Nokea
The client had an allergic reaction to poison oak two (2) weeks ago. He has returned to the clinic with severe itching and weeping vesicles on the arms and legs. Which intervention should the nurse implement?
- A. Obtain a sample of the drainage for culture and sensitivities.
- B. Determine any allergic reactions to any medications taken recently.
- C. Inquire how the poison ivy/oak plants were destroyed.
- D. Assess for any temperature elevation since the last visit to the clinic.
Correct Answer: D
Rationale: Fever suggests secondary infection in persistent poison oak dermatitis, requiring assessment. Cultures, medication allergies, and plant destruction are secondary.
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Which other assessment finding is most indicative of an infection in the external ear?
- A. Foul-smelling drainage
- B. Scarred tympanic membrane
- C. Diminished hearing
- D. Enlarged lymph nodes
Correct Answer: A
Rationale: Foul-smelling drainage is a hallmark of external ear infections.
Which finding in the health history would the nurse expect of a client with otosclerosis?
- A. Hearing loss beginning in childhood
- B. Upper respiratory infections with high fevers
- C. One or more relatives similarly diagnosed
Correct Answer: C
Rationale: Otosclerosis often has a familial component, with relatives affected.
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.
Which response will the nurse most likely observe during the caloric test if the client has Meniere's disease?
- A. Onset of severe symptoms
- B. No response or change in symptoms
- C. Improvement in balance
- D. Aphasia and loss of consciousness
Correct Answer: A
Rationale: Meniere's disease causes an exaggerated response to caloric stimulation.
The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychosocial problem of 'fear.' Which nursing interventions should be included in the plan of care?
- A. Explain to the client that the fears are unfounded.
- B. Encourage the client to verbalize the feeling of being afraid.
- C. Have the HCP discuss the client’s fear with the client.
- D. Instruct the client regarding all planned procedures.
Correct Answer: B
Rationale: Verbalizing fear helps address anxiety and promotes coping. Dismissing fears, deferring to HCP, or procedure instruction are less therapeutic.