Nokea
The mother of an adolescent tells the clinic nurse, 'My son has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.' What instruction should the nurse provide?
- A. Antibiotics take two weeks to become effective against fungal infections like athlete's foot.
- B. Continue using the ointment for a full week, even after the symptoms disappear.
- C. Applying too much ointment can reduce its effectiveness. Apply a thin layer to prevent maceration.
- D. Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
Correct Answer: D
Rationale: The correct answer is D. Athlete's foot (tinea pedis) is a fungal infection, not a bacterial infection that would respond to antibiotics. The primary management involves keeping the feet well-ventilated, dry after bathing, and wearing clean socks to prevent moisture buildup, which promotes fungal growth. Using an antibiotic ointment like triple antibiotic ointment is not effective for treating athlete's foot. Therefore, the nurse should advise the mother to stop using the antibiotic ointment and focus on promoting proper foot hygiene to manage the fungal infection. Choices A, B, and C are incorrect as they do not address the fungal nature of athlete's foot and the ineffectiveness of antibiotic ointments in its treatment.
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A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding is most concerning?
- A. Peripheral edema
- B. Confusion and altered mental status
- C. Yellowing of the skin
- D. Increased abdominal girth
Correct Answer: C
Rationale: In a client with cirrhosis presenting with jaundice and ascites, yellowing of the skin (icterus) is the most concerning assessment finding. This indicates significant liver dysfunction and a high level of bilirubin in the blood. Yellowing of the skin suggests a severe impairment of the liver's ability to process bilirubin, which can lead to serious complications. Peripheral edema and increased abdominal girth are common manifestations of cirrhosis but are not as acutely concerning as skin yellowing. Confusion and altered mental status are also critical findings in cirrhosis, indicating hepatic encephalopathy, but skin yellowing is more closely associated with the severity of liver dysfunction in this scenario.
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
- A. Respiratory apnea of 30 seconds
- B. Oxygen saturation rate of 88%
- C. Eight premature ventricular beats every minute
- D. Disconnected monitor signal for the last 6 minutes.
Correct Answer: A
Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.
An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?
- A. Addiction
- B. Phobia
- C. Compulsion
- D. Obsession
Correct Answer: C
Rationale: The client's handwashing ritual is a compulsion, a repetitive behavior driven by the need to reduce anxiety associated with an obsession. In this case, the client's need to wash her hands excessively stems from an obsession with cleanliness, leading to the compulsive behavior of extensive handwashing. 'Addiction' (Choice A) involves a dependence on a substance or behavior, not related to this scenario. 'Phobia' (Choice B) is an intense fear of a specific object or situation, not applicable here. 'Obsession' (Choice D) refers to persistent and intrusive thoughts, while the handwashing behavior in this case is the compulsive action taken to alleviate the anxiety related to the obsession.
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory value requires immediate intervention?
- A. Serum glucose of 300 mg/dL
- B. Serum potassium of 4.5 mEq/L
- C. Serum bicarbonate of 15 mEq/L
- D. Serum pH of 7.28
Correct Answer: D
Rationale: A serum pH of 7.28 indicates metabolic acidosis in a client with diabetic ketoacidosis (DKA), requiring immediate intervention. In DKA, the body produces excess ketones, leading to acidosis. Monitoring and correcting the pH level is crucial in managing DKA. Serum glucose levels may be high in DKA, but the immediate concern is correcting the acidosis to prevent complications. Serum potassium and bicarbonate levels are also important but not as immediately critical as correcting the acidosis in DKA.
A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
- A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure
- B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness
- C. The additive effect of multiple medications has caused the blood pressure to drop too low.
- D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.
Correct Answer: C
Rationale: When medications with a similar action are administered, an additive effect occurs that is the sum of the effects of each medication. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension.