During the initial assessment, the nurse can assist the physician in determining the etiology of the client's problem by assessing if there is a history of which condition?
- A. Recent nasal injury
- B. Respiratory allergies
- C. Previous nasal surgery
- D. A past tonsillectomy
Correct Answer: B
Rationale: Respiratory allergies are a common cause of nasal polyps.
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After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?
- A. Wrap ice in a washcloth and put it on the burn area.
- B. Come to the ED so a doctor can assess your fingers.
- C. Run cool water over the burned area on your fingers.
- D. Apply an antibiotic skin ointment to prevent infection.
Correct Answer: C
Rationale: Ice causes vasoconstriction and can worsen the tissue damage. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing.
The nurse who documents the burn injury is accurate in identifying the full-thickness burns as having what appearance?
- A. White and leathery
- B. Pink and blistered
- C. Red and painful
- D. Mottled and wet
Correct Answer: A
Rationale: Full-thickness burns appear white, leathery, and painless due to nerve destruction.
The nurse is planning the care of a client diagnosed with psoriasis. Which psychosocial problem should be included in the plan?
- A. Alteration in comfort.
- B. Altered body image.
- C. Anxiety.
- D. Altered family processes.
Correct Answer: B
Rationale: Psoriasis’s visible plaques often cause body image disturbance. Comfort, anxiety, and family processes are secondary.
Which assessment finding is commonly noted when the intraocular pressure (IOP) of a client with angle-closure glaucoma becomes dangerously high?
- A. Spots in the visual field
- B. Severe eye pain
- C. Pinpoint pupils
- D. Bulging eyes
Correct Answer: B
Rationale: Acute angle-closure glaucoma causes severe eye pain due to rapidly elevated IOP.
The nurse participating in a health fair is discussing malignant melanoma with a group of clients. Which information regarding the use of sunscreen is important to include?
- A. Sunscreen is only needed during the hottest hours of the day.
- B. Toddlers should not have sunscreen applied to their skin.
- C. Sunscreen does not help prevent skin cancer.
- D. The higher the number of the sunscreen, the more it blocks UV rays.
Correct Answer: D
Rationale: Higher SPF numbers block more UV rays, reducing melanoma risk. Sunscreen is needed all day, safe for toddlers, and prevents skin cancer.
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