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A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer. Which diagnostic test should the nurse anticipate being ordered for this client?
- A. Punch skin biopsy
- B. Viral cultures
- C. Wood's lamp examination
- D. Diascopy
Correct Answer: A
Rationale: This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Wood's lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates polymorph making skin lesions easier to examine.
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A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers. Which condition should the nurse suspect?
- A. Scabies
- B. Psoriasis
- C. Eczema
- D. Contact dermatitis
Correct Answer: A
Rationale: White ridges on the skin between the fingers, especially with scratching and rubbing, are characteristic of scabies, a parasitic infestation caused by mites. Psoriasis typically presents with scaly, red patches, eczema with inflamed, itchy skin, and contact dermatitis with localized redness from an allergen or irritant. Scabies is the most likely condition based on the description.
A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse?
- A. Recent wound assessment, including size and appearance
- B. Insurance information for billing and coding purposes
- C. Complete health history and physical assessment findings
- D. Resources available to the client for wound care supplies
Correct Answer: A
Rationale: The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.
A nurse evaluates the following data in a clients chart: 66-year-old male with a health history of cerebral vascular accident and left-side paralysis, white blood cell count: 8000/mm^3, prealbumin: 15.2 mg/dL, albumin: 4.2 g/dL, lymphocyte count: 2000/mm^3, sacral ulcer 4 cm x 2 cm x 1.5 cm. Based on this information, which action should the nurse take?
- A. Consult a dietitian to increase nutritional intake.
- B. Apply a transparent film dressing to the ulcer.
- C. Reposition the client every 4 hours.
- D. Administer antibiotics for wound infection.
Correct Answer: A
Rationale: The prealbumin level of 15.2 mg/dL is low (normal range is typically 15"?36 mg/dL), indicating potential malnutrition, which can impair wound healing. Consulting a dietitian to optimize nutritional intake is the priority to support tissue repair. The white blood cell count is normal, so antibiotics are not indicated. Transparent film dressings are not suitable for deep ulcers, and repositioning should occur more frequently than every 4 hours.
A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.)
- A. Prepare a room for reverse isolation.
- B. Assess staff for a history of or vaccination for chickenpox.
- C. Check the admission orders for analgesia.
- D. Choose a roommate who also is immune suppressed.
- E. Ensure that gloves are available in the room.
Correct Answer: B,C,E
Rationale: Herpes zoster (shingles) is caused by reactivation of the varicella zoster virus, and staff without immunity to chickenpox are at risk. Analgesia is necessary due to the painful nature of shingles. Gloves and hand hygiene prevent spread, but reverse isolation is not required. An immune-suppressed roommate should be avoided to prevent infection transmission.
A nurse is planning care for a client with a sacral pressure ulcer. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Place a small pillow between bony surfaces.
- B. Elevate the head of the bed to 45 degrees.
- C. Limit fluids and proteins in the diet.
- D. Use a lift sheet to assist with re-positioning.
- E. Re-position the client who is in a chair every 2 hours.
- F. Keep the clients heels off the bed surfaces.
- G. Use a rubber ring to decrease sacral pressure when up in the chair.
Correct Answer: A,D,F
Rationale: A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and keeping heels off the bed reduces pressure on high-risk areas. Limiting fluids and proteins is not appropriate as they are essential for tissue integrity. Clients should be repositioned every hour while in a chair, not every 2 hours. A rubber ring impairs capillary blood flow, increasing pressure sore risk.