Nokea
The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal?
- A. The client will refrain from scratching the skin.
- B. The client will maintain intact skin integrity.
- C. The client will have relief from itching.
- D. The client will not develop a secondary bacterial infection.
Correct Answer: B
Rationale: Maintaining intact skin integrity is a long-term goal, preventing complications from viral lesions. Refraining from scratching, itch relief, and infection prevention are interventions.
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The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?
- A. Wear a sunscreen with a protection factor of 10 or less when in the sun.
- B. Try to stay out of the sun between 0300 and 0500 daily.
- C. Perform a thorough skin check monthly.
- D. Remember caps and long sleeves do not help prevent skin cancer.
Correct Answer: C
Rationale: Monthly skin checks detect early skin cancer changes. SPF 10 is inadequate, 0300–0500 is nighttime, and caps/long sleeves are protective.
The nurse identifies the concept of impaired skin integrity for a pediatric client diagnosed with impetigo on the arms. Which interventions should the nurse implement?
- A. Teach the parents to ensure the child takes all the prescribed antibiotics.
- B. Give the parents a written excuse so the child can go back to school.
- C. Encourage the parents to bathe the child in an oatmeal bath for the itching.
- D. Apply topical lidocaine before debriding the crusts from the lesions.
Correct Answer: A
Rationale: Completing antibiotics ensures impetigo resolution, addressing skin integrity. School return requires clearance, oatmeal baths are for comfort, and lidocaine is unnecessary.
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.
After reviewing the medical orders, which of the following is essential for the nurse to assess preoperatively?
- A. The client's face for skin lesions
- B. The client of the last dose of anticoagulant
- C. The client's right eye for drainage
- D. The client's left eye for signs of strain
Correct Answer: B
Rationale: Assessing the last anticoagulant dose is critical to prevent bleeding during surgery.
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.