Nokea
The long-term care nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The client who has not had a bowel movement today.
- B. The client who needs the indwelling catheter changed.
- C. The client with periorbital skin lesions.
- D. The client with a stage I pressure ulcer.
Correct Answer: C
Rationale: Periorbital skin lesions (e.g., herpes zoster ophthalmicus) risk eye complications, requiring urgent assessment. Constipation, catheter changes, and stage I ulcers are less acute.
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When developing nursing care plans, the nurse is careful to classify which type of wound as a chronic wound?
- A. A gunshot wound with tissue damage
- B. A slow-healing diabetic foot ulcer
- C. A stage I pressure ulcer on the coccyx
- D. A 7-day-old infected surgical wound
Correct Answer: B
Rationale: Diabetic foot ulcers heal slowly, classifying them as chronic.
The nurse is planning the care of a client diagnosed with psoriasis. Which psychosocial problem should be included in the plan?
- A. Alteration in comfort.
- B. Altered body image.
- C. Anxiety.
- D. Altered family processes.
Correct Answer: B
Rationale: Psoriasis’s visible plaques often cause body image disturbance. Comfort, anxiety, and family processes are secondary.
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client’s mental health?
- A. Encourage the client to stay at home as much as possible.
- B. Discuss the importance of not relying on the family for needs.
- C. Tell the client to remember that changes in lifestyle take time.
- D. Instruct the client to discuss feelings only with the therapist.
Correct Answer: C
Rationale: Acknowledging lifestyle changes promotes mental health by fostering realistic expectations. Isolation, independence from family, or limiting discussions hinder recovery.
The nurse is presenting an in-service to participants in a local health fair. Which information regarding the development of skin cancers should the nurse teach?
- A. The fairer the skin, the less the risk of developing skin cancer.
- B. Eating a diet high in fiber helps to minimize the risk of skin cancer development.
- C. Sun exposure at a beach is less dangerous than at a stadium.
- D. The participants should avoid sun exposure in the afternoon hours.
Correct Answer: D
Rationale: Avoiding afternoon sun (10 AM–4 PM) reduces UV exposure, lowering skin cancer risk. Fair skin increases risk, diet is unrelated, and beach/stadium exposure is equivalent.
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.