Nokea
The nurse correctly teaches the client that psoriasis is an inflammatory dermatosis that results from which skin condition?
- A. A superficial skin infection
- B. The effects of dermal abrasion
- C. A proliferation of epidermal cells
- D. An infection of the hair follicles
Correct Answer: C
Rationale: Psoriasis involves rapid epidermal cell turnover.
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Which information is most important for the school nurse to obtain from the client initially?
- A. Whether safety glasses were worn
- B. The name of the splashed chemical
- C. Whether the client's vision is impaired
Correct Answer: B
Rationale: Knowing the specific chemical involved is critical to determine the appropriate treatment and potential severity of the injury.
The nurse is assessing the client's grafted wound following a skin graft. Which information provided during shift report should prompt the nurse to carefully assess if the client has a wound infection?
- A. WBC at 9900/microL
- B. Serosanguineous drainage
- C. Temperature 103°F (39.4°C)
- D. Urine output 100 mL past 4 hours
Correct Answer: C
Rationale: An elevated temperature could be a sign of an infection. Normal WBC is 4500 to 11,100 microL, so 9900 is WNL. Clean wounds have serosanguineous drainage. Decreased urine output can indicate dehydration or renal failure, not infection.
Cimetidine [Tagamet] is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client?
- A. To prevent infection
- B. To restore electrolyte balance
- C. To promote renal function
- D. To prevent Curling's ulcers
Correct Answer: D
Rationale: Cimetidine is used to prevent Curling’s ulcers, stress-induced gastric ulcers common in severe burn clients due to increased gastric acid production.
When examining the electrical burn on the victim, which assessment is most important for the nurse to determine?
- A. The entry and exit wound sites
- B. Degree of skin discoloration
- C. Amount of eschar on the wound bed
- D. Characteristics of wound drainage
Correct Answer: A
Rationale: Identifying entry and exit sites assesses the extent of internal tissue damage.
The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?
- A. I used the comb to remove all the nits.'
- B. I washed my hair with Kwell shampoo.'
- C. I removed all the sheets from my bed.'
- D. I had to fix my daughter’s hair with my brush.'
Correct Answer: D
Rationale: Sharing a brush risks reinfestation with lice, indicating noncompliance. Combing nits, using Kwell, and washing sheets are correct.