Nokea
The client mentions all of the following to the nurse. Which of the following should the client be encouraged to report to the physician immediately?
- A. A small mole on the right thigh that has looked the same ever since the client can remember
- B. A pigmented area that is pink-red in color and has been present since birth
- C. Three small warts on the right hand that have been present for some time
- D. A black and purple mole that is growing larger and has a funny shape
Correct Answer: D
Rationale: A growing, irregularly shaped, and discolored mole may indicate melanoma, requiring immediate medical evaluation.
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The school nurse is discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, 'How can I prevent getting impetigo?' Which statement would be the most appropriate response?
- A. Wash your hands after using the bathroom.'
- B. Do not touch any affected areas without gloves.'
- C. Apply a topical antibiotic to your hands.'
- D. Keep the child with impetigo isolated in the room.'
Correct Answer: B
Rationale: Avoiding contact with impetigo lesions without gloves prevents transmission. Handwashing is general, topical antibiotics are for treatment, and isolation is excessive.
The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first?
- A. The client scheduled for a skin biopsy who is crying.
- B. The client who had surgery three (3) hours ago and is sleeping.
- C. The client who needs to void prior to discharge.
- D. The client who has received discharge instructions and is ready to go home.
Correct Answer: A
Rationale: Crying suggests emotional distress or pain, requiring immediate assessment. Sleeping, voiding, and discharge-ready clients are stable.
While the nurse is assessing the client hospitalized with recurrent lower-extremity cellulitis, the client states, 'I have athlete's foot; do you want to check it?' The nurse concludes that this information is significant for what reason?
- A. Cellulitis is commonly caused by a similar fungal infection.
- B. Both infections should resolve with topical fungicide therapy.
- C. Painful neuralgia can occur after the cellulitis infection has resolved.
- D. The skin disruption with tinea pedis may be the cause of the cellulitis.
Correct Answer: D
Rationale: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Chronic athlete's foot causes minute breaks in the skin, allowing bacteria on the skin to enter the tissue and cause the infectious process. Cellulitis is caused by a bacterial infection, not fungal. Cellulitis requires antibiotics, not fungicides. Neuralgia is associated with herpes zoster, not cellulitis.
The nurse is preparing to irrigate the student's eye. What steps are appropriate in completing the irrigation? Select all that apply.
- A. The use the solution directly into the center of the eye.
- B. Tilt the head toward the opposite eye.
- C. Perform hand hygiene and put on gloves.
- D. Offer the client a paper tissue.
- E. Place the solution into the conjunctival sac.
- F. Continue eye irrigations until all redness is resolved.
Correct Answer: C,E
Rationale: Hand hygiene and gloves prevent infection, and placing the solution in the conjunctival sac ensures effective irrigation without damaging the cornea.
The nurse is preparing the plan of care for a client diagnosed with Stevens-Johnson syndrome. Which interventions should the nurse include? Select all that apply.
- A. Monitor intake and output every eight (8) hours.
- B. Assess breath sounds and rate every four (4) hours.
- C. Assess vesicles, erosions, and crusts frequently.
- D. Perform the whisper test for auditory changes daily.
- E. Assess orientation to person, place, and time every shift.
Correct Answer: A,B,C,E
Rationale: Monitoring I&O, breath sounds, skin lesions, and orientation address SJS complications (fluid loss, respiratory issues, skin breakdown, neurological changes). Whisper test is irrelevant.