Adult Health

1. Adult Health Developed by Dare Domico, RN, DSN Revised by Jill Ray

2. Integumentary Disorders

3. Practice Question 1 A client returns the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion? • Melanoma is the most common type of skin cancer. • Melanoma is often precipitated by pruritus. • Melanoma is highly metastatic • Melanoma is characterized by local invasion

4. Practice Question 1 A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which of the following describes a characteristic of this type of a lesion? • Melanoma is the most common type of skin cancer. Basal cell is the most common type. • Melanoma is often precipitated by pruritus. Can be part of the assessment findings for skin cancer. • Melanoma is highly metastatic highly metastatic – survival dependent upon early dx and tx. • Melanoma is characterized by local invasion can metastasize to the brain, lungs, bone, liver, skin….

5. Practice Question 2 Which lesion best represents Basal Cell Cancer? 2. 1. 3. 4.

6. Practice Question 2 Which lesion best represents Basal Cell Cancer? 1. Basal Cell 2. Mole 4. Melanoma 3. Squamous Cell

7. Basal Cell: • Waxy border • Papule • Red, central crater • Metastasis rare • Squamous Cell: • oozing, bleeding, crusting lesion • Potentially metastatic • Larger tumors higher risk metastasis. • Melanoma: • Irregular, circular, bordered lesion • Hues of tan, black, blue • Rapid infiltration into tissue, rapid metastasis.

8. Practice Question 3 • A client has a superficial skin tear to the arm. The nurse applies which best type of dressing? • Dry sterile dressing • Wet-to-dry dressing • Gelfoam sponge dressing • Semipermeable film dressing

9. A client has a superficial skin tear to the arm. The nurse applies which best type of dressing? • Dry sterile dressing stick to the wound • Wet-to-dry dressing not necessary • Gelfoam sponge dressing type of enzyme dressing used to tx necrotic tissue • Semipermeable film dressing Op-site, duoderm. Allow tissues to heal underneath.

10. Practice Question 4 A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst. Which action by the nurse is most appropriate? 1. Give the client small glasses of clear liquids. 2. Keep the client NPO. 3. Allow the client to have full liquids. 4 Order the client a full meal with extra liquids.

11. Practice Question 4 A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst. Which action by the nurse is most appropriate? 1. Give the client small glasses of clear liquids. 2. Keep the client NPO. Maintain NPO because burn injuries freq. cause paralytic ileus. Fluids could cause vomiting because of the effect of the burn injury on GI fx. Oral care to alleviate thirst is OK 3. Allow the client to have full liquids. 4 Order the client a full meal with extra liquids. Note that 1,3, and 4 are similar choices.

12. Practice Question 5 In the burn unit, a client has partial thickness and full thickness burns over 50% of his body. The nurse has an order for silver sulfadiazine (Silvadene cream). The safest and most therapeutic way of applying this mediation is with a sterile: • Tongue blade • 4 by 4 gauze pad • gloved hand • 4 by 4 soaked in sterile saline

13. In the burn unit, a client has partial thickness and full thickness burns over 50% of his body. The nurse has an order for silver sulfadiazine (Silvadene cream). The safest and most therapeutic way of applying this mediation is with a sterile: • Tongue blade rough surface would be abrasive to the injured skin, and it is too small to be practical for use… • 4 by 4 gauze pad the dry gauze pad would stick to the injured skin • gloved hand allows for better contact and control of the amt of pressure being applied to the burn area. Allows the nurse to feel the surface blisters without breaking them. • 4 by 4 soaked in sterile saline OK – but the gloved hand allows for more precise application and minimal injury to the tissue.

14. Practice Question 6 A client is NPO and has a NG tube in place after suffering bilateral burns to the legs. The nurse determines that the client’s GI status is least satisfactory if which of the following is noted on assessment? • Gastric pH of 3 • Presence of hypoactive bowel sounds • GI drainage that is guaiac negative • Absence of abdominal discomfort

15. Practice Question 6 A client is NPO and has a NG tube in place after suffering bilateral burns to the legs. The nurse determines that the client’s GI status is least satisfactory if which of the following is noted on assessment? • Gastric pH of 3 gastric pH should be maintained at 7 or greater using prescribed antacids and histamine h2 receptor-blocking agents. Lowered pH in the absence of fd or tube feedings can lead to erosion of the gastric lining and ulcer development. (Note that normal gastric pH is 1.5-3.5) • Presence of hypoactive bowel sounds expected as client is NPO and has suffered burn injury • GI drainage that is guaiac negative normal finding – means that it is negative for blood • Absence of abdominal discomfort WNL

16. Practice Question 7 A client is admitted to the emergency department following a burn injury in a house fire. The skin on the client’s trunk is tan, dry, and hard. The skin is edematous but is not very painful. The nurse interprets that this client's burn should be classified as • Superficial thickness burn • Superficial partial thickness • Deep partial thickness • Full thickness

17. Practice Question 7 A client is admitted to the emergency department following a burn injury in a house fire. The skin on the client’s trunk is tan, dry, and hard. The skin is edematous but is not very painful. The nurse interprets that this client's burn should be classified as • Superficial thickness burn these burns are painful • Superficial partial thickness these burns are painful • Deep partial thickness wound surface red, dry, with white areas in deeper areas. • Full thickness involve epidermis, dermis, and some subcutaneous fat. Some nerve endings damaged – may be insensitive to touch with little or no pain.

19. Superficial Thickness burn • Injury to the upper third of the dermis – bld supply to dermis is intact. • Mild to severe erythema (pin to red) • Skin blanches with pressure • Burn painful, tingling, eased by cooling • Discomfort lasts about 48 hrs – heals in 3-5 days • No scarring and skin grafts not required.

20. Superficial Partial-thickness Burn • Injury deeper into dermis, bld supply reduced • Large blisters may cover an extensive area • Edema present • Mottled pin to red base, broken epidermis, with wet, shiny, weeping surface • Burn painful, sensitive to cold air • Heals 0-21 days with no scarring, minor pigment changes possible • Grafts may be needed

21. Deep Partial-thickness Burn

22. Deep Partial-thickness Burn • Extends into dermis • Blister formation usu not seen because dead tissue is thick and sticks to underlying viable dermis • Wound surface is red and dry with white areas in deeper parts • May/may not blanch, edema is moderate • Con convert to full thickness if complications • Heals in 3-6 weeks, scar results, skin graft may be necessary

23. Full-thickness Burn • Involves injury and destruction of the epidermis ad the dermis; wound will not heal by re-epithelializaion, grafting may be required • Appears as a dry, hard, leathery eshcar (burn crust or dead tissue that must slough off or be removed form the wound before healing can occur • Appears as a waxy white, deep • red, yellow, brown, black • Injured are appears dry • Edema present under eschar • Sensation reduced or absent because of nerve ending damage • Healing takes weeks to months and dependent on adequ bld supply • Must remove eschar and split-or full-thickness skin grafting • Scarring and wound contractures likely

24. Deep full-thickness • Extends beyond the skin into underlying fascia and tissues, damage to the muscle, bone, tendons • Injured area appears black and sensation is completely absent • Eschar is hard and • inelastic • Healing takes months • and grafts are required • Mortality rates are higher for children younger than 4 • Debilitating disorders (cardiac, respiratory, endocrine, renal disorders occur and hinder healing) • Mortality rate is higher with preexisting disorder.

25. Practice Question 8 A nurse is monitoring the fluid balance of the client with a burn injury. The nurse determines that the client is less than adequately hydrated if which of the following is noted during assessment.? 1. Urine output of 40 ml/hour. 2. Urine that is pale yellow. 3. Urine specific gravity of 1.032 4. Urine pH of 6.

26. A nurse is monitoring the fluid balance of the client with a burn injury. The nurse determines that the client is less than adequately hydrated if which of the following is noted during assessment.? 1. Urine output of 40 ml/hour. 30ml/hr is WNL, 40 is OK 2. Urine that is pale yellow. Pale urine is normal – would be dark and concentrated if not well hydrated 3. Urine specific gravity of 1.032 (1.016-1.022) 4. Urine pH of 6. OK – urine pH of 6 is adequate (4.5-8 WNL). Do not monitor urine pH to assess hydration.

27. Practice Question 9 A home care nurse visits an older client who was discharged from the hospital following diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which of the following measures would the nurse provide to the client to alleviate this discomfort? • Take baths twice daily using a dilute solution of vinegar and water. • Avoid the use of astringents on the skin • Avoid the use of emollients on the skin • Purchase a dehumidifier for the home.

28. A home care nurse visits an older client who was discharged from the hospital following diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which of the following measures would the nurse provide to the client to alleviate this discomfort? • Take baths twice daily using a dilute solution of vinegar and water. Warm bath or shower per day for 15-20 min with warm water and a mild soap followed immediately by the application of an emollient to prevent evaporation of water form the hydrated epidermis. • Avoid the use of astringents on the skinavoid alcohol, astringents, or other drying agents to the skin. tend to have a drying affect on the skin • Avoid the use of emollients on the skin need to incr use of emollients • Purchase a dehumidifier for the home. A dehumidifier would further dry room air.

29. Practice Question 10 The evening nurse reviews the nursing documentation in the client’s chart and notes that the day nurse has documented that he client has a stage 2 pressure ulcer (decubitus) in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area? • Intact skin • Partial-thickness skin loss of the epidermis • Deep, crater-like appearance • Presence of sinus tracts

30. Practice Question 10 The evening nurse reviews the nursing documentation in the client’s chart and notes that the day nurse has documented that he client has a stage 2 pressure ulcer (decubitus) in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area? • Intact skin • Partial-thickness skin loss of the epidermis • Deep, crater-like appearance • Presence of sinus tracts

31. Classification of Pressure Ulcers

32. Stage I (no skin loss) Stage II (Shallow crater – involves epidermis and/or dermis)

33. Stage III (Full thickness involving damage/necrosis of subc. Tissue. Does not extend down through underlying fascia) Stage III or IV

34. Stage IV Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.

35. Oncology

36. Practice Question 11 The nurse recognizes which of the following conditions as an oncological emergency? Select all that apply. 1. Cardiac tamponade 2. Leukopenia 3. Syndrome of inappropriate ADH 4. Hypercalcemia 5. Hypophosphatemia 6. Tumor lysis syndrome

37. The nurse recognizes which of the following conditions as an oncological emergency? Select all that apply. 1. Cardiac tamponadecould result from direct pressure from a tumor, complication from chemo (decrease platelets increase chances of hemorrhage) 2. Leukopenia 3. Syndrome of inappropriate ADHtumors can produce, secrete, or stimulate substances that mimic ADH hormone – low serum Na levels result and can lead to seizures, coma, death 4. Hypercalcemialate manifestation of extensive malignancy 5. Hypophosphatemia 6. Tumor lysis syndromelarge quantities of tumor cells are destroyed rapidly. Can lead to renal failure.

38. Practice Question 12 The nurse is giving discharge instructions to a client with cancer who is taking doxorubicin (Adriamycin). What is important to tell the client. 1. Avoid folic acid intake. 2. Increase intake of oral fluids. 3. Report symptoms of dyspnea. 4. Report symptoms of hematuria.

39. Practice Question 12 The nurse is giving discharge instructions to a client with cancer who is taking doxorubicin (Adriamycin). What is important to tell the client? 1. Avoid folic acid intake. 2. Increase intake of oral fluids. 3. Report symptoms of dyspnea. This medication can cause cardio toxicity, cardiomyopathy, EKG changes. CHF (dyspnea, tachycardia, peripheral edema) and myocardial toxicity are potential adverse reactions. 4. Report symptoms of hematuria.

40. Practice Question 13 A client had a modified radical mastectomy of the left breast. What would be important for the nurse to include in a discharge teaching plan? (Select all that apply) 1. Avoid any needle sticks in the left arm. 2. Avoid abduction & external rotation of left arm. 3. Begin pendulum arm swings & full ROM immediately. 4. Elevate left arm on pillows to prevent edema. 5. Have all blood pressure readings taken on the right arm. 6. Massage wound site with essential oils once incision has healed.

41. A client had a modified radical mastectomy of the left breast. What would be important for the nurse to include in a discharge teaching plan? (Select all that apply) 1. Avoid any needle sticks in the left arm. 2. Avoid abduction & external rotation of left arm. Gradual abduction and external rotation of the affected arm is encouraged. May be more comfortable elevating the arm. 3. Begin pendulum arm swings & full ROM immediately. These activities are started after the incision has healed. 4. Elevate left arm on pillows to prevent edema. 5. Have all blood pressure readings taken on the right arm. 6. Massage wound site with essential oils once incision has healed. No indication for this

42. Postoperative Mastectomy • Gradual abduction and external rotation of the affected arm is encouraged. • Avoid activities that might lead to the development of lymphedema • Begin finger, wrist, and hand exercises to facilitate muscle contraction and to help prevent edema. • Active exercises, such as pendulum swings and wall climbing are started after the incision has healed

43. Practice Question 14 A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis? 1. Use lemon-flavored glycerin swabs 2. Apply antacid coating solutions and viscous lidocaine 3. Brush oral plaques off with a soft toothbrush. 4. Have client swish mouth with weak hydrogen peroxide solution

44. Practice Question 14 A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis? 1. Use lemon-flavored glycerin swabs could cause pain 2. Apply antacid coating solutions and viscous lidocaine Antacids, Benadryl, and viscous lidocaine have been mixed in equal proportions to use as a component of oral care. 3. Brush oral plaques off with a soft toothbrush. could cause pain 4. Have client swish mouth with weak hydrogen peroxidesolution

45. Practice Question 15 A client with breast cancer is being treated with external radiation therapy. What will be important for the nurse to teach the client regarding skin care of the area? 1. Use mild soap and do not rub with abrasive materials. 2. Do not use any lotions on the area being treated. 3. Expose the area to sunshine to maximize healing. 4. Wear clothing and bras that support the area.

46. A client with breast cancer is being treated with external radiation therapy. What will be important for the nurse to teach the client regarding skin care of the area? 1. Use mild soap and do not rub with abrasive materials. Skin being tx is fragile and easily damaged. Mild soap and thorough rinsing with warm water. 2. Do not use any lotions on the area being treated. A hydrophilic moisture lotion can be used if the skin becomes dry. 3. Expose the area to sunshine to maximize healing. The area cannot be exposed to sun 4. Wear clothing and bras that support the area. Clothing should be loose and nonbinding.

47. Practice Question 16 Which of the following is a priority nursing intervention for a client with a vaginal radium implant? 1. Clamp and drain the Foley catheter at intervals. 2. Provide a high residue diet. 3. Place the client in a semiprivate room. 4. Raise the head of the bed no more than 20 degrees.

48. Which of the following is a priority nursing intervention for a client with a vaginal radium implant? 1. Clamp and drain the Foley catheter at intervals. 2. Provide a high residue diet. Good idea – maintain optimal GI fx. Note that “4” is the BEST choice but that this is appro. 3. Place the client in a semiprivate room. No -Private room, private bath 4. Raise the head of the bed no more than 20 degrees. Once the implant is in place, important to keep in the exact location. HOB only raised slightly if at all after placement.

49. Practice Question 17 The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to • Call the MD • Pick up the implant with gloved hands and flush it down the toilet • Reinsert the implant into the vagina immediately • Pick up the implant with long handled forceps and place it in a lead container

50. Practice Question 17 The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to • Call the MD yes, but initial action is “4” • Pick up the implant with gloved hands and flush it down the toilet do not touch the implant • Reinsert the implant into the vagina immediately inappro action. • Pick up the implant with long handled forceps and place it in a lead container Key word is “initial” action.