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The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client’s fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data?
- A. Tinea capitis.
- B. Herpes simplex 2.
- C. Scabies.
- D. Psoriasis.
Correct Answer: C
Rationale: Itching and threadlike burrows between fingers indicate scabies. Tinea capitis affects the scalp, HSV-2 is genital, and psoriasis causes plaques.
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When assessing the client's skin the nurse notices a rounded area of hair loss with redness, pustules, and scales that appear greenish-yellow when exposed to a black light (Wood's lamp). The nurse should plan to implement treatment for which condition?
- A. Lyme disease
- B. Fungal infection
- C. Anaerobic infection
- D. Contact dermatitis
Correct Answer: B
Rationale: A fungal infection that manifests on the scalp with red, scaly lesions and hair loss will appear either greenish-yellow or bluish-green under a Wood's lamp. Lyme disease produces a bull's-eye rash that does not fluoresce. Anaerobic infections have diffuse redness and do not fluoresce. Contact dermatitis does not display a discrete, rounded area of hair loss or fluoresce.
The nurse is caring for the client with a large, open sternal wound resulting from a burn injury. The client is receiving enteral feeding, Oxepa (an anti-inflammatory, pulmonary 1.5 Cal/mL formula), at 25 mL/hour. Which laboratory value finding best indicates that the client is receiving inadequate nutrition?
- A. Phosphorus
- B. Platelets
- C. Prealbumin
- D. Potassium
Correct Answer: C
Rationale: Prealbumin is used to evaluate nutritional status. A low level of prealbumin indicates inadequate nutrition. Prealbumin has a half-life of 2 days and reflects changes in serum protein stores more rapidly than other indices. The phosphorus level decreases in malnutrition as well as other conditions, but this is not the best indicator of inadequate nutrition. Platelets are essential to blood clotting and may or may not be altered with inadequate nutrition. Potassium is the major cation within the cell and may be low due to renal failure or GI disorders.
The experienced nurse is observing the new nurse administer medications. Which actions by the new nurse require the experienced nurse to intervene? Select all that apply.
- A. Applies tretinoin to an open wound on the face of the client with acne
- B. Withholds isotretinoin until the client's pregnancy status is known
- C. Withholds fluorouracil because the client's papules of actinic keratosis are worse
- D. Waits two hours after the client bathes and uses lotion to apply tacrolimus
- E. Tells the client taking acitretin for psoriasis to prevent pregnancy for a year
Correct Answer: A,C,E
Rationale: Tretinoin (Retin-A) should not be applied to open wounds; the experienced nurse should intervene. Actinic keratosis treatment using fluorouracil (Carac) causes the affected area to become worse before getting better; the medication should not be withheld. When taking acitretin (Soriatane), the client should not become pregnant for three years following treatment. Withholding isotretinoin until pregnancy status is known is appropriate. Waiting two hours to apply tacrolimus after lotion is correct.
On inspecting the client's eye, the nurse will note which symptom of conjunctivitis in addition to erythema?
- A. Dried drainage along the eyelid
- B. Lack of pupil response to light
- C. Bulging of the eye from the orbit
- D. Loss of moisture on the cornea
Correct Answer: A
Rationale: Conjunctivitis often presents with dried, crusty drainage along the eyelid.
The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority.
- A. Estimate the amount of burned area using the rule of nines.
- B. Insert two (2) 18-gauge catheters and begin fluid replacement.
- C. Apply sterile saline dressings to the burned areas.
- D. Determine the client’s airway status.
- E. Administer morphine sulfate, IV.
Correct Answer: D,B,E,A,C
Rationale: Priority: 1) Airway status (ABCs); 2) IV catheters/fluids (prevent shock); 3) Morphine (pain control); 4) Rule of nines (guide resuscitation); 5) Sterile dressings (infection prevention).