Nokea
The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize?
- A. Keep the skin moist by leaving the skin damp after the bath.
- B. Do not rub any lotion into the skin.
- C. Turn clients who are immobile at least every two (2) hours.
- D. Only the licensed nursing staff may care for the client’s skin.
Correct Answer: C
Rationale: Turning every 2 hours prevents pressure ulcers by relieving pressure. Damp skin risks breakdown, lotion is beneficial, and UAPs can assist with skin care.
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Once the victim's blood pressure is stabilized, the best indication of successful response to the initial burn treatment is which assessment finding?
- A. Normal body temperature
- B. Minimal level of pain
- C. Adequate urine output
- D. Ability to perform exercises
Correct Answer: C
Rationale: Adequate urine output indicates successful fluid resuscitation.
Which problem should the nurse identify for the client recently diagnosed with leprosy (Hansen’s disease)?
- A. Social isolation.
- B. Altered body image.
- C. Potential for infection.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Leprosy’s stigma often leads to social isolation, a priority psychosocial problem. Body image, infection, and comfort are secondary.
The client is diagnosed with acne vulgaris. Which psychosocial problem is priority?
- A. Impaired skin integrity.
- B. Ineffective grieving.
- C. Body image disturbance.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Acne vulgaris often causes body image disturbance, especially in adolescents, due to visible lesions. Skin integrity, grieving, and knowledge are secondary.
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.
Which nursing intervention is most appropriate to include in the care plan of an anxious client who is blind or has the eyes patched?
- A. Touch the client before speaking.
- B. Explain what you plan to do beforehand.
- C. Stand in front of the client when speaking.
- D. Leave the room lights on at all times.
Correct Answer: B
Rationale: Explaining actions beforehand reduces anxiety by preparing the client for what to expect.