Nokea
A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?
- A. Dandruff
- B. Alopecia
- C. Pediculosis
- D. Xerostomia
Correct Answer: A
Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.
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A healthcare professional is assessing a client's oculomotor nerve functions. Which of the following actions should the healthcare professional take?
- A. Check the client's pupillary reaction to light
- B. Ask the client to read print from the Snellen chart
- C. Ask the client to identify different scents
- D. Use cotton to lightly touch the client's cornea
Correct Answer: A
Rationale: Checking the client's pupillary reaction to light is a key assessment to evaluate the oculomotor nerve function. The oculomotor nerve controls the pupil's constriction response to light. Choices B, C, and D are incorrect because testing vision with a Snellen chart, identifying scents, or touching the cornea are not specific assessments for oculomotor nerve function.
A healthcare provider is preparing to provide hygiene care. Which principle should the provider consider when planning hygiene care?
- A. Hygiene care is not performed in the same way by all individuals.
- B. No two individuals perform hygiene in the same manner.
- C. Standardizing a patient's hygienic practices is crucial.
- D. Understanding patient needs is not essential during hygiene care.
Correct Answer: B
Rationale: The correct answer is B: 'No two individuals perform hygiene in the same manner.' It is crucial to individualize a patient's care based on understanding the patient's unique hygiene practices and preferences. Choice A is incorrect because hygiene care should be tailored to the individual's needs and preferences, not seen as routine and expected for everyone. Choice C is incorrect as standardizing a patient's hygienic practices may not address their specific needs. Choice D is incorrect because understanding patient needs is essential during hygiene care to provide personalized and effective care.
Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?
- A. Insert an indwelling urinary catheter.
- B. Limit caloric and protein intake.
- C. Turn the patient every 2 hours.
- D. Assess for pain during a bath.
Correct Answer: D
Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (Choice A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (Choice B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (Choice C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.
A client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?
- A. Tell me how you are feeling right now.
- B. Describe the pain you are experiencing.
- C. Can you tell me more about your back pain?
- D. When did the pain start and how severe is it?
Correct Answer: B
Rationale: The correct answer is B: 'Describe the pain you are experiencing.' This question is the most effective as it prompts the client to provide detailed information about the nature of the pain, including its characteristics, intensity, and location. This detailed description can help the nurse in assessing the possible cause and severity of the pain. Choices A, C, and D are not as effective as they are either too general ('Tell me how you are feeling right now'), redundant ('Can you tell me more about your back pain?'), or focused only on timing and severity ('When did the pain start and how severe is it?').
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage
- B. Notify the pharmacy when wasting the medication
- C. Lock the remaining medication in the controlled substance cabinet
- D. Dispose of the vial with the remaining medication in a sharps container
Correct Answer: A
Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.