Nokea
The client is at risk for impaired skin integrity related to the need for several
weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best
action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are
still present
Correct Answer: D
Rationale:
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What is not an inappropriate nursing intervention for psoriasis?
- A. Teach the client how to utilize UV radiation
- B. Apply rubbing alcohol to plaques
- C. Apply corticosteroids as ordered
- D. Urge the client to consider participating in support groups
Correct Answer: B
Rationale:
The nurse has documented the following wound assessment. "Shallow, open,
reddened ulcer with no slough on the anterior region of the right heel?"? what
stage is the wound?
- A. Stage 3
- B. Stage 4
- C. Stage 1
- D. Stage 2
Correct Answer: D
Rationale:
The client complains of fatigue and joint pain and reports that they are
unable to walk due to pain in the knees. What is the most appropriate statement
by the nurse?
- A. "You just have arthritis and should take some ibuprofen."?
- B. "You should avoid walking. This might be osteoporosis."?
- C. "Please tell me more about when your pain started."?
- D. "You need to lose weight or the pain won't go away."?
Correct Answer: C
Rationale:
Which practice is recommended to prevent human immune deficiency virus
(HIV) transmission by health care workers?
- A. Wearing a mask within three feet of the client
- B. Intentional
- C. Using standard precautions
- D. Proliferative
Correct Answer: C
Rationale:
What is an example of a client's primary defense to infection?
- A. Intact skin
- B. Inflammation
- C. Phagocytosis
- D. Fever
Correct Answer: A
Rationale: