SAUNDERS HESI MED SURG Questions
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A+GRADED
The nurse is conducting a session about the principles of first aid and is discussing the
interventions for snakebite to an extremity. The nurse should inform those attending the
session that the first priority intervention in the event of this occurrence is which action?
1. Immobilize the affected extremity.
2. Remove jewelry and constricting clothing from the victim.
3. Place the extremity in a position so that it is below the level of the heart.
4. Move the victim to a safe area away from the snake and encourage the victim to rest.
- correct answer...✔✔4
In the event of a snakebite, the first priority is to move the victim to a safe area away
from the snake and encourage the victim to rest to decrease venom circulation. Next,
jewelry and constricting clothing are removed before swelling occurs. Immobilizing the
extremity and maintaining the extremity at the heart level would be done next; these
actions limit the spread of the venom. The victim is kept warm and calm. Stimulants
such as alcohol or caffeinated beverages are not given to the victim because these
products may speed the absorption of the venom. The victim should be transported to
an emergency facility as soon as possible.
A client calls the emergency department and tells the nurse that he came directly into
contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on
the skin and asks the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rinsing several times."
4. "It is not necessary to do anything if you cannot see anything on your skin." - correct
answer...✔✔3
When an individual comes in contact with a poison
ivy plant, the sap from the plant forms an invisible film on the human skin. The client
should be instructed to cleanse the area by showering immediately and to lather the
skin several times and rinse each time in running water. Removing the poison ivy sap
will decrease the likelihood of irritation. Calamine lotion
may be one product recommended for use if dermatitis
develops. The client does not need to be seen in the emergency department at this
time.
AGRADESOLUTIONS
,A client is being admitted to the hospital for treatment of acute cellulitis of the lower left
leg. During the admission assessment, the nurse expects to note which finding?
1. An inflammation of the epidermis only
2. A skin infection of the dermis and underlying hypodermis
3. An acute superficial infection of the dermis and lymphatics
4. An epidermal and lymphatic infection caused by Staphylococcus - correct answer...✔
✔2
Cellulitis is an infection of the dermis and underlying hypodermis that results in deep red
erythema without
sharp borders and spreads widely throughout tissue spaces. The skin is erythematous,
edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly
spreading inflammation of the dermis and lymphatics. The infection is not superficial
and extends deeper than the epidermis.
The clinic nurse assesses the skin of a client with psoriasis after the client has used a
new topical treatment for 2 months. The nurse identifies which characteristics as
improvement in the manifestations of psoriasis? (SELECT ALL THAT APPLY)
1. Presence of striae
2. Palpable radial pulses
3. Absence of any ecchymosis on the extremities
4. Thinner and decrease in the number of reddish papules
5. Scarce amount of silvery-white scaly patches on the arms - correct answer...✔✔4, 5
Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-
white patches. A decrease in the severity of these skin lesions is noted as an
improvement. The presence of striae (stretch marks), palpable pulses, or lack of
ecchymosis is not related to psoriasis.
The clinic nurse notes that the health care provider has documented a diagnosis of
herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of
this disorder, the nurse determines that this definitive diagnosis was made by which
diagnostic test?
1. Positive patch test
2. Positive culture results
3. Abnormal biopsy results
4. Wood's light examination indicative of infection - correct answer...✔✔2
With the classic presentation of herpes zoster, the
clinical examination is diagnostic. However, viral culture of the lesion provides a
definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-
zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves
the administration of an allergen to the surface of the skin to identify specific allergies. A
AGRADESOLUTIONS
,biopsy would provide a cytological examination of tissue. In a Wood's light examination,
the skin is viewed under ultraviolet light to identify superficial infections of the skin.
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 melanoma has which characteristics? (SELECT
ALL THAT APPLY.)
1. Lesion is painful to touch.
2. Lesion is highly metastatic.
3. Lesion is a nevus that has changes in color.
4. Skin under the lesion is reddened and warm to touch.
5. Lesion occurs in body area exposed to outdoor sunlight. - correct answer...✔✔2, 3
Melanomas are pigmented malignant lesions originating in the melanin-producing cells
of the epidermis. Melanomas cause changes in a nevus (mole), including color and
borders. This skin cancer is highly metastatic, and a person's survival depends on early
diagnosis and treatment. Melanomas are not painful or accompanied by sign of
inflammation. Although sun exposure increases the risk of melanoma, lesions are most
commonly found on the upper back and legs and on
the soles and palms of persons with dark skin.
When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely
expects to note which findings? (SELECT ALL THAT APPLY.)
1. An irregularly shaped lesion
2. A small papule with a dry, rough scale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a central crater and a waxy border
5. Location in the bald spot atop the head that is exposed to outdoor sunlight - correct
answer...✔✔4, 5
Basal cell carcinoma appears as a pearly papule with
a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk
factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-,
white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small
macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell
carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.
A client arriving at the emergency department has experienced frostbite to the right
hand. Which finding would the nurse note on assessment of the client's hand?
1. A pink, edematous hand
2. Fiery red skin with edema in the nail beds
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch - correct answer...✔✔4
AGRADESOLUTIONS
, Assessment findings in frostbite include a white or
blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs,
flushing of the skin, the development of blisters or blebs, or tissue edema appears.
Options 1, 2, and 3 are incorrect.
The evening nurse reviews the nursing documentation in a client's chart and notes that
the day nurse has documented that the client has a stage II pressure ulcer in the sacral
area. Which finding would the nurse expect to note on assessment of the client's sacral
area?
1. Intact skin
2. Full-thickness skin loss
3. Exposed bone, tendon, or muscle
4. Partial-thickness skin loss of the dermis - correct answer...✔✔4
In a stage II pressure ulcer, the skin is not intact.
Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open
ulcer with a red-pink wound bed, without slough. It may also present as an intact or
open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss
occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV
An adult client was burned in an explosion. The burn initially affected the client's entire
face (anterior half of the head) and the upper half of the anterior torso, and there were
circumferential burns to
the lower half of both arms. The client's clothes caught on fire, and the client ran,
causing subsequent burn injuries to the posterior surface of the head and the upper half
of the posterior torso.
Using the rule of nines, what would be the extent of the burn injury?
1. 18%
2. 24%
3. 36%
4. 48% - correct answer...✔✔3
According to the rule of nines, with the initial burn,
the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%,
and the lower half of both arms equals 9%. The subsequent burn included the posterior
half of the head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This
totals 36%.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure
being performed for a third-degree circumferential arm burn. The nurse understands
that which finding
is the anticipated therapeutic outcome of the
escharotomy?
AGRADESOLUTIONS
