NURSING CARE OF ADULTS EXAM 3 WITH COMPLETE SOLUTIONS

While the nurse is performing an initial assessment, a patient with extensive burn injuries suddenly develops increasing hoarseness and stridor. Pulse oximetry is 86%. What is the priority nursing action? Encourage the patient to take deep breaths. Provide humidified oxygen. Administer respiratory treatments. Suction respiratory secretions. 1 of 24 Term A nurse is supervising a new graduate nurse (GN) who is examining a new patient with skin lesions. The nurse would intervene if the GN: gently handles the patient's extremities to prevent skin tears. observes the condition of the skin and measures the size of the lesions. removes the scales and crusts from the lesions to clean the skin. assesses for and documents any home remedies that the patient has tried. 2 of 24 Term The patient presents with a rash of unknown origin. Which assessment question(s) would help determine the cause? (Select all that apply.) 1. "When did the rash or lesion first appear?" 2. "Can you think of any event or different food you ate or substance you were using just before the rash appeared?" 3. "Which drugs are you taking? Do you take any over the-counter preparations?" 4. "Have you ever had radiation therapy?" 5. "Do you have a history of any skin disorders in your family?" 1,2,3,4,5 1,2,4,5 1,2,5 1,2,3,4 3 of 24 Term A major type of skin disorder is acne rosacea. What information may be valuable for the patient education plan? (SATA) 1. Acne rosacea usually occurs in adolescence and then begins to subside during adulthood. 2. Diet is important, and flare ups may be caused by caffeine containing foods, spicy foods, sunlight, and alcohol 3. Comedos may occur on the face, upper shoulders, and back. 4. The primary location for occurence is on the face over the cheeks and bridge of the nose. 5. Treatments may include metronidazole, retinoids, and occasionally antibiotics. 1,2,5 1,2,3,4,5 2,4,5 1,2,4,5 4 of 24 Term Which physiologic change(s) associated with aging predispose(s) older adults to skin breakdown? (Select all that apply.) 1. Decreased melanocytes 2. Loss of collagen 3. Increased elastic fibers 4. Decreased adipose tissues 5. Reduced sebaceous gland activity 1,2,3,4,5 1,2,4,5 1,2,3,4 2,4,5 5 of 24 Term