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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.
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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.
While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patients ear. The nurse knows that this lesion is consistent with what type of skin cancer?
- A. Basal cell carcinoma
- B. Squamous cell carcinoma
- C. Dermatofibroma
- D. Malignant melanoma
Correct Answer: D
Rationale: Malignant melanoma often appears as a blue-black lesion with irregular colors and borders. Basal cell carcinoma is waxy with pearly borders, squamous cell carcinoma is scaly and may bleed, and dermatofibroma is a benign, firm nodule.
A 35-year-old kidney transplant patient comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposis sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposis sarcoma?
- A. Classic
- B. AIDS-related
- C. Immunosuppression-related
- D. Endemic
Correct Answer: C
Rationale: Immunosuppression-related Kaposis sarcoma occurs in transplant recipients due to immunosuppressive therapy. Classic KS affects older Mediterranean or Jewish men, endemic KS is African, and AIDS-related KS occurs in HIV patients.
A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment?
- A. Chemotherapy
- B. Immunotherapy
- C. Wide excision
- D. Radiation therapy
Correct Answer: C
Rationale: Wide excision is the primary treatment for malignant melanoma to remove the lesion and assess staging. Chemotherapy, immunotherapy, and radiation are secondary or palliative options.
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.