Medsurg 2 Final Exam questions and COMPLETE answers

Medsurg 2 Final Exam The client reports that a previously sensitive area of skin no longer responds to temperature changes or painful stimuli. This finding indicates a functional abnormality for which skin layer? A. Stratum corneum B. Adipose layer C. Epidermis D. Dermis ANSWER: D. Dermis During skin inspection the nurse observes three lesions on the client's right knee. The lesions are round, have a raised border, and are grouped in a "smiley face" pattern. Which descriptors does the nurse use to document these observations? A. Annular, circinate, clustered B. Linear, confluent, vesicular C. Circumscribed, universal, pustular D. Serpiginous, coalesced, wheal-like ANSWER: A. Annular, circinate, clustered Which technique for obtaining a specimen for bacterial culture is most correct for the nurse to use with a client who has crusted skin lesions on the upper back? A. Remove several crusts, and swab the underlying exudate. B. Dampen the culture swab with sterile water, and then roll the swab over the central crusts. C. Apply a gauze bandage to the area, remove it after 1 hour, and send the entire gauze to the laboratory. D. Clean the area with an antibacterial solution, remove a crust from the center of the cluster of lesions, and send it to the laboratory. ANSWER: A. Remove several crusts, and swab the underlying exudate. An 88-year-old man is admitted to the ED from home with weakness and acute confusion.What is the nurse's priority for his care to maintain client safety? A. Assess his mental status every 30minutes B. Ensure that siderails are raised on his stretcher C. Check his bowel sounds for intestinal obstruction D. Teach him to move slowly when walking ANSWER: B. Ensure that siderails are raised on his stretcher A client is admitted to the ED with multiple stab wounds to his chest, abdomen and arms. What is the nurse's priority upon admission to the ED? A. Check for bleeding from the stab wounds B. Assess and maintain the client's airway C. Start 2 large-bore IV lines D. Assess the level of consciousness ANSWER: B. Assess and maintain the client's airway An older client with heat stroke is being cooled with a cooling blanket and ice packs under her arms and behind her neck. What assessment indicates to the nurse that the cooling process is effective? A. The client is alert and oriented