Nokea
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority?
- A. High risk for infection.
- B. Ineffective coping.
- C. Impaired physical mobility.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Extensive burns increase infection risk due to loss of skin barrier; this is the priority. Coping, mobility, and knowledge are secondary in acute burn care.
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Which statement by the client diagnosed with chickenpox indicates that the client understands the teaching?
- A. I should put rubbing alcohol on the lesions twice a day.'
- B. I should not scratch myself if at all possible. It might lead to scarring.'
- C. I can go to work when my lesions have all disappeared.'
- D. I need to take all my antibiotics no matter how I feel.'
Correct Answer: B
Rationale: Avoiding scratching prevents scarring and infection in chickenpox. Alcohol is harmful, contagiousness persists post-lesions, and antibiotics are not used.
The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
- A. Instruct the clients to wear dark clothes when hunting.
- B. Use a sunscreen of at least SPF 30 when outside.
- C. Avoid dense undergrowth when in a wooded area.
- D. Do not use any type of insect repellant when deer hunting.
Correct Answer: C
Rationale: Avoiding dense undergrowth reduces tick exposure, preventing Lyme disease. Dark clothes attract ticks, sunscreen is irrelevant, and insect repellent is recommended.
The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychosocial problem of 'fear.' Which nursing interventions should be included in the plan of care?
- A. Explain to the client that the fears are unfounded.
- B. Encourage the client to verbalize the feeling of being afraid.
- C. Have the HCP discuss the client’s fear with the client.
- D. Instruct the client regarding all planned procedures.
Correct Answer: B
Rationale: Verbalizing fear helps address anxiety and promotes coping. Dismissing fears, deferring to HCP, or procedure instruction are less therapeutic.
After cleaning a client's prescription eyeglasses with soap and warm water or a commercial glass cleaner, which nursing action is best for drying the moist lenses?
- A. Rub the lenses with a paper tissue.
- B. Wipe the lenses with a soft cloth.
- C. But the lenses with a paper towel.
- D. Blow on the lenses to promote air drying.
Correct Answer: B
Rationale: A soft cloth prevents scratches and effectively dries the lenses.
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.