Nokea
The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is 'tired of it all.' Which is the nurse’s best therapeutic response?
- A. These wounds can heal if we get enough protein into you.'
- B. Are you tired of the treatments and needing to be cared for?'
- C. Why would you say that? We are doing our best.'
- D. Have you made out an advance directive to let the HCP know your wishes?'
Correct Answer: B
Rationale: Reflecting the client’s feelings encourages discussion, addressing emotional distress. Protein focus, defensiveness, or advance directives dismiss the client’s emotions.
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When instilling prescribed medication into the ear of an adult, which is the correct technique for the nurse to use to straighten the ear canal?
- A. Pull the ear upward and backward.
- B. Pull the ear upward and forward.
- C. Pull the ear downward and backward.
Correct Answer: A
Rationale: Pulling the ear upward and backward straightens the adult ear canal.
Which subjective symptom is the client most likely to report to the nurse?
- A. Burning
- B. Pressure
- C. Vertigo
- D. Pain
Correct Answer: C
Rationale: Vertigo is a hallmark symptom of Meniere's disease due to inner ear fluid imbalance.
The nurse is caring for the client with the pressure ulcer illustrated. Which stage should the nurse document?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: C
Rationale: Stage III pressure ulcer is full-thickness skin loss that extends to the subcutaneous fat, but not fascia; bone, tendon, and muscle are not visible. Stage I is intact but red and nonblanching. Stage II involves a break in the skin with partial-thickness loss. Stage IV is full-thickness loss with exposed muscle and bone.
Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis?
- A. The client will have no further outbreaks.
- B. The client will follow medical protocol.
- C. The client will shampoo three (3) times a week.
- D. The client will apply bacitracin twice daily.
Correct Answer: B
Rationale: Following medical protocol ensures effective management of seborrheic dermatitis. No outbreaks is unrealistic, shampoo frequency varies, and bacitracin is for bacterial infections.
When the nurse prepares the client for the myringotomy, which statement best explains the purpose of the procedure?
- A. A myringotomy prevents permanent hearing loss.
- B. A myringotomy provides a pathway for drainage.
- C. A myringotomy aids in administering medications.
- D. A myringotomy maintains motion of the ear bones.
Correct Answer: B
Rationale: A myringotomy creates an opening for fluid drainage, relieving pressure.