Chapter 13: Intergumentary Function-For which patient would the nurse prioritize care?

CHAPTER 13: INTEGUMENTARY FUNCTION
1. For which patient would the nurse prioritize care?
A) Patient with scabies
B) Patient with folliculitis
C) Patient with furuncles
D) Patient with hemangiomas
ANSWER:
EXPLANATION why each one are wrong or right:
2. Which question is most important for the nurse to ask the family members of the patient with herpes zoster?
A) “Have you ever had measles?”
B) “Have you ever had mumps?”
C) “Have you ever had chickenpox?”
D) “Were you vaccinated against polio?”
ANSWER:
EXPLANATION why each one are wrong or right:
3. An older patient expresses concern that he is developing age spots. Which instruction is most important for the
nurse to provide to the patient?
A) “Limit the time you spend in the sun.”
B) “Monitor for signs of infection.”
C) “Monitor spots for color change.”
D) “Use skin creams to prevent drying.”
ANSWER:
EXPLANATION why each one are wrong or right:
4. Which statement by a patient with psoriasis indicates a need for further teaching?
A) “At the next family reunion, I’m going to ask if any of my relatives have psoriasis.”
B) “I have to make sure I have this covered so I do not spread it to others.”
C) “I expect that these patches will get smaller when I lie out in the sun.”
D) “I should continue to use the cortisone ointment as the patches shrink and dry out.”
ANSWER:
EXPLANATION why each one are wrong or right:
5. Which statement made by the patient indicates correct knowledge about the causes and treatments of common
warts?
A) “Washing my hands more frequently will prevent the warts from coming back.”
B) “I will have to be careful because warts increase the risk for skin cancer.”
C) “Surgical removal of the warts is the best treatment.”
D) “Because warts are caused by a virus, they can occur anywhere on my body.”

ANSWER:
EXPLANATION why each one are wrong or right:
6. A young male patient presents to the emergency department with suspected necrotizing fasciitis of the right
arm. The nurse reading the culture report would expect which of the following organisms to be present?
A) Group A beta-hemolytic Streptococcus
B) Staphylococcus aureus
C) Herpes simplex virus type 1
D) Escherichia coli
ANSWER:
EXPLANATION why each one are wrong or right:

7. A patient has numerous skin lesions. Which one will the nurse evaluate first?
A) Raised tubular white snakelike areas on the inner aspects of the wrists
B) Irregular blue mole with white specks on the lower leg
C) Beige freckles on the backs of both hands
D) Large cluster of pustules in the right axilla
ANSWER:
EXPLANATION why each one are wrong or right:
8. What is a raised thin-walled lesion containing clear fluid called?
A) Papule
B) Pustule
C) Vesicle
D) Vacule
ANSWER:
EXPLANATION why each one are wrong or right:
9. A nursing instructor has just completed a lecture to nursing students regarding care of the patient with a burn
injury, and a major aspect of the lecture was care of the patient at the scene of a fire. Which statement indicates a
need for further instruction?
A) “Flames should be doused with water.”
B) “Flames may be extinguished by rolling the patient on the ground.”
C) “Flames may be smothered by the use of a blanket or another cover.”
D) “The patient should be maintained in a standing position because the flames may spread to the other parts of
the body.”
ANSWER:
EXPLANATION why each one are wrong or right:
10. In preparation for a patient being admitted with herpes zoster, what will the nurse do? (Select all that apply.)
A) Prepare a room for reverse isolation.
B) Inventory the staff for a history of or vaccination for varicella.
C) Check the admission orders for analgesia.
D) Choose a roommate who also is immunosuppressed.
E) Ensure that there are gloves in the room.

ANSWER:
EXPLANATION why each one are wrong or right:

CHAPTER 14: SENSORY FUNCTION
1. The nurse assesses several patients. Which one is most likely to have open-angle glaucoma?
A) A patient with sudden-onset eye pain
B) A patient who has recently had eye surgery
C) A patient who sees halos around lights
D) A patient with reactive pupils and clear sclera
ANSWER:
EXPLANATION why each one are wrong or right:
2. You are the RN triaging phone calls in a busy ophthalmology clinic. Which of these patient phone calls should
you take first?
A) The 25-year-old patient complaining of scleral pruritus and redness
B) The 32-year-old patient who says, “My eyes feel dry all the time”
C) The 49-year-old patient with blunt trauma to the left eye
D) The 67-year-old patient with a pustule at the right canthus
ANSWER:
EXPLANATION why each one are wrong or right:
3. The nurse has interviewed these patients in the emergency department triage area. Which one warrants
immediate medical evaluation?
A) The 18-year-old with periorbital ecchymosis acquired during an altercation
B) The 24-year-old who has a foreign body sensation in the right eye after gardening
C) The 30-year-old with nausea after a scleral buckling procedure yesterday
D) The 35-year-old who has sudden-onset eye pain and decreased vision
ANSWER:
EXPLANATION why each one are wrong or right:
4. What causes a gradual clouding of the lens of the eye?
A) Cataracts
B) Keratitis
C) Glaucoma
D) Macular degeneration
ANSWER:
EXPLANATION why each one are wrong or right:
5. The nurse is admitting a patient in the emergency room with a foreign body in the ear identified as an insect.
Which of the following interventions is a priority for the nurse to perform?
A) Place a cotton plug in the affected ear.
B) Instill diluted alcohol or mineral oil in the affected ear.
C) Instill a cortisone ointment into the affected ear.
D) Instill an antibiotic ointment into the affected ear.

ANSWER:
EXPLANATION why each one are wrong or right:
6. A patient has disabling attacks of vertigo. The nurse suspects that the patient has Meniere’s disease. The
nurse is aware that the diet of the patient must be modified. Which of the following is the best diet for the patient?
A) High protein
B) Low carbohydrate
C) Low sodium
D) Low fat
ANSWER:
EXPLANATION why each one are wrong or right:
7. Closed-angle glaucoma is caused by:
A) abnormal drainage of the aqueous humor through the trabecular meshwork that controls the flow of aqueous
humor into the canal of Schlemm.
B) narrow anterior chamber angle that interferes with outflow of aqueous humor from the anterior chamber.
C) increased production of aqueous humor.
D) decreased production of aqueous humor.
ANSWER:
EXPLANATION why each one are wrong or right:
8. Which is the priority nursing diagnosis for a patient who has a severe visual impairment?
A) Risk for injury
B) Chronic confusion
C) Risk for loneliness
D) Disturbed body image
ANSWER:
EXPLANATION why each one are wrong or right:
9. Which statement indicates that the patient needs additional teaching about ear hygiene?
A) “I will wash my hands before I put in my earplugs at work.”
B) “I will clean my ears with plain warm water and a washcloth every day.”
C) “I will use a cotton swab to get the extra water out of my ears after I swim.”
D) “I can rinse my ears with lukewarm sterile water if ear wax builds up.”
ANSWER:
EXPLANATION why each one are wrong or right:
10. In planning care for a patient with a detached retina, which of the following nursing diagnoses should receive
priority?
A) Alteration in comfort
B) Alteration in mobility
C) Alteration in skin integrity
D) Alteration in tissue perfusion