Nokea
The client is diagnosed with acne vulgaris. Which psychosocial problem is priority?
- A. Impaired skin integrity.
- B. Ineffective grieving.
- C. Body image disturbance.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Acne vulgaris often causes body image disturbance, especially in adolescents, due to visible lesions. Skin integrity, grieving, and knowledge are secondary.
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What is the most common profile of a client with malignant melanoma?
- A. An African American client with dark skin and dark hair
- B. A Scandinavian client with freckles and blue eyes
- C. A Mexican client with tan skin and dark brown hair
- D. A Caucasian client with brown hair and brown eyes
Correct Answer: B
Rationale: Fair-skinned individuals with freckles are at higher risk for melanoma.
The nurse determines that the fluid status of the client with a second-degree burn is inadequate and immediately notifies the HCP. The client is 5 hours postburn and weighs 60 kg. Which findings prompted the nurse's action?
- A. Blood pressure 92/60 mm Hg and pulse 100 bpm
- B. Respirations 18 per minute and pulse 60 bpm
- C. Pulse 130 bpm and urine output 25 mL/hr
- D. Pulse 106 bpm and temperature 98.4°F (36.9°C)
Correct Answer: C
Rationale: The client weighing 60 kg weighs 132 lb (1 kg = 2.2 lb). For the adult client weighing 132 lb, a pulse rate of 130 bpm (tachycardia) and a low urine output of 25 mL/hr are signs of inadequate circulating fluid volume. The MAP for a BP of 92/60 mm Hg is 70.7, indicating adequate perfusion. A pulse of 100 bpm is WNL. Respirations of 18 per minute and pulse of 60 bpm are both WNL. A pulse of 106 bpm could be elevated due to pain, and the temperature of 98.4°F (36.9°C) is considered normal.
The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse?
- A. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance.
- B. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit.
- C. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift.
- D. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing.
Correct Answer: B
Rationale: Delaying turning immobile clients risks pressure ulcers, requiring immediate intervention. Bed elevation, restocking, and Thick-It are appropriate.
Which nursing intervention is most appropriate to include in the care plan of an anxious client who is blind or has the eyes patched?
- A. Touch the client before speaking.
- B. Explain what you plan to do beforehand.
- C. Stand in front of the client when speaking.
- D. Leave the room lights on at all times.
Correct Answer: B
Rationale: Explaining actions beforehand reduces anxiety by preparing the client for what to expect.
The nurse is caring for the client with psoriasis taking methotrexate. Which laboratory tests are most important for the nurse to monitor? Select all that apply.
- A. Serum potassium level
- B. Liver function tests
- C. Serum glucose level
- D. Arterial blood gases
- E. White blood cells
Correct Answer: B,E
Rationale: The nurse should monitor liver function tests because methotrexate (Trexall) is metabolized by the liver, and a side effect is hepatotoxicity. The nurse should monitor WBCs because a side effect of methotrexate use is leukopenia. Methotrexate has no effect on serum potassium unless complications arise. Glucose monitoring is needed only if the client is diabetic. ABGs are not prescribed for routine monitoring.