Nokea
A person who has psoriasis is seen in the clinic. The lesions are covered with coal tar. Which instruction should the nurse give the client?
- A. Call if you have nausea and vomiting.'
- B. Protect the area from sunlight for 24 hours.'
- C. Wash off the solution after six to eight hours.'
- D. Call if your skin looks dark during the treatment.'
Correct Answer: B
Rationale: Coal tar increases photosensitivity; protecting the area from sunlight for 24 hours prevents burns. Nausea, washing off, or skin darkening are not primary concerns.
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The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse?
- A. Female client with a fractured pelvis who is 4 months pregnant
- B. Female client with cytomegalovirus pneumonia
- C. Male client with an open bowel resection with a Foley catheter
- D. Male client with history of Billroth II surgery who is septic
Correct Answer: A
Rationale: The OB nurse’s expertise in pregnancy care makes the pregnant client with a fractured pelvis (A) the best assignment, as it aligns with their skills in managing maternal-fetal health. Other clients (B, C, D) require general medical-surgical care unrelated to OB.
A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to
- A. Promote the client's comfort
- B. Reduce the drying time
- C. Decrease irritation to the skin
- D. Improve venous return
Correct Answer: D
Rationale: Elevating the leg both improves venous return and reduces swelling. Client comfort will be improved as well.
The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
- A. Did you hear that voice? It told me to kill my parent.
- B. I need to get rid of the bugs that are crawling under my skin.
- C. The song on the radio is a message sent to me in secret code.
- D. I will not drink the tap water. The aliens are trying to poison me.
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (C). Auditory hallucinations (A) involve hearing voices, not reference. Tactile hallucinations (B) involve false sensations, and persecutory delusions (D) involve belief in harm without reference to neutral stimuli.
An adult is prescribed lovastatin (Mevacor). The nurse should teach the client that while he is taking lovastatin (Mevacor), he must avoid:
- A. eating apples.
- B. drinking grapefruit juice.
- C. using aspirin.
- D. using ibuprofen.
Correct Answer: B
Rationale: Grapefruit juice inhibits CYP3A4, increasing lovastatin levels and risking toxicity, such as myopathy. Apples, aspirin, and ibuprofen do not have significant interactions with lovastatin.
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
- A. Report a persistent cough to the health care provider
- B. The child can return to school in 4 days
- C. Administer chewable aspirin for pain
- D. The child may gargle with saline as necessary for discomfort
Correct Answer: A
Rationale: Report a persistent cough to the health care provider. Persistent coughing may indicate bleeding, which requires immediate attention.