Term
| A clients ankles and are edematous, with obvious pitting. The nurse documents these findings as: |
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Definition
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Term
| The nurse will document a decrease in skin turgor when the skin is gently pinched _____________ and a few moments lapse before the skin resumes a normal position. |
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Definition
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Term
| An Asian client comes to the emergency room with a complaint of anxiety, shortness of breath, and a history of asthma. Which of the following client findings does the nurse recognize as a potential for influencing this client's color? |
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Definition
- shortness of breath
- level of carotene
- O2 saturation
- Anxiety |
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Term
| A client is suspected of having capitis (scalp ringworms). The nurse should carefully inspect the scalp for: |
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Definition
| Bald spots, pustules, and crusting. |
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Term
| A client is scheduled for a scratch test for a diagnosis of allergies of unkown origin says to the nurse, I didn't understand what the doctor explained about the test to me. What would be the best response by the nurse to interpret the doctor's explanation to the client? |
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Definition
| Suspected allergens are scratched on the skin. |
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Term
| During the health interview, the older client is asked, "Do you have any problems with wound healing? The nurse documents the clients response as a functional health pattern related to: |
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Definition
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Term
| Rank order skin composition from outermost to innermost layers: |
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Definition
1. Epithelial Cells
2. Stratum Basale
3. Pain Receptors
4. Sweat glands |
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Term
| Over the phone, the nurse tells a parent who suspects her child of having early stages of chickenpox to examine the child's scalp and body for: |
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Definition
| Raised, fluid filled masses with circumscribed edges. |
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Term
| A client's teaching plan to decrease a primary risk for malignant melanoma would include: |
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Definition
| Avoiding use of tanning parlors. |
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Term
| When collecting the health history, the client says he has chronic anemia. As a result of this dagnosis, the nurse would be careful to assess the client for: |
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Definition
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Term
| Which statement by an older clients about skin integrity would indicate a need for the nurse to investigate further? |
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Definition
| With aging, my skin has become less dry. |
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Term
| A client has an increase in serum bilirubin. To assess for early evidence of jaundice, the nurse would: |
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Definition
| Expose the palms of the clients hands. |
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Term
| A client is admitted to the medical unit with a deep, irregular-shaped are on the sacrum that extends into the subcataneous tissue. The most appropriate nursing diagnosis would be: |
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Definition
| Impaired tissue integrity |
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Term
| During a change of shift report, the nurse is told the client has several keloids on the left upper arm. The client later asks the nurse what can be done to prevent additional keloids from forming after surgery. The nurse informs the client that: |
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Definition
| They are more common in dark-skinned individuals who have a genetic predisposition, therefore they are difficult to prevent. |
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Term
| When assessing the skin of a confused elderly client who has resided at a long-term care facility for six months, the nurse should be especially vigilant about noting: |
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Definition
| changes from normally expected finding. |
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Term
| A client with vitiligo is concerned about preventing the condition from getting worse. The nurse would suggest that the client: |
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Definition
| avoid sun exposure and use liberal amounts of sun screen. |
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Term
| When the nurse in an out-patient setting assesses the skin of an elderly client and notes several ecchymotic areas on one leg, the nurse is aware that these are most likely caused by increased capillary permeability and fragility. The client says that every small bump seems to result in a bruise. The nurse would therefore ask the client about: |
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Definition
| what kinds of things get bumped into that cause the bruises |
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Term
| What is the priority nursing diagnosis for an adult client who is anxious about a pruritic condition and is responding by scratching the affected areas? |
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Definition
| Altered comfort related to pruritus |
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Term
| When assessing the skin of an adult client who was exposed to poison ivy recently, the nurse expects to use: (Select all that apply.) |
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Definition
1. Inspection
2. Palpation |
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Term
| When an elderly client points to several skin tags near the left ear and ask what should be done about them, the nurse responds that: |
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Definition
| this may be a normal finding in the elderly and of no consequence. |
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Term
| The nurse checks the skin turgor of a client in an outpatient setting who is recovering from a gastrointestinal virus resulting in nausea, vomiting, and diarrhea for 48 hours to assess for: |
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Definition
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Term
| After a punch biopsy, the nurse knows the client understands the discharge instructions when the client states: |
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Definition
| “I will return in a week to have stitches removed.” |
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Term
| A client is going to have a biopsy to a lesion on the face. The nurse will explain to the client that a skin biopsy is performed when: |
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Definition
| a definitive diagnosis is needed. |
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Term
| Upon assessment, the nurse finds a skin lesion that looks like a flat or raised macule or papule with a rounded, well defined border. The nurse suspects what type of diagnosis. |
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Definition
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Term
| Which is not an appropriate instruction to teach a client about the care for psoriasis? |
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Definition
| Avoid exposure to the sun. |
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Term
| Which of the following is an infection of the skin most often caused by a group A streptococci? |
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Definition
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Term
| Which behavior demonstrates the clients understanding of the nurses teaching about a vaginal candida albicans infection? |
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Definition
| The client report bathing more regularly |
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Term
| Which form of dematitis is a chrinic inflammatory disorder of the skin that involves the scalp, eyebrows, eyelids, ear canals, nasolabial folds, axillae and trunk? |
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Definition
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Term
| Which is not a risk factor for nonmelanoma skin cancer? |
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Definition
| Protected exposure to UV radiation |
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Term
| At what temperature does skin freeze? |
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Definition
| 14-24.8 degrees farenheit |
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Term
| The client has a port wine stain. What treatment will be used to reduce the lesion? |
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Definition
|
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Term
| Identify the correct statement about skin grafts. |
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Definition
| A full thickness graft is best able to withstand trauma |
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Term
| Which is not a cause of hirsutism? |
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Definition
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Term
| A frail elerly client has been ordered to bedrest after placement of a pacemaker defibrillator. What precautions should the nurse institute to prevent the development of pressure ulcers? |
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Definition
| Develop a written turning schedule. |
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Term
| During a blood pressure screening, the nurse notices that the client is scratching her abdomen. When the nurse asks about the scratching, the client states that she has a red itchy rash under her breast. What is the most appropriate response from the nurse? |
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Definition
| How long ago did the itching start? |
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Term
| While assessing a client the nurse sees that the clients ankles and feet are swollen to the point that her shoes are too tight. However the skin slowly returns to normal when depressed by the nurses thumb. This finding is most accurately documented as: |
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Definition
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Term
| A client has a significantly receding hairline and a dark suntan. The nurse notices that he has a bandage on top of his head. When asked about it he states that it is an odd mole that bleeds sometimes. Which of the following factors would increase the clients risk of skin cancer? |
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Definition
| Construction worker for ten years |
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Term
| A nurse has been asked to speak to a community group about the risk factors associated with skin cancers. Which statement by the nurse would be the most accurate? |
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Definition
| A tendency to sunburn, even with sunscreen, increases your risk. |
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Term
| When assessing a client with dark skin color for jaundice, the best place to look is the: |
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Definition
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Term
| The nurse notices a client scratching her head. The nurse assesses the are and finds pustules and some hair loss. The nurse knows that these symptoms are associated with: |
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Definition
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Term
| When assessing a clients nails, the nurse notices that they are thick and yellow in color. The nurse knows that this is associated with: |
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Definition
1. Fungal infection
2. Psoriasis |
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Term
| A client is scheduled for a Tzaqnct test. Which statement is the most accurate when discussing this test with the client? |
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Definition
| The fluid will be examined under a microscope and will tell us if you have a herpes infection. |
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Term
| When assessing the skin of a client, the nurse notices that it is course. The nurse knows that coarse, dry skin is associated with: |
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Definition
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Term
| A nurse is caring for a weak client with a compromised immune system. The client is unable to independently change positions while in bed. What nursing interventions should the nurse include in the plan of care to prevent skin breakdown? Select all that apply. |
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Definition
1. Turn and re-position every two hours.
2. Support boney prominences with pillows.
3. Elicit nutritional support from the dietician. |
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Term
| A nurse is caring for a client with a pressure ulcer on the right heel near two o’clock. The wound is 4.3 cm in length, 3.2 cm in width, and .5 cm in depth. A moderate amount of yellow exudate is present with foul odor. How should the nurse document the assessment findings? |
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Definition
| Right heel wound: located at two o’clock; measures 4.3cm x 3.2cm x .5cm; foul, moderate, yellow exudate noted. |
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Term
| The nurse is caring for a client who is being treated for herpes zoster. The client is being treated every four hours for pain. The client rates pain as 8/10. The healthcare provider ordered 200 mg of intravenous acyclovir (Zovirax) twice per day. The client remains afebrile. Which nursing diagnosis takes priority for this client? |
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Definition
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Term
| The nurse is caring for a client with vesicles on the left lateral thorax. The client is complaining of severe pain in this area. Based on the assessment, what precautions should the nurse employ? |
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Definition
| Place the client on contact precautions, in a private room. |
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Term
| You are caring for an 80 year-old immobilized client with pneumonia. The client consumes 50% of breakfast, 30% of lunch, and 10 % of supper. As you assess the client’s skin, you observe a reddened area on the client’s sacrum. Which nursing diagnosis should you address first? |
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Definition
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Term
| A client is being treated for a decubitus ulcer on the left hip. Which indication demonstrates the greatest improvement in wound status? |
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Definition
| A decrease in diameter to 2cm x 2cm x 1 cm |
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Term
| The nurse assesses a foul smelling pressure wound on a client’s sacrum which extends into the muscle and contains a large amount of purulent exudates. Thirty percent (30%) of the wound is covered by a black eschar. How should the nurse interpret these findings? |
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Definition
| The wound is unstageable due to the black eschar present. |
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Term
| Which of the following the clients is most likely to develop skin cancer? |
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Definition
| A female client with radiation burns |
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Term
| A nurse is caring for a client with malignant melanoma. The client comments, “I feel helpless, and useless. I’m afraid my life will end.” Based on the client’s comments, which nursing diagnosis should the nurse add to the plan of care? |
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Definition
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Term
| What should the nurse include in the plan designed to teach the client how to prevent skin cancer. Select all that apply. |
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Definition
Minimize exposure to sunlight.
Apply sunscreen with adequate protection factor.
Wear a hat and sunglasses while out in the sun. |
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Term
| What pre-operative teaching should be integrated in the plan for a client who will receive a rhytidectomy to remove facial wrinkles. What pre-operative teaching should be integrated in the teaching plan? Select all that apply. |
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Definition
Desanitizing scalp hair three times the night before surgery
Cleansing facial skin the morning before surgery with antibacterial soap
Avoiding aspirin and any blood thinning agents |
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Term
| A nurse is caring for a client who takes oral minoxidil (Loniten) to treat hypertension. The client is experiencing hirsutism. A nursing diagnosis of Disturbed Body Image r/t excessive facial hair was added to the plan of care. Which statement by the client indicates effective coping? |
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Definition
| “I know a side effect of the medication is excessive body hair.” |
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Term
| A client descrines having the itch scrath itch cycle for two days. The nurse understand that the priority outcome for this complaint is to: |
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Definition
| Identify and eliminate the cylce cause. |
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Term
| The surface of a clients lower arms has the appearance of fish scales. The nurse concludes that this finding is most likely caused by: |
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Definition
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Term
| A client expresses a concern about an irregular shaped enlarging scar on his lower lef sustained in a car accident six months ago. Teaching by the nurse relative to this concern would include: |
|
Definition
As time passes the scar can continue to extend.
This condition is likely to occur with future scars.
Eventually, the scar will become smooth and hyperpigmented. |
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Term
| A client newly diagnosed with psoriasis demonstrates a need for further instruction when the client tells the nurse: |
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Definition
| Several drinks a day, especially before bedtime, will help me to stay calm. |
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Term
| Which outcome would be the most appropriate for a client recoving from a bacterial infection? |
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Definition
| The spread of the infection has been prevented. |
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Term
| What information would the client tell the nurse that would indicate a potential for acquiring a fungal infection during the summer months? |
|
Definition
| She frequently wears plastic flip-flops |
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Term
| Discharge teaching includes how to manage the use of topical corticosteroids. The nurse knows that the instruction have not been understood when the client reports: |
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Definition
| An occlusive dressing should be maintained at all times |
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Term
| A small, non melanoma skin cancer on the cheekbones that extends into the subcutaneous tissue has been diagnosed. The client asks about the major advantage of having a Moh's surgical procedure for the removal. The nest answer by the nurse is that with this procedure: |
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Definition
| The tumor is shaved in layers, allowing concervation of non-cancerous surrounding tissue |
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Term
| A mother asks what information her teenager should know about management of acne. What important strategies should the nurse teach? |
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Definition
| Eat a regular, well balanced diet. |
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Term
| A client with herpes zoster says, I have had chickenpox, why would I get herpes zoster - best response is: |
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Definition
| The caricella virus in your body has reactivated. |
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Term
| The best rationale the nurse can give for taking prescribed herpes zoster medication in a regular schedule is to: |
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Definition
| Promote the control of discomfort. |
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Term
| A client shows the nurse her hands that are erythemic and swollen, and have generalized vesicles. Based on this information, the nurse concludes that the client probably has a: |
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Definition
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Term
| A client diagnosed with malignant melanoma becomes apathetic, refused to make eye contact, is eating very little, and sleeps most of the time. Based on the cues, what is the most appropriate nursing diagnosis for this client? |
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Definition
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Term
| Which of the following would be an important intervention in the plan of care for a client with a stage 3 pressure ulcer? |
|
Definition
| Provide a moist wound environment |
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Term
| A client is admitted to a medical unit with pneumonia. When the nurse helps the client change to a hopsital gown, she notes skin lesion on the clients shoulders, extending down to the trunk and buttocks. Scarring and hyperpigmentation also are present. What would be the most important initial measure for the nurse to take. |
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Definition
| Initiate isolation precautions |
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Term
| Which layer of the skin containes most of the follicles, subaceous glands, and sweat glands. |
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Definition
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|
Term
| What pigment is responsible for skin tanning? |
|
Definition
|
|
Term
| Which of the four assessment techniques are used during assessment of the integumentary system? |
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Definition
|
|
Term
| What change in skin color is associated with an elevated body temperature? |
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Definition
|
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Term
| You are assessing a client who is complaining of sever itching. What would be an appropriate interview question? |
|
Definition
| Have you used a new soap? |
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Term
| You are assessing the skin of an elderly client for dehydration. What finding would indicate this condition? |
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Definition
|
|
Term
| What part of the body would you palpate to assess edema? |
|
Definition
|
|
Term
| You note that your client with chronic dermatitis has rough, thickened ares of skin. You document these areas as: |
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Definition
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|
Term
| While making a home visit to an older woman, you notice multiple bruises on her amrs and body. What might these indicate? |
|
Definition
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|
Term
| While assessing the hair of a family, you note small white eggs on the hair shaft. What type of infestation are you assessing? |
|
Definition
|
|
Term
| Your elderly client has sever xerosis. What topic should be included in your teaching plan? |
|
Definition
| Apply skin lotions after a bath. |
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|
Term
| Which of the following common skin lesions has the potetial of becoming malignant. |
|
Definition
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|
Term
| You have been asked to teach a woman with generalized psoriasis about ultraviolet light therapy (UVB). What should be inclided in teaching? |
|
Definition
| UVB slows the growth of epidermal cells and decreases keratosis. |
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Term
| Which of the following clients is at risk for the development of a candidiasis infection. |
|
Definition
| A young woman who is pregnant. |
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Term
| What question should be included in a health history if a client with a linear pattern of painful vesicles over the left thorax. |
|
Definition
| Did you have chickenpox when you were young? |
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|
Term
| Which of the following statements is true of an infestation with lice. |
|
Definition
|
|
Term
| Which assessments would indicate a greater risk to develop a conmelanoma skin cancer? |
|
Definition
| Blond hair, freckles, and fair skin |
|
|
Term
| Of the following, which is most significant to the development of a malignant melanoma? |
|
Definition
| A change in color or size of nevus |
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Term
| The rational for lifting, rather than pulling a client in the bed is: |
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Definition
| Lifting a client prevents tissue injury from shearing forces. |
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Term
| You are caring for a young adult with acne scars. He asks about treatment to reduce the scarring. Which of the following might you discuss? |
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Definition
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