Nokea
A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse?
- A. Recent wound assessment, including size and appearance
- B. Insurance information for billing and coding purposes
- C. Complete health history and physical assessment findings
- D. Resources available to the client for wound care supplies
Correct Answer: A
Rationale: The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.
You may also like to solve these questions
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.
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.
A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? (Select all that apply.)
- A. Have you eaten a large amount of chocolate lately?
- B. Have you been under a lot of stress lately?
- C. Have you recently used a public shower?
- D. Have you been out of the country recently?
- E. Have you recently had any other health problems?
- F. Have you changed any medications recently?
Correct Answer: B,E,F
Rationale: Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.
A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers. Which condition should the nurse suspect?
- A. Scabies
- B. Psoriasis
- C. Eczema
- D. Contact dermatitis
Correct Answer: A
Rationale: White ridges on the skin between the fingers, especially with scratching and rubbing, are characteristic of scabies, a parasitic infestation caused by mites. Psoriasis typically presents with scaly, red patches, eczema with inflamed, itchy skin, and contact dermatitis with localized redness from an allergen or irritant. Scabies is the most likely condition based on the description.
A nurse is planning care for a client with a sacral pressure ulcer. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Place a small pillow between bony surfaces.
- B. Elevate the head of the bed to 45 degrees.
- C. Limit fluids and proteins in the diet.
- D. Use a lift sheet to assist with re-positioning.
- E. Re-position the client who is in a chair every 2 hours.
- F. Keep the clients heels off the bed surfaces.
- G. Use a rubber ring to decrease sacral pressure when up in the chair.
Correct Answer: A,D,F
Rationale: A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and keeping heels off the bed reduces pressure on high-risk areas. Limiting fluids and proteins is not appropriate as they are essential for tissue integrity. Clients should be repositioned every hour while in a chair, not every 2 hours. A rubber ring impairs capillary blood flow, increasing pressure sore risk.