Nokea
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?
- A. Are you using lotion on your skin?
- B. Do you have a family history of this?
- C. Do your arms itch?
- D. What medications are you taking?
Correct Answer: D
Rationale: Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.
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A nurse is preparing a client for skin grafting and notes that the physician has documented that the client is scheduled for heterograft. The nurse understands that the heterograft used for the burn client is skin from:
- A. another species
- B. a cadaver
- C. the burned client
- D. a skin bank
Correct Answer: A
Rationale: A heterograft (xenograft) uses skin from another species, typically pig skin, as a temporary covering.
A hospitalized client is diagnosed with scabies. Which of the following would a nurse expect to note on inspection of the client's skin?
- A. the appearance of vesicles or pustules
- B. the presence of white patches scattered about the trunk
- C. multiple straight or wavy threadlike lines beneath the skin
- D. patchy hair loss and round, red macules with scales
Correct Answer: C
Rationale: Scabies is characterized by burrows (threadlike lines) created by mites beneath the skin.
During a home health visit, the client indicates he feels he might need physical therapy to facilitate his recovery. What action by the nurse is indicated?
- A. The nurse should contact the client's insurance carrier to determine benefit eligibility.
- B. The nurse should provide the client with the contact information for a local agency that offers physical therapy services.
- C. The nurse should contact the physician to discuss the client's concerns.
- D. The nurse should advise the client to contact the physician to discuss his concerns.
Correct Answer: C
Rationale: The home health nurse is responsible for coordinating care, including contacting the physician to initiate physical therapy, which requires a physician's order.
When performing the caloric test, nystagmus develops in the left eye while irrigating the right ear. The nurse evaluates the client further for which condition that contributes to the results of the caloric test?
- A. Alcohol, CNS depression, or barbiturate use
- B. Increased anterior pressure in the left eye
- C. Nothing further, since nerves are intact in the inner ear
- D. Increased pressure from brain lesions
Correct Answer: C
Rationale: Nystagmus is a normal response to ear irrigation in the opposite eye, reflecting intact vestibular function. No further evaluation is needed unless other symptoms suggest abnormalities.
Which statement by the client prescribed calcitonin, a thyroid hormone, indicates to the nurse the teaching has been effective?
- A. I should administer the medication in a different nostril each day.'
- B. I need to drink a lot of water when I take my medicine.'
- C. I have to dilute the medication with vitamin D before I take it.'
- D. This medication will help the calcium leave my bones.'
Correct Answer: A
Rationale: Alternating nostrils for calcitonin nasal spray prevents irritation, indicating effective teaching.