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The nurse in a dermatology clinic is taking the history of a client. Which questions should the nurse ask the client? Select all that apply.
- A. When did you first notice the skin problem?
- B. What cosmetics or skin products do you use?
- C. Have you experienced any loss of sensation?
- D. What is your current and previous occupation?
- E. Do you experience any itching, burning, or tingling?
Correct Answer: A,B,C,D,E
Rationale: All listed questions assess onset, triggers, symptoms, and occupational exposures, critical for dermatologic history.
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The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
- A. Use a pillow to keep the heels off the bed when supine.
- B. Order a low air-loss therapy bed immediately.
- C. Prepare to insert a nasogastric feeding tube.
- D. Order an occupational therapy consult for strength training.
Correct Answer: A
Rationale: Heel elevation prevents pressure ulcers in paralyzed clients. Low air-loss beds require HCP orders, NG tubes are premature, and OT is for rehabilitation, not immediate care.
The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client’s fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data?
- A. Tinea capitis.
- B. Herpes simplex 2.
- C. Scabies.
- D. Psoriasis.
Correct Answer: C
Rationale: Itching and threadlike burrows between fingers indicate scabies. Tinea capitis affects the scalp, HSV-2 is genital, and psoriasis causes plaques.
The client has had a squamous cell carcinoma removed from the lip. Which discharge instructions should the nurse provide?
- A. Notify the HCP if a nonhealing lesion develops around the mouth.
- B. Squamous cell carcinoma tumors do not metastasize.
- C. Limit foods to liquid or soft consistency for one (1) month.
- D. Apply heat to the area for 20 minutes every four (4) hours.
Correct Answer: A
Rationale: Nonhealing lesions suggest recurrence, requiring HCP notification. Squamous cell carcinoma can metastasize, diet restrictions are unnecessary, and heat is inappropriate.
The nurse is speaking with clients during a wellness fair. What information should the nurse provide to prevent or minimize burn injury? Select all that apply.
- A. Wear flame-retardant clothing, especially near flames.
- B. Use 'stop, drop, and roll' maneuvers if clothing is on fire.
- C. Burn candles that are placed only in glass containers.
- D. Put out a cooking fire by throwing salt on the fire.
- E. Install smoke detectors, including one by the furnace.
Correct Answer: A,B,E
Rationale: The nurse should discuss flame-retardant clothing. 'Stop, drop, and roll' maneuvers should be used to minimize burn. Smoke detectors should be included throughout the home, including one near the furnace. It does not matter what type of container holds the burning candle. For a small fire on the stove, covering the flame with a lid is recommended.
Which symptom related to the chronic progression of untreated glaucoma will a client most likely report to the nurse?
- A. Tunnel vision
- B. Double vision
- C. Bulging eyes
- D. Bloodshot eyes
Correct Answer: A
Rationale: Untreated glaucoma leads to tunnel vision due to progressive peripheral vision loss.