Nokea
The nurse has completed the teaching plan for the client diagnosed with psoriasis. Which statement indicates the need for further teaching?
- A. I will check my skin every day for redness with tenderness.'
- B. I must take my psoralen medication two (2) hours before my treatment.'
- C. I will wear dark glasses during my treatment and the rest of the day.'
- D. The coal-tar ointments and lotions will not stain my clothes.'
Correct Answer: D
Rationale: Coal-tar ointments stain clothes, indicating a need for further teaching. Daily skin checks, psoralen timing, and dark glasses are correct for PUVA therapy.
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Which health teaching information is most appropriate for a client with a herpes simplex virus type 1 infection?
- A. Apply petroleum jelly to the lesions to prevent spreading the virus to adjacent areas.
- B. Use good personal hygiene to prevent spreading the virus to other body parts.
- C. Avoid using soap and water on open lesions.
- D. Remove the scabs daily by soaking with hot compresses.
Correct Answer: B
Rationale: Good hygiene prevents viral spread to other areas.
A young man has extensive burns on the front and back of the chest. His treatment includes the use of Sulfamylon to the burned areas. How should the nurse apply this medication?
- A. With a sterile, gloved hand
- B. With a sterile applicator
- C. With sterile 4x4's
- D. By aerosol spray
Correct Answer: C
Rationale: Sulfamylon is applied using sterile 4x4 gauze pads to ensure even coverage and maintain sterility while minimizing pain.
The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which interventions should the nurse implement? Select all that apply.
- A. Place the client in contact isolation.
- B. Administer a corticosteroid IVP.
- C. Assess the client’s pain on a 1-to-10 scale.
- D. Request that the client not have any visitors.
- E. Ensure that only nurses who have had chickenpox care for this client.
Correct Answer: A,C,E
Rationale: Contact isolation, pain assessment, and assigning immune nurses prevent transmission and manage disseminated zoster. Corticosteroids are contraindicated, and visitor bans are excessive.
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.
The nurse is caring for an elderly female client preoperative for facial reconstruction. Which client problem should the nurse include in the preoperative plan of care?
- A. Loss of self-esteem.
- B. Alteration in comfort.
- C. Ineffective airway clearance.
- D. Impaired communication.
Correct Answer: A
Rationale: Facial reconstruction may impact self-esteem due to appearance concerns. Comfort, airway, and communication are less relevant preoperatively.