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A patient diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?
- A. Assess the drainage in the dressing.
- B. Slowly remove the soiled dressing.
- C. Perform hand hygiene.
- D. Don non-latex gloves.
Correct Answer: C
Rationale: Hand hygiene is the first step in wound care to prevent infection, per standard precautions. Assessing drainage, removing the dressing, and donning gloves follow.
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A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply.
- A. Risk for Infection Related to Lesions
- B. Impaired Skin Integrity Related to Epidermal Blisters
- C. Disturbed Body Image Related to Presence of Skin Lesions
- D. Acute Pain Related to Disruption in Skin Integrity
- E. Hyperthermia Related to Disruptions in Thermoregulation
Correct Answer: A,B,C,D
Rationale: Pemphigus vulgaris causes blisters, leading to infection risk, impaired skin integrity, pain, and disturbed body image. Hyperthermia is not a concern; hypothermia is more likely.
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 nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)?
- A. Teaching participants to improve their overall health through nutrition
- B. Encouraging participants to identify their family history of cancer
- C. Teaching participants to limit their sun exposure
- D. Teaching participants to control exposure to environmental and occupational radiation
Correct Answer: C
Rationale: Limiting sun exposure is the most effective way to reduce BCC risk, as UV radiation is the primary cause. Nutrition, family history, and other radiation exposures are less directly related.
When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what?
- A. Impaired Skin Integrity Related to Scaly Lesions
- B. Acute Pain Related to Blistering and Erosions of the Oral Cavity
- C. Impaired Tissue Integrity Related to Epidermal Shedding
- D. Anxiety Related to Risk for Melanoma
Correct Answer: A
Rationale: Psoriasis causes scaly lesions, leading to impaired skin integrity. It does not typically affect the oral cavity, cause epidermal shedding, or increase melanoma risk.
A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment?
- A. Assessment of the patients stool for evidence of intestinal sloughing
- B. Assessment of the patients apical heart rate for dysrhythmias
- C. Assessment of the patients joints for pain and decreased range of motion
- D. Assessment for cognitive changes resulting from neurologic lesions
Correct Answer: C
Rationale: Psoriasis can lead to psoriatic arthritis in up to 30% of cases, necessitating joint assessment for pain and reduced mobility. It does not affect GI, cardiac, or neurologic function.