Nokea
The male client diagnosed with acquired immunodeficiency syndrome (AIDS) states that he has developed a purple-brown spot on his calf. Which action should the nurse do first?
- A. Refer the client to an HCP for a biopsy of the area.
- B. Assess the lesion for size, color, and symmetry.
- C. Discuss end-of-life decisions with the client.
- D. Report the sexually transmitted illness to the health department.
Correct Answer: B
Rationale: Assessing the lesion provides data for suspected Kaposi’s sarcoma, common in AIDS. Biopsy referral, end-of-life discussions, and reporting are secondary.
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The nurse writes the problem 'impaired skin integrity' for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply.
- A. Turn the client every three (3) to four (4) hours.
- B. Ask the dietitian to consult.
- C. Have the client sign a consent for pictures of the wounds.
- D. Obtain an order for a low air-loss bed.
- E. Elevate the head of the bed at all times.
Correct Answer: B,C,D
Rationale: Dietitian consult, wound photos (with consent), and low air-loss bed address stage IV ulcers. Turning every 3–4 hours is too infrequent, and constant head elevation increases coccyx pressure.
Before leaving the room, which of the following nursing access to the nurse's place, the client's place.
- A. The nurse straightens the client's linens.
- B. The nurse informs the client when leaving the room.
- C. The nurse offers to give the client a back rub.
- D. The nurse shares some current events with the client.
Correct Answer: B
Rationale: Informing the client when leaving reduces anxiety and enhances safety.
The nurse is caring for the client diagnosed with contact dermatitis. Which collaborative intervention should the nurse implement?
- A. Encourage the use of support stockings.
- B. Administer a topical anti-inflammatory cream.
- C. Remove scales frequently by shampooing.
- D. Shampoo with lindane 1%, an antiparasitic, weekly.
Correct Answer: B
Rationale: Topical anti-inflammatory cream (e.g., steroids) treats contact dermatitis. Stockings, scale removal, and lindane are irrelevant.
The female teacher comes to the school nurse’s office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement?
- A. Instruct the teacher to go to her HCP today.
- B. Tell the teacher to wash her hands with soap and water.
- C. Encourage the teacher to rub vitamin E oil on the lesions.
- D. Explain that the rash will go away in a few days.
Correct Answer: A
Rationale: Impetigo requires HCP evaluation for antibiotics. Handwashing is preventive, vitamin E is ineffective, and spontaneous resolution is unlikely.
Which action is most appropriate to include in the postoperative care plan when a client has skin grafts?
- A. Minimize movement to prevent graft disruption.
- B. Change the dressing over the graft every 8 hours.
- C. Reinforce the graft dressing if drainage occurs.
- D. Apply wet soaks to the graft every 4 hours.
Correct Answer: A
Rationale: Minimizing movement ensures graft adherence and healing.