Nokea
The client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse?
- A. The client has bilaterally weak radial pulses.
- B. The client is able to move the left fingers.
- C. The client has a CRT less than three (3) seconds.
- D. The client is unable to remove the wedding ring.
Correct Answer: D
Rationale: Inability to remove a ring in cellulitis suggests severe edema, risking compartment syndrome, requiring immediate intervention. Weak pulses, finger movement, and normal CRT are less urgent.
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Which health teaching instruction given by the nurse is most important for a client with conjunctivitis?
- A. Eat a well-balanced, nutritious diet with plenty of fluids.
- B. Always wear dark sunglasses when in bright light.
- C. Do not share towels or washcloths with family members.
- D. Avoid all aspirin-containing products.
Correct Answer: C
Rationale: Preventing the spread of conjunctivitis involves avoiding shared items like towels.
Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion?
- A. The client will express feelings of fear.
- B. The client will ask questions about the diagnosis.
- C. The client will state a diminished level of pain.
- D. The client will demonstrate care of the operative site.
Correct Answer: D
Rationale: Demonstrating operative site care ensures healing and prevents infection, a physiological outcome. Fear, questions, and pain are psychosocial or secondary.
The nurse knows that the client who underwent a stapedectomy understands the discharge instructions when the client identifies which activity to avoid for the next 6 months?
- A. Listening to music
- B. Flying in an airplane
- C. Driving an automobile
- D. Singing in the choir
Correct Answer: B
Rationale: Pressure changes during flying can disrupt healing after a stapedectomy.
Which client signs and symptoms indicate contact dermatitis to the nurse?
- A. Erythema and oozing vesicles.
- B. Pustules and nodule formation.
- C. Varicosities and edema.
- D. Telangiectasia and flushing.
Correct Answer: A
Rationale: Erythema and oozing vesicles are hallmark signs of contact dermatitis. Pustules, varicosities, and telangiectasia suggest other conditions.
Which client is at the greatest risk for the development of skin cancer?
- A. The African American male who lives in the northeast.
- B. The elderly Hispanic female who moved from Mexico as a child.
- C. The client who has a family history of basal cell carcinoma.
- D. The client with fair complexion who cannot get a tan.
Correct Answer: D
Rationale: Fair complexion and inability to tan increase UV damage risk, elevating skin cancer likelihood. Darker skin, geography, and family history are less significant.