<P> client presents with silvery plaques on both elbows that are not itchy, but

<Q>A
<TYPE>single</TYPE>
bleed when the scales are removed. The nurse concludes that the client most lik
ely has whichivy</MC4>
<MC2>Contact
<MC1>Eczema</MC1>
<MC4>Poison
<MC3>Psoriasis</MC3>
<F>Rationale:
<CORRECT>3</CORRECT>
dermatitis</MC2>
of the following
Psoriasis is characterized
conditions?</Q>by the presence of silvery plaques, par
ticularly on the extensor prominences, that bleed when scales are removed (optio
n 3). Eczema is also scaly but can be found throughout the body (option 1). Cont
act dermatitis
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Factual
Process:
Physiological
Adult
andApplication
information
poison
Nursingivy
Health: Integrity:
Process:
Integumentary
erupt
is needed
into
Assessment
Physiological
tovesicles
answer this
(options
Adaptation
question.
2 and Based
4). on the de
scription of the skin changes, eliminate all distracters that do not fit that de
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
scription.
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 443-444.</F>
presents to the primary care clinic reporting frequent scratching an
d itching of the skin that is worse at night. The nurse should gather additional
<MC4>Drug
<MC3>Fleas</MC3>
<MC2>Hives</MC2>
<MC1>Scabies</MC1>
<F>Rationale:
<CORRECT>1</CORRECT>
data thatreaction</MC4>
would
Evenbethough
consistent
all these
with problems
which of may the cause
following
itching,
skin adisorders?</Q>
classical symp
tom of scabies is pruritus with worsening at night (option 1). The mites tend to
have increased movement at night, which accounts for the worsening symptoms at
that time.
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
The
ThePhysiological
Process:
Adult
symptoms
other
Application
Nursing
Health:
distracters
presented
Integrity:
Process:
Integumentary
appear
in this
Assessment
Physiological
atitem
alloccur
times,primarily
Adaptation
not justatatnight.
night.Delete a
ny distracters
Reference: LeMone,
thatP., present
& Burke,otherK.times
(2008). during
<i>Medical-surgical
the day. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 451.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse determines that which of the following reported by a client with ac
ne would not contribute
<MC2>Oil-based
<MC1>Stress</MC1>
<F>Rationale:
<CORRECT>3</CORRECT>
<MC4>Moisturizers</MC4>
<MC3>Diet</MC3> Dietary
cosmetics</MC2>
restrictions
to the severitywere once
of thebelieved
acne?</Q>to be necessary to decreas
e acne, but this has not been clinically relevant or supported in research (opti
on 3). Stress (option 1) and the use of moisturizers (option 4) and oil-based co
smeticsNeed:
Cognitive
Client
Integrated
Content
Strategy:(option
Area:
Level:
Recall
Process:
Health
Adult
2)that
Application
doHealth:
Promotion
Nursing
seem is
acne toIntegumentary
Process:
affect
and
related
Maintenance
the
Analysis
to clogged
severitypores
of theanddisorder.
stress. Select the di
stracter that
Reference: LeMone,
does P.,not &reflect
Burke,these
K. (2008).
causes.<i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>multi</TYPE>
<P>
</P> 458-459.</F>
is caring for a client with a Stage 4 pressure ulcer. During the dr
essing change the nurse notes which of the following characteristics? Select all
<MC2>Subcutaneous
<MC1>Erythema</MC1>
<F>Rationale:
<CORRECT>[3,4]</CORRECT>
<MC5>Dermis</MC5>
<MC4>Muscle</MC4>
<MC3>Bone</MC3>
that apply.</Q> Skintissue</MC2>
breakdown occurs when the skin is compressed against a bony s
urface and blood flow to the area is restricted. In Stage 1 the skin is intact b
ut reddened without blanching. In Stage 2, skin is lost from the dermis or epide
rmis. An abrasion, blister, or shallow crater may be present. There is a full th
ickness skin loss in Stage 3, but it does not extend through the fascia. There i
s either a deep crater or eschar forms over the area of breakdown. Breakdown may
extend under the skin and beyond the margins of the wound. In Stage 4, there is
extensive breakdown that extends into the muscle and bone. There are usually ar
eas of breakdown that extend under the skin and beyond the margins of the wound.
Cognitive
Client
Integrated
Content
Strategy:
Necrosis
Need:
Area:
isProcess:
Level:
Describe
often
Physiological
AdultApplication
present.
the
Nursing
Health:
fourIntegrity:
Process:orAssessment
Integumentary
stages PhysiologicalforAdaptation
development a pressure ulcer. Select t
he distracters
Reference: LeMone,
thatP., reflect
& Burke,thisK.description.
(2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 452.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is caring for a client admitted to the emergency department followi
ng a fire. The client has a blood pressure of 96/62 and has partial thickness bu
rns on thethe
<MC1>Hang
<MC2>Cleanse
<MC3>Call
<MC4>Observe
<F>Rationale:
<CORRECT>3</CORRECT>
achest
saline
the
physician
Clients
andinfusion
skin
clientneck.
with
andburns
for The
sterile
widenurse's
prepare
evidence
open
around
saline
tooftointubate
immediate
distress.</MC4>
the
keep
toface
prevent
thethe
response
are
BPclient.</MC3>
normal.</MC1>
infection.</MC2>
at increased
is to:</Q>
risk of an inh
alation injury. The edema that results can be sudden and occlude the airway almo
st immediately. Most burn centers intubate immediately when the risk of inhalati
on injury is present (option 3). The skin should be cleaned to prevent infection
but this clearly is not the priority (option 2). The client has a normal blood
pressure at present. The massive fluid shifts will happen imminently, but the ai
rway comes first (option 1). Observation is not indicated with this type of inju
ry (option
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
Apply
4).Physiological
Process:
Adult
the
Analysis
Nursing
Health:
ABCs (airway,
Integrity:
Process:
Integumentary
breathing,
Planning
Physiological
and circulation)
Adaptationof emergency manag
ement of clients. Always protect the airway first before attending to other aspe
cts of care.LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
Reference:
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 491-494.</F>
is caring for a client with full thickness burns on 50% of his body
. The spouse asks "Why does he look so different? He's all puffy." What is the b
est response
<MC1>"We are giving
by the him nurse?</Q>
a great deal of intravenous solution and that is causing
<MC2>"It
<MC3>"The
the edema."</MC1>
isburn
normal
causes at his
thisfluids
stage toof shift
a burninto injury."</MC2>
his tissues and that is causing t
he puffiness."</MC3>
<MC4>"When
<F>Rationale:
<CORRECT>3</CORRECT>
he After
receives a burn,
his diuretic,
the bloodmost vessels
of the
dilate
puffiness
and fluid
willleaks
go away."</MC4>
into the in
terstitial spaces (option 3). This is known as third spacing. The fluid shifts a
re treated with massive amounts of intravenous fluids to maintain the circulatin
g blood volume, but this is not the initial cause of the edema (option 1). It is
a normal stage in a burn injury, but the spouse is asking for an explanation (o
ption 2). It is a dismissive response. Conserving fluids is more important than
diuresing
Cognitive
Client
Integrated
Content
Strategy:Need:
Area:
(option
Level:
Select
Process:
Physiological
Adult
Analysis
the
4).Health:
Nursing
distracter
Integrity:
Process:
Integumentary
that best
Analysis
Physiological
reflects theAdaptation
pathophysiology of burns
and fluid shifts.
Reference: LeMone,The P.,best
& Burke,
distracter
K. (2008).
directly
<i>Medical-surgical
answers the spouse's
nursing:
question.
Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 494-495.</F>
explains to the family that a family member needs to have an eschar
otomy. The nurse includes which of the following statements in the explanation?<
<MC1>It is only
/Q>
<MC2>It
<MC3>It
<MC4>It
<F>Rationale:
<CORRECT>1</CORRECT>
exactly
doneThedone
toeschar
prevent
the
promote
onsame
extremities</MC4>
thatischemia
drainage
asforms
a fasciotomy</MC2>
andthe
of
on edema
necrosis</MC1>
surface
fluid</MC3>
of a burn injury is hard and
can prevent expansion of soft tissue with edema. As the edema accumulates, it co
mpresses inward and puts the area at risk for loss of innervation and circulatio
n (option 1). It is done on extremities and the thorax (option 4). The incision
extends into the subcutaneous tissue as opposed to a fasciotomy, which extends i
nto theNeed:
Cognitive
Client
Integrated
Content
Strategy: fascia
Area:
Level:
Defining
Process:
Physiological
Adult
(option
Application
eschar
Nursing
Health:
2),isIntegrity:
and
Process:
Integumentary
theenables
firstImplementation
Reduction
the tissue
step in selecting
oftoRisk
expand
Potential
the(option
correct3).
response. T
he correct distracter answers the question of why it is done, not how it is done
.Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 502.</F>
<Q>When
<TYPE>single</TYPE>
<P>
</P> caring for a client with a burn in the emergent stage, which of the foll
owing has lowest
<MC1>Where
<MC2>Cause
<MC3>First-aid
<F>Rationale:
<CORRECT>4</CORRECT>
<MC4>Gender</MC4>
it In
of occurred</MC1>
the
treatment
priority
the
burn</MC2>
emergent
given</MC3>
as part
stage,
of the
an accurate
nurse assesses
burn assessment?</Q>
the cause and extent of
the burn and determines first aid measures that were used (options 1, 2, and 3).
Cognitive
Client
Integrated
Content
Strategy:
GenderNeed:
isImmediate
Area:
Level:
notPhysiological
Process:
Adult
a Analysis
factor
Nursing
Health:
treatment
in Integrity:
burn
Process:
Integumentary
ofassessment
a burn
Analysis
Physiological
depends
(option
on the
4).
Adaptation
location and extent of th
e burn. Apply the ABCs (airway, breathing, circulation) to determine the priorit
y ranking. LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
Reference:
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 497-498.</F>
is gathering intake information from a client in the outpatient cli
nic who reports discomfort in the vaginal area. Upon questioning, the nurse dete
rmines that the client has never been sexually active. The nurse determines that
<MC1>Herpes
<MC2>Herpes
<MC4>Herpes
<MC3>Candidiasis</MC3>
<F>Rationale:
<CORRECT>3</CORRECT>
the client zoster</MC4>
isCandidiasis
virus
mosttype
likely
1</MC1>
2</MC2>
istoabeyeast
infected
infection
with that
whichcan
of occur
the following?</Q>
whenever there is
a disruption in the balance of normal flora. An example of a causative factor wo
uld be antibiotic therapy. Further questioning by the nurse would likely elicit
this data. Herpes virus type 1 typically occurs on the lips or oral mucosa (opti
on 1). Herpes virus type 2 is a sexually transmitted disease (option 2). Herpes
zoster usually occurs on the trunk along discrete dermatomes and commonly occurs
Cognitive
Client
Integrated
Content
Strategy:
in immunosuppressed
Need:
Area:
Level:
Eliminate
Process:
Physiological
Adult
Application
Nursing
Health:
all
individuals
distracters
Integrity:
Process:
Integumentary
(option
that
Analysis
Physiological
4). sexuallyAdaptation
are transmitted or do not caus
e symptoms LeMone,
Reference: in the genital
P., & Burke,
area. K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 449-450.</F>
in the community conducting health promotion about maintaining heal
thy skin teaches clients that the epidermis has which of the following functions
<MC1>To protect
?</Q>
<MC2>To
<MC3>To
<MC4>To
<F>Rationale:
<CORRECT>4</CORRECT>
regulate
produce Thethe
foreign
androgens
body
epidermis
tissues
heat
objects
and
byprotects
from
excretion
regulate
from
physical
penetrating
thetemperature</MC3>
oftissues
damage
perspiration</MC2>
mucous
and
from prevent
damage
membranes</MC1>
waterprevents
and loss</MC4>
fluid
loss of the body (option 4). The dermis (the next underlying layer of skin) regu
lates body temperature (options 2 and 3). Option 1 is a false statement because
the focus
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
ofProcess:
Level:
Firstthe
Health
Adult
eliminate
discussion
Application
Promotion
Nursing
Health: anyIntegumentary
isdistracters
Process:
and
theMaintenance
epidermis,
Implementation
thatnot
aremucous
unrelated
membranes.
to the skin (option
1). Then discriminate among the other options by considering the functions of t
he various LeMone,
Reference: layers ofP.,skin.
& Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp. 443-444.</F>
</P>