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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.
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Because the immobile client slides down in bed, the nurse is correct to assess for which type of skin injury?
- A. One that results from continuous pressure
- B. One that results from a shearing force
- C. One that results from friction
- D. One that results from agitation in bed
Correct Answer: B
Rationale: Sliding causes shearing forces, damaging skin and underlying tissue.
The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client’s fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data?
- A. Tinea capitis.
- B. Herpes simplex 2.
- C. Scabies.
- D. Psoriasis.
Correct Answer: C
Rationale: Itching and threadlike burrows between fingers indicate scabies. Tinea capitis affects the scalp, HSV-2 is genital, and psoriasis causes plaques.
Which action is the nurse's immediate priority?
- A. Rub petroleum jelly into the burned areas.
- B. Wrap the affected areas with a clean cloth.
- C. Apply cool water to the burns.
- D. Roll the victim to smother the flames.
Correct Answer: D
Rationale: Smothering flames stops the burning process, the immediate priority.
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.
Which signs and symptoms indicate that the nursing assistant has had an allergic reaction to the latex gloves? Select all that apply.
- A. Raised areas and blisters on the hands
- B. Itchy, red, watery eyes
- C. Nausea and vomiting
- D. Hives
- E. Chest tightness
Correct Answer: A,B,D,E
Rationale: These symptoms indicate a latex allergy, ranging from local to systemic reactions.