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A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)
- A. Cool, moist compresses
- B. Topical corticosteroids
- C. Heating pad
- D. Tepid bath with cornstarch
- E. Back rub with baby oil
Correct Answer: A,D
Rationale: Cool, moist compresses and tepid baths with cornstarch reduce inflammation and help debride crusts in eczematous dermatitis. Topical corticosteroids are pharmacologic, and heating pads or baby oil may increase inflammation and discomfort.
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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.
After educating a caregiver of a home care client, a nurse assesses the caregivers understanding. Which statement indicates that the caregiver needs additional education?
- A. I can help him shift his position every hour when he sits in the chair.
- B. If his tailbone is red and tender in the morning, I will massage it with baby oil.
- C. Applying lotion to his arms and legs every evening will decrease dryness.
- D. Drinking a nutritional supplement between meals will help maintain his weight.
Correct Answer: B
Rationale: Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care?
- A. Change the dressing every 6 hours.
- B. Assess the wound bed once a day.
- C. Change the dressing when it is saturated.
- D. Contact the provider when the dressing leaks.
Correct Answer: A
Rationale: Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum debridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.
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.
After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs further education?
- A. I'll avoid scratching the patches to prevent worsening.
- B. I'll use moisturizers to keep my skin hydrated.
- C. I'll apply sunscreen to protect my skin from UV damage.
- D. I'll take hot baths daily to soothe the lesions.
Correct Answer: D
Rationale: Hot baths can exacerbate psoriasis by drying out the skin and increasing irritation. The other statements reflect appropriate self-care measures for managing psoriasis, such as avoiding scratching, using moisturizers, and protecting skin from UV damage.