Nokea
A severely burned man had his last tetanus shot when he started work at his job two years ago. What should the nurse expect to administer now?
- A. Tetanus toxoid booster
- B. Tetanus antitoxin
- C. Hyperimmune human tetanus globulin
- D. DPT booster
Correct Answer: A
Rationale: A tetanus toxoid booster is appropriate for a burn client with a tetanus shot within the past five years to ensure immunity against tetanus, common in burn wounds.
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Which client signs and symptoms indicate contact dermatitis to the nurse?
- A. Erythema and oozing vesicles.
- B. Pustules and nodule formation.
- C. Varicosities and edema.
- D. Telangiectasia and flushing.
Correct Answer: A
Rationale: Erythema and oozing vesicles are hallmark signs of contact dermatitis. Pustules, varicosities, and telangiectasia suggest other conditions.
The nurse completes teaching the client with a second-degree burn about silver sulfadiazine. Which client statements should indicate to the nurse that the teaching was effective? Select all that apply.
- A. I apply the cream only to the opened areas of the burned area.
- B. Silver sulfadiazine will prevent an infection of the burned area.
- C. I never should apply a dressing after applying silver sulfadiazine.
- D. I use a tongue blade to remove the old ointment before reapplying.
- E. The cream is dark colored and cannot be removed with water.
Correct Answer: A,B
Rationale: Silver sulfadiazine (Silvadene) is only applied to opened areas; this statement indicates client understanding of the instructions. Silver sulfadiazine is used to reduce/prevent bacterial growth and thus an infection; this statement indicates client understanding of the instructions. Dressings can be applied but are not necessary; this statement does not indicate client understanding. Removal of old ointment with a tongue blade can damage new granulation tissue; this statement does not indicate client understanding. The cream is white in color and water-soluble; if it darkens it should not be used; this statement does not indicate client understanding.
Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion?
- A. The client will express feelings of fear.
- B. The client will ask questions about the diagnosis.
- C. The client will state a diminished level of pain.
- D. The client will demonstrate care of the operative site.
Correct Answer: D
Rationale: Demonstrating operative site care ensures healing and prevents infection, a physiological outcome. Fear, questions, and pain are psychosocial or secondary.
The 55-year-old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox?
- A. Deep vein thrombosis.
- B. Varicella pneumonia.
- C. Pericarditis.
- D. Scarring of the skin.
Correct Answer: B
Rationale: Varicella pneumonia is a serious complication in adults with chickenpox, especially older adults. DVT, pericarditis, and scarring are less common.
When the client asks about the cause of shingles, the nurse answers correctly with which cause of the disease?
- A. The reactivation of a dormant virus
- B. A vector insect such as a tick
- C. A toxin from a bacterial infection
- D. An antibody response to a drug allergen
Correct Answer: A
Rationale: Shingles results from reactivation of the varicella-zoster virus.