SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX THREE

1) The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for?  Lesions with well-defined geometric margins 2) The nurse is providing home care ...

1) The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for?  Lesions with well-defined geometric margins 2) The nurse is providing home care instructions to the client who just had surgery for squamous cell carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which characteristics of this type of skin carcinoma?  Firm, nodular lesion topped with a crust or with a central area of ulceration 3) The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate that teaching was successful? Select all that apply.  "I have to avoid excessive exposure to sunlight."  "I am at higher risk for skin cancer because my mother had one." 4) The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply.  Lips  Conjunctiva  Mucous membranes 5) The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is expected from the chemotherapeutic agent. Which statement made by the client indicates a need for further teaching?  "I can't believe my hair loss will be permanent." 6) The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? High pressure alarm keeps sounding on the ventilator 7) A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem?  Blotchy brown macules across the cheeks and forehead 8) The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition?  Hypertrophy of collagen fibers 9) The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure. View Figure  Stage IV pressure ulcer 10) A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply.  Hepatitis  Infection 11) The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions?  "I need to assess my skin for lesions that appear net-like." 12) A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply.  Fever Vasodilation  Inflammation  Excessively high environmental temperature 13) An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions?  Spider angioma 14) An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area?  Greater trochanter 15) In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem?  Altered body image 16) The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first?  Nails 17) A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term?  Ecchymosis 18) A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound?  Autograft 19) The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? "You will need to wear dark eye goggles during the treatment." 20) The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy of a client's skin lesion. Which interventions should be included in the preprocedure plan of care? Select all that apply.  Obtain an informed consent.  Prepare to apply direct pressure to the biopsy site after the procedure.  Tell the client that a small piece of tissue will be removed for examination. 21) The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply.  The exact cause of acne is unknown.  Acne requires active treatment for control until it resolves.  Oily skin and a genetic predisposition may be contributing factors for acne.  The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules. 22) The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder?  An outdoor construction worker 23) A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is. Which statement is the appropriate response by the nurse?  "The local anesthetic may cause a burning or stinging sensation." 24) The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure? Ensure that the consent form has been signed. 25) The nurse prepares to assist a health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include in the plan for this procedure?  Darken the room for the examination. 26) The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition?  Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs 27) The presence of which finding leads the home health nurse to suspect infestation of a client with scabies?  Multiple straight or wavy, threadlike lines beneath the skin 28) The nurse suspects herpes zoster (shingles) when which assessment finding is noted?  Clustered skin vesicles 29) Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction?  "The UV light treatments are given on consecutive days." 30) The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply.  Antibiotic therapy  Warm compresses to the affected area 31) Which individuals are most likely to be at risk for development of psoriasis? Select all that apply.  A woman experiencing menopause  A client with a family history of the disorder  An individual who has experienced a significant amount of emotional distress 32) A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, theminimum fluid requirements are which during the first 24 hours after the burn?  9600 mL of lactated Ringer's solution 33) The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation?  Heart rate of 95 beats/minute 34) The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client?  Oral mucosa 35) The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition?  Acne 36) The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity?  Erythema 37) A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint?  Chronic kidney disease 38) A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder?  Systemic lupus erythematosus (SLE) 39) The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? Appears to have cherry angiomas on trunk and thighs 40) The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful?  "My nails may become clubbed." 41) The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching?  "I can sit in my favorite chair all day." 42) The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply.  Use a mild soap when washing the feet.  Use lanolin on the feet to prevent dryness.  Exercise the feet daily by walking and flexing at the ankle.