Nokea
A nurse is completing a focused assessment of an older adult's skin. The nurse notes a crusted 0.7 cm lesion on the client's forehead. Which action should the nurse take in response to this finding?
- A. Report the finding to the healthcare provider
- B. Place a clear occlusive dressing over the site
- C. Apply a warm compress to remove the crusted area
- D. Explain that this is a normal skin change with aging
Correct Answer: A
Rationale: A crusted lesion, especially in an older adult, could be indicative of skin cancer or another serious condition. Therefore, reporting this finding to the healthcare provider is crucial for further evaluation and appropriate management. Placing an occlusive dressing (Choice B) could prevent proper assessment and treatment. Applying a warm compress (Choice C) may not be suitable for a suspicious skin lesion as it could worsen the condition. Explaining it as a normal skin change (Choice D) without proper evaluation can delay necessary interventions and potentially harm the patient.
You may also like to solve these questions
In what order should the PN implement these steps to provide wound care? (Place in correct order.)
- A. Don procedure gloves
- B. Remove the dressing
- C. Apply prescribed medications to the wound
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is 'D - All of the Above.' The PN should first don procedure gloves to maintain aseptic technique, then remove the dressing to assess the wound, and finally apply prescribed medications to the wound. This sequence ensures that non-sterile tasks like donning gloves are done before sterile tasks like applying medications, reducing the risk of wound contamination. Choices A, B, and C are all essential steps in providing effective wound care.
The practical nurse is caring for a client whose urine drug screen is positive for cocaine. Which behavior is this client likely to exhibit during cocaine withdrawal?
- A. Elevated energy level
- B. Euphoria
- C. High self-esteem
- D. Powerful craving for more
Correct Answer: D
Rationale: The correct answer is D: Powerful craving for more. During cocaine withdrawal, individuals often experience intense cravings for the drug, along with symptoms such as fatigue, depression, and anxiety. These cravings can be overpowering and lead to a strong desire to seek out more cocaine to alleviate the withdrawal symptoms. Choices A, B, and C are incorrect as elevated energy level, euphoria, and high self-esteem are more associated with the effects of cocaine rather than withdrawal symptoms. Withdrawal from cocaine is characterized by the opposite, such as fatigue, low mood, and intense cravings.
A client with a recent total knee replacement is scheduled for physical therapy. The client refuses to participate, stating that the pain is too intense. What should the nurse do first?
- A. Administer the prescribed analgesic and encourage participation after it takes effect.
- B. Reschedule the physical therapy session for later in the day.
- C. Explain the importance of physical therapy for recovery.
- D. Notify the physical therapist of the client's refusal.
Correct Answer: A
Rationale: Administering pain medication before physical therapy helps manage the pain, making it easier for the client to participate in the necessary exercises to improve recovery and prevent complications such as joint stiffness. Choice B is not the first step as addressing the pain should take precedence. Choice C is important but should come after managing the pain to facilitate participation. Choice D involves another healthcare provider and is not the immediate action needed in this situation.
A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the nurse plan to include in the child's plan of care?
- A. Recommend parents bring favorite snacks
- B. Encourage ambulation daily to the playroom
- C. Measure blood pressure every 4 to 6 hours
- D. Offer a selection of fresh fruit for each meal
Correct Answer: C
Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. Monitoring blood pressure frequently is crucial in managing glomerulonephritis, as hypertension is a common complication during the acute edematous phase. Choice A is incorrect as it does not address the specific needs of a child with glomerulonephritis. Choice B is incorrect as excessive activity may not be suitable during the acute phase, as rest and monitoring are more important. Choice D is incorrect as the focus should be on monitoring vital signs rather than meal options.
A client post-mastectomy is concerned about the risk of lymphedema. What should the nurse include in the discharge instructions to minimize this risk?
- A. Wear compression garments on the affected arm.
- B. Avoid venipunctures and blood pressure measurements on the affected arm.
- C. Perform vigorous exercises to strengthen the affected arm.
- D. Keep the affected arm elevated at all times.
Correct Answer: B
Rationale: To minimize the risk of lymphedema after a mastectomy, it is essential to instruct the client to avoid venipunctures and blood pressure measurements on the affected arm. These procedures can lead to trauma or impede lymphatic flow, increasing the risk of lymphedema. Wearing compression garments helps manage lymphedema but is not preventive. Performing vigorous exercises can strain the affected arm and increase the risk of lymphedema. Keeping the affected arm elevated at all times is unnecessary and not an effective preventive measure against lymphedema.