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A nurse is working with a family whose 5 year-old daughter has been diagnosed with impetigo. What educational intervention should the nurse include in this familys care?
- A. Ensuring that the family knows that impetigo is not contagious
- B. Teaching about the safe and effective use of topical corticosteroids
- C. Teaching about the importance of maintaining high standards of hygiene
- D. Ensuring that the family knows how to safely burst the childs vesicles
Correct Answer: C
Rationale: Impetigo is linked to poor hygiene, so teaching hygiene practices is key. It is contagious, corticosteroids are ineffective, and bursting vesicles is harmful.
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A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?
- A. The childs scalp should be monitored for 48 to 72 hours before starting treatment.
- B. Nits may have to be manually removed from the childs hair shafts.
- C. The disease is self-limiting and symptoms will abate within 1 week.
- D. Efforts should be made to improve the childs level of hygiene.
Correct Answer: B
Rationale: Manual removal of nits is often necessary after medicated shampoo for pediculosis capitis. The condition is not self-limiting, requires prompt treatment, and is not caused by poor hygiene.
A patient who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Disturbed Body Image Related to Disfigurement. What would be an appropriate nursing intervention related to this diagnosis?
- A. Referring the patient to a speech therapist
- B. Gradually adding soft foods to diet
- C. Administering analgesics as prescribed
- D. Teaching the patient how to use and care for the prosthesis
Correct Answer: D
Rationale: Teaching prosthesis care fosters independence and addresses body image concerns by empowering the patient. Speech therapy, diet changes, and analgesics do not directly address disturbed body image.
A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?
- A. Deficient Knowledge about Early Signs of Melanoma
- B. Chronic Pain Related to Surgical Excision and Grafting
- C. Depression Related to Reconstructive Surgery
- D. Anxiety Related to Lack of Social Support
Correct Answer: A
Rationale: Advanced melanoma suggests a lack of early detection, indicating deficient knowledge about melanoma signs. Excision does not cause chronic pain, and depression or anxiety may not be primary concerns.
A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond?
- A. Liaise with the physical therapist to ensure that the patient is performing exercises safely.
- B. Validate the patients efforts to increase blood perfusion to the graft site.
- C. Remind the patient that ROM exercises should be passive, not active.
- D. Remind the patient of the need to immobilize the graft to facilitate healing.
Correct Answer: D
Rationale: Immobilization of the graft site is critical to promote healing and prevent damage. Active or passive ROM exercises can disrupt the graft, and perfusion is not enhanced by early movement.
An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this residents plan of care?
- A. Avoid the application of skin emollients.
- B. Apply antibiotic ointment as ordered following baths.
- C. Avoid using hot water during the patients baths.
- D. Administer acetaminophen 4 times daily as ordered.
Correct Answer: C
Rationale: Using tepid water for baths reduces pruritus in older adults with dry skin. Emollients help, antibiotics are unnecessary without infection, and acetaminophen does not address itching.