Nokea
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.
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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 planning care for the client with a Stage II pressure ulcer on the ball of the right foot. Which interventions should the nurse include in this client's care? Select all that apply.
- A. Obtain cultures of the wound daily.
- B. Clean vigorously to remove dead tissue.
- C. Cover with a protective dressing.
- D. Reposition at least every two hours.
- E. Elevate the right heel completely off the bed.
Correct Answer: C,D,E
Rationale: The dressing protects the underlying wound and provides a moist environment for healing. The client should be repositioned at least every 2 hours. Positioning devices are utilized to keep the load or pressure off the wound. Daily wound cultures are unnecessary, as all wounds contain bacteria. The wound should be cleansed gently to prevent further tissue trauma.
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.
When the nurse applies mafenide acetate cream to the burn wound, the nurse should recognize which of the following as its chief disadvantage?
- A. Skin discoloration
- B. Pain on application
- C. Unpleasant odor
- D. Contact dermatitis
Correct Answer: B
Rationale: Mafenide acetate causes significant pain upon application.
The client is diagnosed with herpes simplex 2 and prescribed the antiviral medication valacyclovir (Valtrex). Which instructions should the nurse teach?
- A. This medication will prevent pregnancy and treat the virus.
- B. This medication must be tapered when discontinuing the medication.
- C. This medication will suppress symptoms but does not cure the disease.
- D. This medication may cause the client’s urine to turn orange.
Correct Answer: C
Rationale: Valacyclovir suppresses HSV-2 symptoms but does not cure it. It does not prevent pregnancy, require tapering, or change urine color.