The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?
- A. This surgery will create a skin flap to cover my wounds.'
- B. This surgery will get all the old black tissue out of the wound so it can heal.'
- C. The surgery is important to allow oxygen to get to the tissue for healing to occur.'
- D. Stool will come out an opening in my abdomen so it won’t get in the sore.'
Correct Answer: D
Rationale: Fecal diversion (colostomy) prevents stool contamination of coccyx ulcers, aiding healing. Skin flaps, debridement, and oxygen delivery are unrelated to this surgery.
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Which finding of the client's biographical data most likely contributed to developing skin cancer?
- A. The client is a chronic cigarette smoker.
- B. The client has male pattern baldness.
- C. The client works for a drug manufacturer.
- D. The client bathes with a deodorant soap.
Correct Answer: B
Rationale: Baldness increases scalp sun exposure, a risk factor for skin cancer.
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 is caring for clients with second- and third-degree burns. Which medication should the nurse plan to apply topically to treat bacterial and yeast infections?
- A. Bismuth subsalicylate
- B. Gold sodium thiomalate
- C. Silver sulfadiazine
- D. Arsenic trioxide
Correct Answer: C
Rationale: Silver sulfadiazine (Silvadene) is a topical anti-infective agent for prevention and treatment of wound infection in second- and third-degree burn clients. Bismuth subsalicylate (Kaopectate) is an antidiarrheal medication. Gold sodium thiomalate (Aurolate) is used to treat rheumatoid arthritis resistant to conventional therapy. Arsenic trioxide (Trisenox) is an antineoplastic.
Which statement by the client diagnosed with chickenpox indicates that the client understands the teaching?
- A. I should put rubbing alcohol on the lesions twice a day.'
- B. I should not scratch myself if at all possible. It might lead to scarring.'
- C. I can go to work when my lesions have all disappeared.'
- D. I need to take all my antibiotics no matter how I feel.'
Correct Answer: B
Rationale: Avoiding scratching prevents scarring and infection in chickenpox. Alcohol is harmful, contagiousness persists post-lesions, and antibiotics are not used.
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client’s mental health?
- A. Encourage the client to stay at home as much as possible.
- B. Discuss the importance of not relying on the family for needs.
- C. Tell the client to remember that changes in lifestyle take time.
- D. Instruct the client to discuss feelings only with the therapist.
Correct Answer: C
Rationale: Acknowledging lifestyle changes promotes mental health by fostering realistic expectations. Isolation, independence from family, or limiting discussions hinder recovery.
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