Nokea
The nurse completes teaching the client with a second-degree burn about silver sulfadiazine. Which client statements should indicate to the nurse that the teaching was effective? Select all that apply.
- A. I apply the cream only to the opened areas of the burned area.
- B. Silver sulfadiazine will prevent an infection of the burned area.
- C. I never should apply a dressing after applying silver sulfadiazine.
- D. I use a tongue blade to remove the old ointment before reapplying.
- E. The cream is dark colored and cannot be removed with water.
Correct Answer: A,B
Rationale: Silver sulfadiazine (Silvadene) is only applied to opened areas; this statement indicates client understanding of the instructions. Silver sulfadiazine is used to reduce/prevent bacterial growth and thus an infection; this statement indicates client understanding of the instructions. Dressings can be applied but are not necessary; this statement does not indicate client understanding. Removal of old ointment with a tongue blade can damage new granulation tissue; this statement does not indicate client understanding. The cream is white in color and water-soluble; if it darkens it should not be used; this statement does not indicate client understanding.
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The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is 'tired of it all.' Which is the nurse’s best therapeutic response?
- A. These wounds can heal if we get enough protein into you.'
- B. Are you tired of the treatments and needing to be cared for?'
- C. Why would you say that? We are doing our best.'
- D. Have you made out an advance directive to let the HCP know your wishes?'
Correct Answer: B
Rationale: Reflecting the client’s feelings encourages discussion, addressing emotional distress. Protein focus, defensiveness, or advance directives dismiss the client’s emotions.
When the client asks about the cause of shingles, the nurse answers correctly with which cause of the disease?
- A. The reactivation of a dormant virus
- B. A vector insect such as a tick
- C. A toxin from a bacterial infection
- D. An antibody response to a drug allergen
Correct Answer: A
Rationale: Shingles results from reactivation of the varicella-zoster virus.
How can the nurse best relieve the client's fear and anxiety?
- A. Recline the client so as to avoid seeing the blood.
- B. Give the client a popular magazine to read.
- C. Replace the client's clothing with a hospital gown.
- D. Cover the client's eyes with a bath towel.
Correct Answer: C
Rationale: Changing stained clothing reduces visual reminders of bleeding, easing fear.
When instilling prescribed medication into the ear of an adult, which is the correct technique for the nurse to use to straighten the ear canal?
- A. Pull the ear upward and backward.
- B. Pull the ear upward and forward.
- C. Pull the ear downward and backward.
Correct Answer: A
Rationale: Pulling the ear upward and backward straightens the adult ear canal.
The nurse is preparing the plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care?
- A. Apply a thin dusting with Mycostatin, an antifungal powder, over the area.
- B. Cover the area with an occlusive dressing after applying a steroid cream.
- C. Administer acyclovir, an antiviral medication, to the affected areas six (6) times a day.
- D. Teach the client the risks and hazards of implanted radiation therapy.
Correct Answer: B
Rationale: Occlusive dressings with steroids enhance absorption, treating psoriasis. Mycostatin is for fungal infections, acyclovir is for viral infections, and radiation is irrelevant.