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An area of erythema on the child's skin is being assessed by the nurse. The
nurse presses down on the area, and the area becomes white. What time does
the nurse document for this finding?
- A. Non-blanching
- B. Blanching
- C. Redness
- D. Warmth
Correct Answer: B
Rationale:
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The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?
- A. "My grandfather always had problems with his arthritis, and he would tell me that it is better to be more stoic and not let pain interrupt your life"?
- B. "There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."?
- C. "Place throw rugs throughout your home. You will enjoy how pretty they are, and you can use them to cover up power cords, so you do not trip on them."?
- D. "Lack of home safety may be an issue of compliance. Are you being compliant with your medication?"?
Correct Answer: B
Rationale: The correct answer is B. This statement is the most appropriate because it focuses on providing practical solutions to enhance the client's safety at home while managing rheumatoid arthritis. Adaptive devices like grab bars, reaching tools, grasping devices, and adaptive silverware can help the client maintain independence and prevent accidents. Choice A is incorrect as it does not provide practical advice on home safety but rather a personal anecdote. Choice C is incorrect as throw rugs can pose a tripping hazard instead of enhancing safety. Choice D is also incorrect as it does not directly address home safety measures but rather shifts the focus to medication compliance.
Where will the nurse collect the most reliable source of pain assessment?
- A. From the nurse-to-nurse bedside report
- B. From a medical surgical book
- C. From the client
- D. From the client's chart
Correct Answer: C
Rationale:
By providing measures to reduce skin breakdown, how does the nurse break the
chain of infection?
- A. Sterilizing the area to reduce the reservoir risk
- B. Maintaining the integrity of a portal of entry
- C. Creating a reservoir to decrease the risk of infection
- D. Creating a susceptible host
Correct Answer: B
Rationale:
A nurse is caring for a client who has acute osteomyelitis. Which of the
following interventions is the nurse's priority?
- A. Administer antibiotics to the client
- B. Increase the client's protein intake
- C. Teach relaxation breathing to reduce the client's pain
- D. Provide the client with anti-pyretic therapy
Correct Answer: A
Rationale:
The nurse is caring for a client who develops compartment syndrome from a
severely fractured arm. The client asks how this can happen. What is the best
response by the nurse?
- A. . "The fascia expands with injury, causing pressure on underlying nerves and muscles."?
- B. "An injured artery causes impaired arterial perfusion through the compartment."?
- C. "Bleeding and swelling cause increased pressure in an area that cannot expand."?
- D. . "A bone fragment has injured the nerve supply in the area."?
Correct Answer: C
Rationale: