Nokea
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, 'What is a xenograft?' Which statement by the nurse would be the best response?
- A. The doctor will graft skin from your back to your leg.'
- B. The skin from a donor will be used to cover your burn.'
- C. The graft will come from an animal, probably a pig.'
- D. I think you should ask your doctor about the graft.'
Correct Answer: C
Rationale: A xenograft uses animal skin (e.g., porcine) for temporary burn coverage. Autografts use the patient’s skin, allografts use donor human skin, and deferring to the doctor avoids education.
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When the client asks the nurse about the purpose of the eye shield, which explanation is best?
- A. The shield keeps foreign substances out of the eye.
- B. The shield protects the eye from accidental trauma.
- C. The shield reduces rapid eye movement when dreaming.
- D. The shield promotes dilation of the pupil at night.
Correct Answer: B
Rationale: The shield prevents accidental trauma to the healing eye during sleep.
The nurse is caring for the client diagnosed with contact dermatitis. Which collaborative intervention should the nurse implement?
- A. Encourage the use of support stockings.
- B. Administer a topical anti-inflammatory cream.
- C. Remove scales frequently by shampooing.
- D. Shampoo with lindane 1%, an antiparasitic, weekly.
Correct Answer: B
Rationale: Topical anti-inflammatory cream (e.g., steroids) treats contact dermatitis. Stockings, scale removal, and lindane are irrelevant.
The nurse correctly hands the physician which solution?
- A. Povidone-iodine (Betadine)
- B. Gentian violet
- C. Will have to remove my prosthesis for cleaning.
- D. Fluorescein
Correct Answer: D
Rationale: Fluorescein is used to stain the cornea to detect foreign bodies or injuries.
The nurse is assessing the client with atopic dermatitis. Which finding should the nurse expect?
- A. Patchy loss of skin pigmentation called vitiligo.
- B. Trichotillomania, a type of hair loss from compulsive pulling and/or twisting of the hair.
- C. Blistering, redness, and a white patch between the fingers, characteristic of candidiasis.
- D. Atopic dermatitis, which is characterized by redness and irregular, scaly lesions.
Correct Answer: D
Rationale: Atopic dermatitis is characterized by redness and irregular, scaly lesions. Vitiligo shows patchy loss of pigmentation. Trichotillomania involves hair loss from compulsive pulling. Candidiasis shows blistering, redness, and white patches.
When the nurse inspects the client's eyes, which clinical finding is most indicative of cataracts?
- A. Ruptured blood vessels in the eye
- B. An irregularly shaped iris
- C. A white spot behind the pupil
- D. A painless corneal lesion
Correct Answer: C
Rationale: A white spot behind the pupil indicates lens clouding, characteristic of cataracts.