Nokea
An 80-year-old man with a decubitus ulcer has just been admitted to the floor. Upon assessment of the wound, the nurse notes that an area of skin under the wound extends and creates another opening in the skin 4 centimeters away. She would chart this as
- A. tunneling.
- B. dehiscence.
- C. undermining.
- D. evisceration.
Correct Answer: A
Rationale: Tunneling is a narrow channel extending from a wound, creating another skin opening, as described. Undermining involves a wider area under intact skin, dehiscence is wound separation, and evisceration is organ protrusion.
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The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- A. Russell's traction
- B. Buck's traction
- C. Halo traction
- D. Crutchfield tong traction
Correct Answer: C
Rationale: Halo traction is used for cervical fractures and can be maintained post-discharge for stabilization.
The nurse is preparing to admit a client from the emergency department with tuberculosis. Which of the following should the nurse anticipate in caring for this client? Select all that apply.
- A. fall precautions
- B. droplet precautions
- C. airborne precautions
- D. standard precautions
- E. placement in a negative airflow room
- F. use of PPE, including an N95 mask or powered air purifying respirators (PAPRs)
Correct Answer: C, D, E, F
Rationale: Tuberculosis requires airborne precautions, standard precautions, negative airflow rooms, and N95/PAPR use due to respiratory transmission. Fall precautions are not specific, and droplet precautions are incorrect.
The nurse is caring for a client with depression over the recent death of her father from cancer. The client states, 'It's my fault. I should have insisted he get regular checkups instead of letting him put it off.' The nurse responds, 'You feel like it's your fault?' Which therapeutic communication technique is the nurse using?
- A. exploring
- B. reflecting
- C. restating
- D. focusing
Correct Answer: B
Rationale: Reflecting mirrors the client’s feelings, encouraging further expression and exploration of emotions.
Following eruption of the primary teeth, the mother can promote chewing by giving the toddler:
- A. Pieces of hot dog
- B. Carrot sticks
- C. Pieces of cereal
- D. Raisins
Correct Answer: C
Rationale: Cereal pieces are soft, safe, and promote chewing without the choking risk posed by hot dogs, carrots, or sticky raisins in toddlers.
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
- A. Brushing the teeth
- B. Drinking a glass of juice
- C. Holding a cup of coffee
- D. Brushing the hair
Correct Answer: C
Rationale: Holding a warm cup of coffee can reduce morning stiffness in rheumatoid arthritis by providing warmth and gentle joint movement.