to impaired circulation and oxygen delivery to damaged tissue, which can result in cell death and impaired healing.

Answer: B
 Hyperkalemia is a potential complication in burn patients due to potassium release from damaged cells, which can lead to elevated serum potassium levels and cardiac arrhythmias.

Question 16

The home health nurse gives instructions to a patient in avoiding recurrence of athlete's foot,which includes: (Select all that apply.)

Accepted Answer

Tinea pedis is a common fungal infection.All options listed will be helpful in avoiding a recurrence of the infection except application of an antibacterial medication.An antifungal medication should be used.

Question 17

Using the Parkland formula,the fluid needed for a person weighing 140 pounds with a 25% burn would be _____ mL.

Accepted Answer

The answer of Using the Parkland formula,the fluid needed for...

Question 18

The mother of a 4-year-old child reports concerns about how to completely rid her home of lice.Which response by the patient indicates the need for further instruction?

Accepted Answer

For items that cannot be cleaned,such as some stuffed animals,sealing them in plastic bags with the air expelled for 14 days can be effective.The remaining statements are correct.

Question 19

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it.

-Increased viscosity of blood slowing blood flow to small vessels

Accepted Answer

Tissue hypoxia occurs when there is increased viscosity of blood, which slows down the blood flow to small vessels, leading to inadequate oxygen supply to tissues.

Question 20

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it.

-Loss of fluid from vascular space

Accepted Answer

Hypovolemia is a common complication in burn patients due to loss of fluid from the vascular space.

Answer: A 
 Edema occurs due to the accumulation of fluid in the tissues surrounding the burn area.

Answer: D 
 Tissue hypoxia occurs when there is not enough oxygen getting to the tissues surrounding the burn area.

Answer: E 
 Hypermetabolism may occur in burn patients due to increased energy needs required for the healing process.

Answer: B 
 Hyperkalemia may occur as a result of the breakdown of burned muscle tissue, leading to an increase in potassium levels in the blood.

Quiz 43: Care of Patients With Integumentary Disorders and Burns

The nurse read in the patient's chart that the patient has a stage III pressure ulcer.Which assessment findings are consistent with this stage of ulcer?

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it. -Inflammatory response causing fluid shift

The nurse is providing education about dietary selections that will promote wound healing.The selection of which menu options should be included? (Select all that apply.)

Matching The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.) -Mast cell-stimulated release of histamine

An 86-year-old resident struck her forearm on a table,causing a category I L-shaped skin tear 6 cm ´ 2 cm.The nurse should: (Select all that apply.)

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it. -Potassium released from damaged cells

Matching The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.) -Cell-mediated immunity resulting in inflammatory response

Matching The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.) -Rash associated with poison ivy

Matching The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.) -Lesions may become ulcerated

Matching The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.) -Erythema and pruritus with scaling associated with phlebitis

An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg,front of the right arm,and one half of the front torso.The nurse,using the "rule of nines," assesses the burn as ____%.

Matching The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.) -Scaly lesions on scalp,ear canals,and eyebrows

The interventions for a burn patient newly admitted to the emergency department include: (Select all that apply.)

Matching The nurse differentiates the various type of dermatitis.Match each option with the characteristics that best describe it.(Options may be used once, more than once, or not at all.) -Appearance of vesicular lesions following inflammatory response

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it. -Negative nitrogen balance

The home health nurse gives instructions to a patient in avoiding recurrence of athlete's foot,which includes: (Select all that apply.)

Using the Parkland formula,the fluid needed for a person weighing 140 pounds with a 25% burn would be _____ mL.

The mother of a 4-year-old child reports concerns about how to completely rid her home of lice.Which response by the patient indicates the need for further instruction?

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it. -Increased viscosity of blood slowing blood flow to small vessels

The nurse describes common complications that burn patients may experience.Match the burn complication with the description that best fits it. -Loss of fluid from vascular space