Nokea
The client is complaining of severe itching following a course of antibiotics. Which independent nursing action should the nurse implement?
- A. Refer to an allergy specialist to begin desensitization.
- B. Use a tar-preparation gel after each shower or bath.
- C. Keep the covers tightly around the client at night.
- D. Take baths with an OTC colloidal oatmeal preparation.
Correct Answer: D
Rationale: Colloidal oatmeal baths relieve itching, an independent nursing action. Specialist referral, tar gels, and tight covers are inappropriate or dependent.
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The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?
- A. I used the comb to remove all the nits.'
- B. I washed my hair with Kwell shampoo.'
- C. I removed all the sheets from my bed.'
- D. I had to fix my daughter’s hair with my brush.'
Correct Answer: D
Rationale: Sharing a brush risks reinfestation with lice, indicating noncompliance. Combing nits, using Kwell, and washing sheets are correct.
The client with thick, crusty, yellow toenails is diagnosed with tinea unguium (onychomycosis) and asks the clinic nurse what happens if he can’t afford to take the medication the physician prescribed. The nurse’s response will be based on which scientific rationale?
- A. The toes will become gangrenous and may have to be amputated.
- B. Over-the-counter antifungal creams can be substituted for the oral medication.
- C. The toenail plate will separate and the entire toenail may be destroyed.
- D. Take all the prescribed antibiotics or the infection may return.
Correct Answer: C
Rationale: Untreated onychomycosis can destroy the toenail plate, causing separation. Gangrene is unlikely, OTC creams are less effective, and antibiotics are irrelevant.
Which statement by the nurse most accurately explains the pathophysiology of conductive hearing loss?
- A. Sound waves do not travel to the inner ear.
- B. There is a malfunction of inner ear structures.
- C. The auditory nerve does not transmit sound to the brain.
Correct Answer: A
Rationale: Conductive hearing loss occurs when sound waves are blocked from reaching the inner ear.
Which response demonstrates that the parents understand the nurse's explanation of why organisms travel more easily from the nasopharynx to the middle ear in a child?
- A. A child's eustachian tube is shorter and straighter.
- B. A child's eustachian tube is longer and straighter.
- C. A child's eustachian tube is longer and more curved.
Correct Answer: A
Rationale: A shorter, straighter eustachian tube in children facilitates organism travel.
Which of the following clients should have his clothing removed immediately?
- A. A 32-year-old man who was burned while working on high-tension wires
- B. A 14-year-old boy who suffered severe smoke inhalation during a fire at school
- C. A 78-year-old man who was burned during a fire that started when the client fell asleep while smoking
- D. A 19-year-old student who spilled chemicals on himself in the chemistry lab at school
Correct Answer: D
Rationale: Clothing must be removed immediately in chemical burns to prevent further skin exposure and damage from the corrosive substance.