Nokea
After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?
- A. Wrap ice in a washcloth and put it on the burn area.
- B. Come to the ED so a doctor can assess your fingers.
- C. Run cool water over the burned area on your fingers.
- D. Apply an antibiotic skin ointment to prevent infection.
Correct Answer: C
Rationale: Ice causes vasoconstriction and can worsen the tissue damage. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing.
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The client is receiving UV light treatments for psoriasis along with methoxsalen, a photosensitizing agent. What precaution should be followed the first day after treatment?
- A. Wear ultraviolet B-protective sunglasses.
- B. Avoid applying skin ointments and lotions.
- C. Check for elevated temperature every 4 hours.
- D. Stop treatments if skin redness or erythema occurs.
Correct Answer: A
Rationale: Treatment with methoxsalen (Uvadex) enhances sensitivity of the eyes to sunlight. Sunglasses that provide UVB protection need to be worn for at least 24 hours following treatments. Skin ointments may be prescribed. Temperature monitoring is not needed. Redness and erythema are normal responses.
Which other assessment finding is most indicative of an infection in the external ear?
- A. Foul-smelling drainage
- B. Scarred tympanic membrane
- C. Diminished hearing
- D. Enlarged lymph nodes
Correct Answer: A
Rationale: Foul-smelling drainage is a hallmark of external ear infections.
The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?
- A. This surgery will create a skin flap to cover my wounds.'
- B. This surgery will get all the old black tissue out of the wound so it can heal.'
- C. The surgery is important to allow oxygen to get to the tissue for healing to occur.'
- D. Stool will come out an opening in my abdomen so it won’t get in the sore.'
Correct Answer: D
Rationale: Fecal diversion (colostomy) prevents stool contamination of coccyx ulcers, aiding healing. Skin flaps, debridement, and oxygen delivery are unrelated to this surgery.
The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
- A. Instruct the clients to wear dark clothes when hunting.
- B. Use a sunscreen of at least SPF 30 when outside.
- C. Avoid dense undergrowth when in a wooded area.
- D. Do not use any type of insect repellant when deer hunting.
Correct Answer: C
Rationale: Avoiding dense undergrowth reduces tick exposure, preventing Lyme disease. Dark clothes attract ticks, sunscreen is irrelevant, and insect repellent is recommended.
Which response will the nurse most likely observe during the caloric test if the client has Meniere's disease?
- A. Onset of severe symptoms
- B. No response or change in symptoms
- C. Improvement in balance
- D. Aphasia and loss of consciousness
Correct Answer: A
Rationale: Meniere's disease causes an exaggerated response to caloric stimulation.