Nokea
The client diagnosed with a verruca vulgaris (wart) on the left ring finger below the knuckle is prescribed a colloidal acid solution. Which information should the nurse discuss with the client?
- A. Apply the solution to the wart every 12 hours.'
- B. Expect the wart to disappear within 1 week.'
- C. Be careful because the wart may spread easily.'
- D. Do not wear any rings on the left hand.'
Correct Answer: A
Rationale: Apply acid (e.g., salicylic/lactic) every 12-24 hours for 2-3 weeks. It takes 2-3 weeks to work, not 1, and it doesn't spread easily or restrict ring use.
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When reading the admission assessment for a patient, the nurse notes that the patient has an excoriated area on the skin of the right forearm. Which nursing action will be included in the plan of care?
- A. Apply moisturizing lotion to the area.
- B. Assess the area daily for atrophy.
- C. Scrub the affected area vigorously.
- D. Cover the area with a sterile dressing.
Correct Answer: D
Rationale: Excoriated areas should be covered with a dressing to decrease the risk for infection. Application of moisturizer would not help the excoriation and might lead to infection. There is no evidence that the skin is atrophied. Scrubbing the excoriated area would cause further damage.
A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus (MRSA)?
- A. Client admitted from a nursing home with furuncles and folliculitis
- B. Client with a leg cut and other trauma from a motorcycle crash
- C. Client with a rash noticed after participating in sporting events
- D. Client transferred from intensive care with an elevated white blood cell count
Correct Answer: A
Rationale: The client in long-term care with furuncles and folliculitis is at high risk for MRSA.
A patient with a sacral stage III pressure ulcer has an elevated temperature. What diagnostic test would help determine if this patient is developing osteomyelitis?
- A. CT scan
- B. Bone biopsy
- C. Venous Doppler
- D. Serum electrolytes
Correct Answer: B
Rationale: Bone biopsy is the gold standard to diagnose osteomyelitis by directly sampling bone for infection, especially in a stage III ulcer context.
The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate?
- A. Gently palpate the affected area using sterile gloves.
- B. Apply vinegar to the affected area to identify the scabies.
- C. Use a magnifying glass and a penlight to visualize the skin.
- D. Obtain a Doppler to assess the movement of the mites.
Correct Answer: C
Rationale: Scabies burrows are best visualized with magnification and light to confirm diagnosis.
A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition?
- A. What do you do for a living?
- B. Are your nails professionally manicured?
- C. Do you have diabetes mellitus?
- D. Have you had a recent fungal infection?
Correct Answer: A
Rationale: The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.