Nokea
A client who has just been diagnosed with psoriasis asks the nurse what should be done to prevent family members from getting the condition. What should the nurse include when responding to this question?
- A. Showering daily with antiseptic soap should be sufficient.
- B. Wearing clothing over the affected part and washing clothes separately from the rest of the family are all that is necessary.
- C. Psoriasis is not contagious, so no special precautions are necessary.
- D. Psoriasis is transmitted primarily by direct contact with the skin.
Correct Answer: C
Rationale: Psoriasis is a non-contagious autoimmune condition, so no precautions are needed to prevent transmission to family members.
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The nurse identifies the concept of impaired skin integrity for a pediatric client diagnosed with impetigo on the arms. Which interventions should the nurse implement?
- A. Teach the parents to ensure the child takes all the prescribed antibiotics.
- B. Give the parents a written excuse so the child can go back to school.
- C. Encourage the parents to bathe the child in an oatmeal bath for the itching.
- D. Apply topical lidocaine before debriding the crusts from the lesions.
Correct Answer: A
Rationale: Completing antibiotics ensures impetigo resolution, addressing skin integrity. School return requires clearance, oatmeal baths are for comfort, and lidocaine is unnecessary.
The nurse is assessing the client's grafted wound following a skin graft. Which information provided during shift report should prompt the nurse to carefully assess if the client has a wound infection?
- A. WBC at 9900/microL
- B. Serosanguineous drainage
- C. Temperature 103°F (39.4°C)
- D. Urine output 100 mL past 4 hours
Correct Answer: C
Rationale: An elevated temperature could be a sign of an infection. Normal WBC is 4500 to 11,100 microL, so 9900 is WNL. Clean wounds have serosanguineous drainage. Decreased urine output can indicate dehydration or renal failure, not infection.
Which response demonstrates that the parents understand the nurse's explanation of why organisms travel more easily from the nasopharynx to the middle ear in a child?
- A. A child's eustachian tube is shorter and straighter.
- B. A child's eustachian tube is longer and straighter.
- C. A child's eustachian tube is longer and more curved.
Correct Answer: A
Rationale: A shorter, straighter eustachian tube in children facilitates organism travel.
The nurse writes the nursing diagnosis 'impaired skin integrity related to open burn wounds.' Which intervention would be appropriate for this nursing diagnosis?
- A. Provide analgesia before pain becomes severe.
- B. Clean the client’s wounds, body, and hair daily.
- C. Screen visitors for respiratory infections.
- D. Encourage visitors to bring plants and flowers.
Correct Answer: B
Rationale: Daily wound cleaning prevents infection and promotes healing, addressing impaired skin integrity. Analgesia addresses pain, visitor screening is for infection control, and plants increase infection risk.
Postoperatively, which of the following client concerns should be the nurse's highest priority?
- A. Pain
- B. Waiting
- C. Anxiety
- D. Fatigue
Correct Answer: A
Rationale: Pain is a priority as it may indicate complications like infection or graft failure.