Nokea
A nurse in a provider's office is caring for a client who has tinea pedis. Which of the following findings should the nurse expect?
- A. Recent exposure to poison ivy
- B. Scaling and redness between the toes
- C. Circular, erythematous patches on the scalp
- D. A recent prescription for an antiseizure medication
Correct Answer: B
Rationale: Tinea pedis, or athlete's foot, commonly presents as scaling and redness between the toes due to fungal infection.
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A nurse is caring for a client who is scheduled to have a colonoscopy. The client states, 'I am so nervous about what the doctor might find during the test.' The nurse asks the client, 'Are you feeling anxious about the results of your colonoscopy?' The nurse's response is an example of which of the following communication techniques?
- A. Clarification
- B. Self-disclosure
- C. Sharing observations
- D. Providing information
Correct Answer: A
Rationale: Clarification helps the nurse ensure understanding of the client's concerns.
A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
- A. Check to see what is on the floor.
- B. Pause and wait until the client looks up.
- C. Move closer to the client.
- D. Continue the discussion while avoiding eye contact.
Correct Answer: D
Rationale: Avoiding direct eye contact is a cultural sign of respect in some Asian cultures, so the nurse should not force eye contact.
A nurse is collecting data from a client's skin. Which of the following actions should the nurse take to assess skin turgor?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size red or purple spots.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: The correct answer is D: Grasp a fold of skin on the client's forearm or near the sternum. This method assesses skin turgor by evaluating how quickly the skin returns to its normal position after being pinched. Adequate skin turgor indicates good hydration status, as hydrated skin will snap back promptly. If the skin remains elevated or "tents," it may indicate dehydration. Choice A involves palpation, which assesses skin temperature and texture but not turgor. Choice B involves assessing edema, not skin turgor. Choice C describes petechiae, which are indicative of bleeding disorders. Overall, choice D is the most appropriate for assessing skin turgor accurately.
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?
- A. Diaphoresis
- B. Retractions
- C. Cyanosis
- D. Restlessness
Correct Answer: D
Rationale: Restlessness is an early sign of inadequate oxygenation, indicating the body's attempt to compensate for low oxygen levels.
A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow. (Move the steps of staple removal into the box on the right, placing them in the selected order of performance. All steps must be used.)
- A. Remove every other staple.
- B. Wipe cleansing solution directly over the surgical incision.
- C. Remove remaining staples.
- D. Remove the wound dressing.
- E. Clean the skin along the sides of the incision.
Correct Answer: D, E, A, C, B
Rationale: First, remove the wound dressing to expose the incision. Then, clean the skin along the sides to reduce infection risk. Next, remove every other staple to maintain stability before removing the remaining ones. Finally, wipe cleansing solution to keep the site clean.