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If a client with a middle ear infection reports the following symptoms, which one suggests that 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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While the nurse is assessing the client hospitalized with recurrent lower-extremity cellulitis, the client states, 'I have athlete's foot; do you want to check it?' The nurse concludes that this information is significant for what reason?
- A. Cellulitis is commonly caused by a similar fungal infection.
- B. Both infections should resolve with topical fungicide therapy.
- C. Painful neuralgia can occur after the cellulitis infection has resolved.
- D. The skin disruption with tinea pedis may be the cause of the cellulitis.
Correct Answer: D
Rationale: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Chronic athlete's foot causes minute breaks in the skin, allowing bacteria on the skin to enter the tissue and cause the infectious process. Cellulitis is caused by a bacterial infection, not fungal. Cellulitis requires antibiotics, not fungicides. Neuralgia is associated with herpes zoster, not cellulitis.
The client has had a squamous cell carcinoma removed from the lip. Which discharge instructions should the nurse provide?
- A. Notify the HCP if a nonhealing lesion develops around the mouth.
- B. Squamous cell carcinoma tumors do not metastasize.
- C. Limit foods to liquid or soft consistency for one (1) month.
- D. Apply heat to the area for 20 minutes every four (4) hours.
Correct Answer: A
Rationale: Nonhealing lesions suggest recurrence, requiring HCP notification. Squamous cell carcinoma can metastasize, diet restrictions are unnecessary, and heat is inappropriate.
Which nursing action is best for controlling the client's nosebleed?
- A. Have the client lie down slowly and swallow frequently.
- B. Have the client lie down and breathe through the mouth.
- C. Have the client lean forward and apply direct pressure to the nose.
- D. Have the client lean forward and clench the teeth.
Correct Answer: C
Rationale: Leaning forward and pinching the nose controls bleeding effectively.
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.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?
- A. Replace fluids and electrolytes.
- B. Prevent contractures of extremities.
- C. Monitor urine output hourly.
- D. Prepare to assist with an escharotomy.
Correct Answer: A
Rationale: Massive fluid loss in 65% burns requires immediate fluid and electrolyte replacement to prevent shock. Contracture prevention, urine monitoring, and escharotomy are secondary after fluid resuscitation.