Question 1

A daughter of an older adult patient who has just returned from surgery is distressed about her father's pale, cold hands and feet.What is the best response by the nurse after covering the patient with an extra blanket?

A) "Don't be concerned.It is quite cold in the operating room.Your dad will be warm in a minute."
B) "Older patients like your dad get a little shocky during surgery."
C) "When patients have blood loss during surgery, superficial vessels close off temporarily, resulting in cold extremities."
D) "We are watching the disturbed circulation in your dad's hands and feet very carefully."

Accepted Answer

The nurse should provide a clear and factual explanation to address the daughter's concerns. The explanation given in option C provides accurate information about how blood loss during surgery can affect circulation and cause temporary coldness in the extremities, which is reassuring and helps the daughter understand what is happening with her father. Options A and B dismiss or minimize the daughter's concerns, which is not helpful or respectful. Option D is vague and does not provide any explanation or reassurance.

Question 2

A nurse is screening patients that the plastic surgeon is considering for phototherapy.Which patient should the nurse exclude?&#10;A) A 34-year-old woman with lupus erythematosus&#10;B) A 5-year-old child with pneumonia&#10;C) A 60-year-old man with a pacemaker&#10;D) A 23-year-old woman who is 3 months' pregnant

Accepted Answer

Patients with lupus erythematosus should be excluded from phototherapy as it can exacerbate their condition.

Question 3

A confused patient has been restrained because of combativeness and hyperactivity.What skin assessment may occur as a result of the restraints?&#10;A) Lentigines&#10;B) Senile purpura&#10;C) Senile angiomas&#10;D) Seborrheic keratoses

Accepted Answer

Restraints can cause pressure and friction on the skin, leading to bruises and areas of petechiae or purpura such as senile purpura. Lentigines, senile angiomas, and seborrheic keratoses are benign age-related skin changes that are unrelated to restraint use.

Question 4

Which conditions can be improved with negative pressure therapy? (Select all that apply.)&#10;A) Pressure ulcers&#10;B) Skin grafts&#10;C) Burns&#10;D) Dehisced surgical wounds&#10;E) Eczema

Accepted Answer

The answer of Which conditions can be improved with negative...

Question 5

A nurse collecting tissue for a Tzanck test should: _____ (Select the appropriate interventions and place the steps in sequence.Do not separate answers with a space or punctuation.Example: ABCD.)&#10;A)Open the lesion with a hypodermic needle.&#10;B)Place the specimen in a culture tube and take it to the laboratory.&#10;C)Saturate the sterile swab with exudates.&#10;D)Wash the lesion.&#10;E)Place a pressure dressing on the lesion.

Accepted Answer

The answer of A nurse collecting tissue for a Tzanck...

Question 6

When assessing the capillary refill, a nurse should document as normal a refill time of _____ seconds.(Use numeric characters only.)

Accepted Answer

The answer of When assessing the capillary refill, a nurse...

Question 7

What information should a nurse provide to a patient with vitiligo receiving phototherapy?&#10;A) &#34;Expose yourself to the sun for several hours before treatment to acclimate the skin surface.&#34;&#10;B) &#34;Wear protective clothing.&#34;&#10;C) &#34;Wear loose clothing such as sleeveless T-shirts and shorts after the treatment.&#34;&#10;D) &#34;Leave off sunglasses after treatment so your eyes can more quickly accommodate.&#34;

Accepted Answer

Patients receiving phototherapy should wear protective clothing to minimize exposure to UV light and reduce the risk of skin damage.

Question 8

What should a nurse ask about when taking the functional assessment of a patient with a skin disorder?&#10;A) A sore that is slow to heal&#10;B) Unusual hair growth&#10;C) Previous skin disorders&#10;D) Exposure to chemicals or irritants

Accepted Answer

The answer of What should a nurse ask about when...

Question 9

Displaying her hands, a patient asks, &#34;Do you think my liver is OK? Look at all these liver spots!&#34; What is the most appropriate nursing response?&#10;A) &#34;The spots could mean something is wrong; I will make a note of it.&#34;&#10;B) &#34;The spots are normal aging changes and have nothing to do with your liver.&#34;&#10;C) &#34;Have you recently been exposed to hepatitis?&#34;&#10;D) &#34;Don't worry about them.They will fade during the winter.&#34;

Accepted Answer

Liver spots (also known as age spots) are a common and harmless part of aging and do not necessarily indicate any liver problems. It is important to reassure the patient that this is a normal part of aging and does not require any further medical intervention.

Question 10

Which age-related skin changes should a nurse anticipate when performing a physical assessment on an 80-year-old man? (Select all that apply.)&#10;A) Increased nasal hair&#10;B) Flattened nails&#10;C) Small macular lesions at the hairline&#10;D) Increased hair on the helix of the ear&#10;E) Presence of seborrheic keratosis

Accepted Answer

Increased nasal hair, flattened nails, increased hair on the helix of the ear, and the presence of seborrheic keratosis are common age-related changes in the skin and hair of elderly individuals. Small macular lesions at the hairline are not typically associated with aging.

Deck 56: Integumentary System Introduction