Test Bank For Adult Health Nursing 6th Edition By kockrow

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Test Bank For Adult Health Nursing 6th Edition By kockrow

Christensen: Adult Health Nursing, 6th Edition

Chapter 03: Care of the Patient with an Integumentary Disorder

Test Bank 

MULTIPLE CHOICE

1.A patient has generalized macular-papular skin eruptions and complains of severe pruritus from contact dermatitis. When the nurse administers his therapeutic bath, it is important to remember that

a.	using Burow’s solution helps promote healing.
b.	rubbing the skin briskly decreases pruritus.
c.	allowing 20 to 60 minutes to complete the bath will prevent pruritus.
d.	sterilizing all equipment used will prevent pruritus.

ANS: A

Pruritus is responsible for most of the discomfort. Wet dressings, using Burow’s solution, help promote the healing process. A cool environment with increased humidity decreases the pruritus.

DIF: Cognitive Level: Application REF: Page 79 OBJ: 7

TOP:PruritusKEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2.A patient, age 63, has cancer of the left breast. After a modified radical mastectomy, she has been receiving chemotherapy. Her grandson, who visited a few days ago, now has varicella (chickenpox). The nurse should observe her carefully for signs of

a.	herpes zoster.
b.	herpes simplex type I.
c.	herpes simplex type II.
d.	impetigo.

ANS: A

Herpes zoster is caused by the same virus that causes chickenpox (Herpes varicella). The greatest risk occurs to patients who have a lowered resistance to infection, such as those on chemotherapy or large doses of prednisone, in whom the disease could be fatal because of the patient’s compromised immune system.

DIF: Cognitive Level: Analysis REF: Pages 72, 74 OBJ: 9

TOP: Chemotherapy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3.A patient has herpes zoster (shingles). A local antiviral agent, which is useful in delaying the progression of herpetic diseases, was prescribed. This medication is

a.	lorazepam (Ativan).
b.	hydroxyzine (Atarax).
c.	acyclovir (Zovirax).
d.	hydrocortisone (Solu-Cortef).

ANS: C

Oral and intravenous acyclovir (Zovirax), when administered early, reduces the pain and duration of the virus.

DIF: Cognitive Level: Comprehension REF: Page 72 OBJ: 9

TOP: Anti-infective KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

4.A child has been sent home from school with pruritus and honey-colored crusts on his lower lip and chin. A probable diagnosis would be

a.	chickenpox.
b.	impetigo.
c.	shingles.
d.	herpes simplex type I.

ANS: B

Impetigo is seen at all ages, but is particularly common in children. The crust is honey-colored and easily removed.

DIF: Cognitive Level: Comprehension REF: Page 76 OBJ: 10

TOP:InfectionKEY:Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

5.A patient has an erythematous patch of vesicles on her scalp, and she complains of pain and pruritus. A diagnosis of tinea capitis is made. The causative organism is

a.	bacterium.
b.	virus.
c.	worm.
d.	fungus.

ANS: D

Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen.

DIF: Cognitive Level: Knowledge REF: Page 78 OBJ: 10

TOP:InfectionKEY:Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6.A patient, age 46, reports to his physician’s office with urticaria and papules on his hands and arms. He says, “It itches so badly.” In assessing the patient, the nurse should gather data regarding recent

a.	travel to foreign countries.
b.	upper respiratory tract infection.
c.	changes in medication.
d.	contact with people who have an infectious disease.

ANS: C

Urticaria is the term applied to the presence of wheals or hives in an allergic reaction commonly caused by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold.

DIF: Cognitive Level: Analysis REF: Page 81 OBJ: 8

TOP:UrticariaKEY:Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

7.A patient has been receiving penicillin, acetaminophen with codeine, and hydrochlorothiazide for 4 days. He now has a urinary tract infection. A sulfonamide has been prescribed to be taken three times per day. Several hours after the second dose , he complains of pruritus. The nurse observes a generalized erythema and rash. The most appropriate nursing intervention would be to hold

a.	all medications, and notify the physician of the signs and symptoms.
b.	the penicillin.
c.	the acetaminophen with codeine.
d.	the sulfonamide.

ANS: A

If a patient develops wheals or hives in an allergic reaction to drugs (urticaria), then all medications should be held.

DIF: Cognitive Level: Analysis REF: Page 80 OBJ: 7

TOP:MedicationKEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8.A patient has acne vulgaris. When the nurse explains this condition, it is most important to

a.	stress the importance of strict hygiene.
b.	discuss the connection of diet and stress.
c.	explore how this condition is affecting his self-image and lifestyle.
d.	describe in detail the proper use of prescribed medication.

ANS: C

The nurse must assess and consider what acne means to a person. Most patients acknowledge that acne affects their self-image.

DIF: Cognitive Level: Analysis REF: Page 83 OBJ: 7

TOP:Self-imageKEY:Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

9.A 30-year-old African American had surgery 6 months ago. Her incisional site is now raised, indurated, and shiny. This tissue growth is most likely a(n)

a.	angioma.
b.	keloid.
c.	melanoma.
d.	nevus.

ANS: B

Keloids, which originate in scars, are hard and shiny and are seen more often in African Americans than Caucasians.

DIF:Cognitive Level: Knowledge

REF: Pages 65, 67, 90, 91, Table 3-1, Figure 3-16 OBJ: 1

TOP:KeloidKEY:Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

10.A patient, age 37, sustained partial- and full-thickness burns to 26% of her body surface area. The greatest fluid loss resulting from her burns will usually occur

a.	within 12 hours after burn trauma.
b.	24 to 36 hours after burn trauma.
c.	24 to 48 hours after burn trauma.
d.	48 to 72 hours after burn trauma.

ANS: A

In a burn injury, usually the greatest fluid loss occurs within the first 12 hours.

DIF: Cognitive Level: Analysis REF: Pages 94-95 OBJ: 14

TOP:BurnsKEY:Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

11.Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from

a.	infection.
b.	dysrhythmias with cardiac arrest.
c.	hypovolemic shock and renal failure.
d.	adrenal failure.

ANS: A

A possible complication that should be addressed at the time of the burn is infection in the wound.

DIF:Cognitive Level: AnalysisREF:Page 98, Figure 3-24

OBJ: 15 TOP: Burns KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

12.A patient, age 26, is admitted to the burn unit with partial- and full-thickness burns to 20% of his body surface area as well as smoke-inhalation injury. Carbon monoxide intoxication secondary to smoke inhalation is often fatal because carbon monoxide

a.	binds with hemoglobin in place of oxygen.
b.	interferes with oxygen intake.
c.	is a respiratory depressant.
d.	is a toxic agent.

ANS: A

Carbon monoxide poisoning is likely if the patient has been in an enclosed area. Carbon monoxide displaces oxygen by binding with the hemoglobin.

DIF: Cognitive Level: Analysis REF: Page 97 OBJ: 14

TOP:BurnsKEY:Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

13.A nurse arrives at an accident scene where the victim has just received an electrical burn. The nurse’s primary concern is

a.	the extent and depth of the burn.
b.	the sites of entry and exit.
c.	the likelihood of cardiac arrest.
d.	control of bleeding.

ANS: C

Most electrical burns result in cardiac arrest, and the patient will require CPR or astute cardiac monitoring.

DIF: Cognitive Level: Analysis REF: Page 97 OBJ: 10

TOP:BurnsKEY:Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

14.A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is

a.	shock.
b.	respiratory arrest.
c.	hemorrhage.
d.	infection.

ANS: D

Infection is the most common complication and cause of death after the first 72 hours.

DIF: Cognitive Level: Analysis REF: Page 98 OBJ: 14

TOP:BurnsKEY:Nursing Process Step: Assessment

MSC:NCLEX: Safe, Effective Care Environment