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During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. Corticosteroid cream was applied to eczema.
- B. A grandson and his new dog recently visited.
- C. An old friend with eczema came for a visit.
- D. Recently received an influenza immunization.
Correct Answer: B
Rationale: Exposure to a new dog may introduce allergens like dander, triggering an eczema flare-up, making this information critical for identifying the cause of the exacerbation.
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Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's syndrome?
- A. Husky voice and complaints of hoarseness.
- B. Warm, soft, moist, salmon-colored skin.
- C. Visible swelling of the neck, with no pain.
- D. Central-type obesity, with thin extremities.
Correct Answer: D
Rationale: Central-type obesity with thin extremities is a hallmark of Cushing's syndrome due to cortisol-induced fat redistribution and muscle wasting, making it a key finding to document.
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?
- A. Joint pain.
- B. Hematuria.
- C. Low grade fever.
- D. Muscle atrophy.
Correct Answer: B
Rationale: Hematuria indicates potential kidney involvement, a serious complication of SLE that can lead to renal failure. Prompt reporting is critical for timely intervention to prevent end-stage renal disease.
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
- A. Explain specific reason for urgent notification.
- B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
- C. Preface the report by stating the client's name and admitting diagnosis.
- D. Communicate the pre-transfusion temperatures.
Correct Answer: C
Rationale: Per SBAR, starting with the client's name and diagnosis establishes identity and context, ensuring clear communication before detailing the situation, background, assessment, and recommendation.
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
- A. Reorient to day and time frequently.
- B. Apply soft wrist restraints bilaterally.
- C. Administer a PRN dose of lorazepam.
- D. Turn the television on for distraction.
- E. Present a calm, supportive demeanor.
Correct Answer: A,C,E
Rationale: Reorienting, administering lorazepam, and presenting a calm demeanor help manage postoperative delirium symptoms like hallucinations, ensuring patient safety and comfort.
A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
- A. Confirmation of the autoimmune disease process.
- B. Evidence of spread of the disease to the kidneys.
- C. Indication of the onset of joint degeneration.
- D. Representative of a decline in the client's condition.
Correct Answer: A
Rationale: Elevated rheumatoid factor is a marker of the autoimmune process in rheumatoid arthritis, confirming the diagnosis and indicating disease severity, not specific organ involvement or decline.