Nokea
The health department nurse is caring for the client who has leprosy (Hansen’s disease). Which assessment data indicate the client is experiencing a complication of the disease?
- A. Elevated temperature at night.
- B. Brownish-black discoloration to the skin.
- C. Reduced skin sensation in the lesions.
- D. A high count of mycobacteria in the culture.
Correct Answer: C
Rationale: Reduced sensation in lesions indicates nerve damage, a leprosy complication. Night fevers, discoloration, and bacterial load are less specific.
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The nurse participating in a health fair is discussing malignant melanoma with a group of clients. Which information regarding the use of sunscreen is important to include?
- A. Sunscreen is only needed during the hottest hours of the day.
- B. Toddlers should not have sunscreen applied to their skin.
- C. Sunscreen does not help prevent skin cancer.
- D. The higher the number of the sunscreen, the more it blocks UV rays.
Correct Answer: D
Rationale: Higher SPF numbers block more UV rays, reducing melanoma risk. Sunscreen is needed all day, safe for toddlers, and prevents skin cancer.
The client is receiving UV light treatments for psoriasis along with methoxsalen, a photosensitizing agent. What precaution should be followed the first day after treatment?
- A. Wear ultraviolet B-protective sunglasses.
- B. Avoid applying skin ointments and lotions.
- C. Check for elevated temperature every 4 hours.
- D. Stop treatments if skin redness or erythema occurs.
Correct Answer: A
Rationale: Treatment with methoxsalen (Uvadex) enhances sensitivity of the eyes to sunlight. Sunglasses that provide UVB protection need to be worn for at least 24 hours following treatments. Skin ointments may be prescribed. Temperature monitoring is not needed. Redness and erythema are normal responses.
The nurse is caring for the immobile client who is at risk for developing pressure ulcers. Which food should the nurse recommend?
- A. Assorted fruit salad
- B. Oatmeal with raisins
- C. Baked chicken breast
- D. Lettuce and tomato salad
Correct Answer: C
Rationale: Chicken is a high-protein food. Proteins are needed to help meet the body's needs for tissue repair and to maintain skin integrity. Fruit salad, oatmeal, and lettuce salad are high-fiber or carbohydrate foods, not high in protein.
Which statement is the best indication that the client understands the purpose of wearing the pressure garment?
- A. It prevents subsequent wound infection.
- B. It prevents exposure to the sun.
- C. It reduces the severity of scar formation.
- D. It reduces the potential for social rejection.
Correct Answer: C
Rationale: Pressure garments minimize hypertrophic scarring.
Which information is most appropriate to include in the discharge instructions for the client who has undergone a cataract extraction?Select all that apply.
- A. Avoid bending over from the waist.
- B. Sleep with the head slightly elevated.
- C. Wash hands before applying eye drops
- D. Sleep with the head elevated
Correct Answer: A,B,C,D
Rationale: Avoiding bending and elevating the head reduce intraocular pressure and promote healing.