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The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include?
- A. Teach the client that there is no more risk for cancer.
- B. Refer the client to a prosthesis specialist for prosthesis.
- C. Instruct the client how to apply sunscreen to the area.
- D. Demonstrate care of the surgical site.
Correct Answer: D
Rationale: Surgical site care prevents infection and promotes healing. Ongoing cancer risk remains, prostheses are irrelevant, and sunscreen is secondary post-surgery.
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The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
- A. Complete the Braden Scale.
- B. Monitor the client on a Glasgow Coma Scale.
- C. Assess for Babinski’s sign.
- D. Initiate a Brudzinski flow sheet.
Correct Answer: A
Rationale: The Braden Scale assesses pressure ulcer risk, guiding interventions. Glasgow, Babinski, and Brudzinski are neurological, not relevant to ulcers.
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.
The nurse is assessing the client with atopic dermatitis. Which finding should the nurse expect?
- A. Patchy loss of skin pigmentation called vitiligo.
- B. Trichotillomania, a type of hair loss from compulsive pulling and/or twisting of the hair.
- C. Blistering, redness, and a white patch between the fingers, characteristic of candidiasis.
- D. Atopic dermatitis, which is characterized by redness and irregular, scaly lesions.
Correct Answer: D
Rationale: Atopic dermatitis is characterized by redness and irregular, scaly lesions. Vitiligo shows patchy loss of pigmentation. Trichotillomania involves hair loss from compulsive pulling. Candidiasis shows blistering, redness, and white patches.
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 client has an entrance wound on the right hand and an exit wound on the left hand after contact with a high-power electrical line. Considering the nature and trajectory of the electrical current, which nursing action is priority?
- A. Obtain a 12-lead ECG
- B. Check pupil size and reaction
- C. Auscultate both lung fields
- D. Check arm range of motion
Correct Answer: A
Rationale: Electrical current will follow through the path of least resistance in the body, which is the bloodstream. The heart could have been damaged by the electrical current. Therefore, obtaining a 12-lead ECG is priority. Pupil checks or lung auscultation may be indicated but are not the priority. ROM is not a priority based on the ABCs of medical emergencies.