Nokea
The clinician is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?
- A. Covering the wound with a dry dressing
- B. Using hydrogen peroxide soaks
- C. Leaving the area open to dry
- D. Applying a hydrocolloid or foam dressing
Correct Answer: D
Rationale: Applying a hydrocolloid or foam dressing is the most effective treatment to promote healing for a Stage 2 skin ulcer. These dressings create a moist environment that supports healing and prevents further tissue damage. Option A (covering the wound with a dry dressing) can lead to drying out the wound bed, hindering healing. Option B (using hydrogen peroxide soaks) can be too harsh and may damage the surrounding healthy tissue. Option C (leaving the area open to dry) can delay healing as it does not provide the necessary moist environment for optimal wound healing.
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The female is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?
- A. Should be postponed because it may cause embarrassment.
- B. Should be unnecessary because the patient is uncircumcised.
- C. Should be done by the patient.
- D. Should be done by the nurse.
Correct Answer: C
Rationale: Perineal care should be encouraged to be done by the patient if they are capable of performing self-care. In this scenario, the patient is not ambulatory and has full function of all extremities, indicating that the patient can independently perform perineal care. Encouraging self-care promotes independence and maintains the patient's dignity. Postponing perineal care (Choice A) is incorrect because it is essential for hygiene. Choice B is incorrect as perineal care is necessary for all patients regardless of circumcision status. Choice D is incorrect as the patient is capable of performing the care independently, and promoting self-care is a priority in nursing practice.
A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect?
- A. Concave thoracic spine posteriorly
- B. Exaggerated lumbar curvature
- C. Concave lumbar spine posteriorly
- D. Exaggerated thoracic curvature
Correct Answer: B
Rationale: When assessing a young adult's musculoskeletal system, the nurse should expect an exaggerated lumbar curvature (lordosis). This is a normal finding in young adults due to the natural curvature of the spine. Concave thoracic spine posteriorly (choice A) and concave lumbar spine posteriorly (choice C) are not typical findings as the spine should have normal curvatures. Exaggerated thoracic curvature (choice D) is also not a typical finding in young adults.
The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority?
- A. Feet
- B. Nail beds
- C. Perineum
- D. Oral cavity
Correct Answer: D
Rationale: The correct answer is the oral cavity. During cancer treatment involving radiation to the head and intravenous chemotherapy, the oral cavity is a priority assessment area. Radiation can reduce salivary flow and lower the pH of saliva, which can lead to stomatitis and tooth decay. Assessing the oral cavity allows for the early identification and management of potential complications.
Choice A, assessing the feet, is not the priority in this scenario as it is not directly impacted by the described cancer treatments.
Choice B, assessing the nail beds, is not the priority compared to the oral cavity. Nail bed assessment may be relevant for certain conditions, but in this case, the oral cavity is of higher priority due to the specific treatment effects.
Choice C, assessing the perineum, is also not the priority in this situation as it is not directly affected by the described cancer treatments, unlike the oral cavity.
A client with rheumatoid arthritis is prescribed prednisone. What information should the LPN/LVN include when teaching the client about this medication?
- A. Take the medication with food to minimize gastrointestinal side effects.
- B. Avoid exposure to sunlight while taking this medication.
- C. Do not discontinue the medication abruptly.
- D. Increase fluid intake while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: 'Do not discontinue the medication abruptly.' It is crucial for clients prescribed prednisone to not stop the medication suddenly to prevent adrenal insufficiency, as this medication suppresses the body's natural production of cortisol. Choice A is incorrect because prednisone should be taken with food to minimize gastrointestinal side effects, not necessarily to prevent stomach upset. Choice B is incorrect as there is no specific need to avoid sunlight while taking prednisone. Choice D is not directly related to prednisone use; while adequate fluid intake is generally beneficial, it is not a specific instruction for prednisone administration.
A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?
- A. Musculoskeletal weakness
- B. Loss of appetite
- C. Increased heart rate during physical activity
- D. Left lower extremity tenderness
Correct Answer: D
Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.