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Because the immobile client slides down in bed, the nurse is correct to assess for which type of skin injury?
- A. One that results from continuous pressure
- B. One that results from a shearing force
- C. One that results from friction
- D. One that results from agitation in bed
Correct Answer: B
Rationale: Sliding causes shearing forces, damaging skin and underlying tissue.
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If a client with a middle ear infection reports the following symptoms, the blood pressure and the infection has spread to the inner ear?
- A. Temporal headaches
- B. A sore throat
- C. Nasal congestion
- D. Postural dizziness
Correct Answer: D
Rationale: Postural dizziness suggests inner ear involvement, such as labyrinthitis.
Which standing nursing order should be eliminated from this client's care plan?
- A. Keep the client's bed in a low position at all times.
- B. Urge the client to cough every 2 hours while awake.
- C. Assist the client when ambulating in the hall or room.
Correct Answer: B
Rationale: Coughing is unnecessary and may increase intraocular pressure, risking complications.
Which laboratory test should the nurse monitor to identify an allergic reaction for the client diagnosed with contact dermatitis?
- A. IgA.
- B. IgD.
- C. IgE.
- D. IgG.
Correct Answer: C
Rationale: IgE mediates allergic reactions, elevated in contact dermatitis. IgA, IgD, and IgG are less relevant.
The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers?
- A. Constant perineal moisture.
- B. Ability of the clients to reposition themselves.
- C. Decreased elasticity of the skin.
- D. Impaired cardiovascular perfusion of the periphery.
Correct Answer: A
Rationale: Perineal moisture is modifiable through hygiene and barriers, reducing ulcer risk. Repositioning ability, skin elasticity, and perfusion are less modifiable.
The nurse is speaking with clients during a wellness fair. What information should the nurse provide to prevent or minimize burn injury? Select all that apply.
- A. Wear flame-retardant clothing, especially near flames.
- B. Use 'stop, drop, and roll' maneuvers if clothing is on fire.
- C. Burn candles that are placed only in glass containers.
- D. Put out a cooking fire by throwing salt on the fire.
- E. Install smoke detectors, including one by the furnace.
Correct Answer: A,B,E
Rationale: The nurse should discuss flame-retardant clothing. 'Stop, drop, and roll' maneuvers should be used to minimize burn. Smoke detectors should be included throughout the home, including one near the furnace. It does not matter what type of container holds the burning candle. For a small fire on the stove, covering the flame with a lid is recommended.