A patient presents with a pruritic, annular rash with central clearing and a raised, scaly border. The lesions have a tendency to spread outward in a centrifugal pattern. Which of the following conditions is most likely responsible for this presentation?
- A. Tinea corporis (ringworm)
- B. Nummular eczema
- C. Pityriasis rosea
- D. Erythema migrans (Lyme disease rash)
Correct Answer: A
Rationale: The described presentation of a pruritic, annular rash with central clearing and a raised, scaly border that spreads outward in a centrifugal pattern is characteristic of tinea corporis, commonly known as ringworm. This fungal infection affects the skin and is typically ring-shaped, with a well-defined, slightly raised, and scaly border. The central area often clears as the lesion enlarges peripherally, resembling a ring. It is important to note that ringworm is not caused by a worm but by a fungus. Treatment typically involves antifungal medications applied topically or taken orally, depending on the severity of the infection.
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Which of the following is a primary consideration in planning for her care?
- A. To prevent problems related to immobility
- B. To prevent infection
- C. Planning for client`s eventual inability communicate
- D. To prevent complications
Correct Answer: A
Rationale: When planning for a client's care, a primary consideration is to prevent problems related to immobility. Immobility can lead to a range of complications such as pressure ulcers, muscle weakness, joint contractures, and decreased circulation. To maintain the client's overall health and well-being, it is essential to address mobility issues and implement strategies to prevent complications associated with immobility. By prioritizing interventions that promote movement and prevent immobility-related problems, the client's quality of life can be improved and potential health risks mitigated.
Nurse Adalynn discusses the possibilities of future postpartum hemorrhage with the patients. Which of the following increases the absorption of vitamin K?
- A. Proteins
- B. Carbohydrates
- C. Minerals
- D. Fats
Correct Answer: D
Rationale: Fats are essential for the absorption of vitamin K in the body. Vitamin K is a fat-soluble vitamin, meaning it is better absorbed in the presence of dietary fats. In the case of postpartum hemorrhage, adequate levels of vitamin K are crucial for proper blood clotting. Thus, incorporating fats in the diet can help ensure sufficient absorption of vitamin K, which can be beneficial in preventing complications related to hemorrhage.
A woman in active labor is experiencing persistent occiput posterior position despite position changes. What nursing intervention is most appropriate to facilitate fetal rotation?
- A. Encourage the mother to remain in a side-lying position.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Perform manual rotation of the fetus during vaginal examination.
Correct Answer: B
Rationale: The most appropriate nursing intervention to facilitate fetal rotation in a woman experiencing persistent occiput posterior position is to assist the mother into a hands-and-knees position. This position can help encourage the baby to rotate into the optimal occiput anterior position for delivery. By being on her hands and knees, gravity can assist in aiding the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially reduce discomfort during labor. Additionally, hands-and-knees position can help open up the pelvis and create more space for the baby to turn. It is a non-invasive and generally well-tolerated intervention to promote fetal rotation in labor.
You cannot open Claudia's eyes due to dried crust. Which of the following actions would you do?
- A. Apply the eye drops the next day
- B. Apply eye ointment to soften the crust
- C. Instill eye drops
- D. Place a warm wet wash cloth over her eyes for at least three minutes
Correct Answer: D
Rationale: The best course of action in this scenario is to place a warm wet washcloth over Claudia's eyes for at least three minutes. This will help soften and loosen the dried crust, making it easier to gently clean her eyes and open them. Applying eye drops or ointment may not be effective if the crust is blocking her eyes completely. By using a warm wet washcloth, you can improve the ability to clean her eyes effectively and without causing discomfort.
In collecting sputum specimen, the nurse should instruct Roy to _____.
- A. breathe slowly, cough and expectorate into the specimen container
- B. breathe deeply and cough, expectorate into the sputum container,
- C. cough and expectorate saliva into the specimen container.
- D. cough and expectorate into the specimen container.
Correct Answer: A
Rationale: In collecting a sputum specimen, the nurse should instruct Roy to breathe slowly, cough, and then expectorate into the specimen container. This ensures that the sputum sample is collected from the lower respiratory tract where it is most likely to contain pathogens or other relevant substances for analysis. By instructing Roy to breathe slowly, it helps him to take deep breaths and effectively cough to produce a good sputum sample. Additionally, asking him to expectorate directly into the specimen container helps prevent contamination from saliva or other sources, ensuring the accuracy of the specimen collected for testing.