Nokea
Before leaving the room, which of the following nursing actions should the nurse perform?
- A. The nurse straightens the client's linens.
- B. The nurse informs the client when leaving the room.
- C. The nurse offers to give the client a back rub.
- D. The nurse shares some current events with the client.
Correct Answer: B
Rationale: Informing the client when leaving reduces anxiety and enhances safety.
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The client is admitted to the outpatient surgery center for removal of a malignant melanoma. Which assessment data indicate the lesion is a malignant melanoma?
- A. The lesion is asymmetrical and has irregular borders.
- B. The lesion has a waxy appearance with pearlike borders.
- C. The lesion has a thickened and scaly appearance.
- D. The lesion appeared as a thickened area after an injury.
Correct Answer: A
Rationale: Asymmetry and irregular borders (ABCD criteria) characterize malignant melanoma. Waxy, scaly, or post-injury lesions suggest other conditions.
What is the best evidence that the antibiotic the nurse is administering for the treatment of acute otitis media is having a therapeutic effect?
- A. The ear feels less warm to the touch.
- B. Ear drainage is thin and watery.
- C. Ear discomfort is relieved.
Correct Answer: C
Rationale: Relief of ear discomfort indicates the infection is responding to treatment.
Which individual would most likely experience the skin disorder pseudofolliculitis barbae (shaving bumps)?
- A. A male African American soldier.
- B. A female Caucasian hairdresser.
- C. A male Asian food server.
- D. A female Hispanic schoolteacher.
Correct Answer: A
Rationale: Pseudofolliculitis barbae is common in African American males due to curly hair causing ingrown hairs post-shaving. Other groups are less affected.
Which response by the nurse is best at this time?
- A. I'm sure you will look absolutely gorgeous.
- B. I didn't think you were unattractive before.
- C. Your face is swollen with bruises around the eyes.
- D. Your personality is more important than your looks.
Correct Answer: C
Rationale: An honest response about expected swelling prepares the client for recovery.
The client sustained partial- and full-thickness burns to the anterior left and right arms, anterior chest and abdominal area, and anterior left leg. Using the Rule of Nines, what is the estimated extent of this injury that the nurse should document? % (Record your answer as a whole number.)
- A. 36
Correct Answer: A
Rationale: According to the Rule of Nines, this client sustained injuries on about 36% of the body surface: right arm is 4.5%; left arm is 4.5%; left leg is 9%; anterior chest and abdomen are 18%.