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A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?
- A. Use friction when washing the affected area.
- B. Use a new cosmetic pad with each limited application of makeup.
- C. Use an oil-based soap to wash affected areas daily.
- D. Express the larger comedones periodically.
Correct Answer: B
Rationale: The correct answer is B: Use a new cosmetic pad with each limited application of makeup. This is important to prevent the spread of bacteria and reduce the risk of exacerbating acne. Using a new pad each time helps to avoid introducing more bacteria to the skin. Choice A is incorrect because friction can irritate the skin and worsen acne. Choice C is incorrect as oil-based soap can clog pores and worsen acne. Choice D is incorrect because expressing comedones can lead to scarring and infection. It's crucial to provide accurate and evidence-based information to clients to promote effective management of their condition.
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A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The ability to comply with anticoagulant therapy for life.
- B. The likelihood of the client experiencing body image problems.
- C. The physical demands of the client’s lifestyle.
- D. The ability to participate in a cardiac rehabilitation program.
Correct Answer: A
Rationale: The correct answer is A: The ability to comply with anticoagulant therapy for life. This is essential because mechanical valve replacement requires lifelong anticoagulant therapy to prevent clot formation. Noncompliance can lead to serious complications such as thromboembolism or valve failure. Assessing the client's understanding, willingness, and ability to adhere to this therapy is crucial for successful outcomes.
Other options are incorrect because:
B: Body image problems are important but not essential before surgery.
C: Physical demands of lifestyle are relevant but not crucial for valve replacement.
D: Participation in cardiac rehab is beneficial post-surgery but not essential before.
Overall, the ability to comply with anticoagulant therapy is the most critical factor to assess preoperatively.
A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?
- A. The ropes are in the center of the wheel grooves.
- B. The ropes are securely attached to the pins.
- C. The weights are equal on each side.
- D. The weights rest against the foot of the bed.
Correct Answer: D
Rationale: The correct answer is D because the weights in skeletal traction should not rest against the foot of the bed to ensure proper traction force. The weights need to hang freely to provide continuous traction on the affected body part. Placing the weights against the foot of the bed could lead to uneven or inadequate traction force, affecting the treatment effectiveness and potentially causing harm to the client.
Choice A is incorrect because the ropes should be in the center of the wheel grooves to maintain proper alignment and prevent slipping. Choice B is incorrect because the ropes should be securely attached to the pins to ensure stability and prevent accidental detachment. Choice C is incorrect because the weights do not need to be equal on each side; the amount of weight applied is determined by the healthcare provider based on the specific treatment plan.
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
- A. Moist skin.
- B. Blood in the urine.
- C. Spider angiomas.
- D. Tarry stools.
Correct Answer: C
Rationale: The correct answer is C: Spider angiomas. In cirrhosis, the liver is damaged leading to increased pressure in the portal vein. This results in dilated blood vessels on the skin surface known as spider angiomas. This finding is expected due to the liver's inability to process blood effectively. Choice A (Moist skin) is incorrect as cirrhosis commonly causes dry and itchy skin. Choice B (Blood in the urine) is incorrect because cirrhosis typically does not directly affect the kidneys. Choice D (Tarry stools) is incorrect as it is a symptom of gastrointestinal bleeding, which can occur in cirrhosis but is not a specific finding.
The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)
- A. Increased appetite.
- B. Nausea.
- C. Increased energy level.
- D. Seeing halos around bright objects.
- E. Photophobia.
Correct Answer: B,D,E
Rationale: The correct manifestations correlating with a digoxin level of 2.3 ng/dL are Nausea, Seeing halos around bright objects, and Photophobia. Nausea is a common side effect of digoxin toxicity. Seeing halos around bright objects is a sign of visual disturbances associated with digoxin toxicity. Photophobia is sensitivity to light, which can occur with digoxin toxicity. Increased appetite and energy levels are not typically associated with digoxin toxicity and are therefore incorrect choices.
Upon assessment, Cullen’s sign is noted. What complication of acute pancreatitis would the nurse suspect that the client might have?
- A. Pancreatic pseudocyst.
- B. Electrolyte imbalance.
- C. Internal bleeding.
- D. Pleural effusion.
Correct Answer: C
Rationale: Rationale: Cullen's sign is bluish discoloration around the umbilicus, indicating internal bleeding in acute pancreatitis. This occurs due to retroperitoneal hemorrhage tracking to the periumbilical area. Choices A, B, and D are not associated with Cullen's sign. Pancreatic pseudocyst may present with epigastric pain, electrolyte imbalance with nausea and vomiting, and pleural effusion with dyspnea.