The nurse is assessing a client with onychocryptosis. Which of the following is evident if the tissue is infected?
- A. Pressure
- B. Redness and swelling
- C. Pain
- D. Purulent drainage and an odor
Correct Answer: D
Rationale: Purulent leakage and an odor are evident if the tissue is infected. A client with onychocryptosis feels a local pressure from the abnormal nail growth, but this is not a sign of the tissue being infected. Redness, swelling, and pain occur where the nail pierces the adjacent tissue.
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The nurse is assessing a client experiencing an exacerbation of plaque psoriasis. The nurse assesses the area and documents a proliferation of which cell type?
- A. Dermal
- B. Epidermal
- C. Endothelial
- D. Epithelial
Correct Answer: B
Rationale: The nurse is correct to document that the proliferation of skin cells occurs in the first layer of skin cells, the epidermis. In the epidermal layer, there is rapid turnover of the cells. The dermis is under the epidermis. Endothelial is the layer on the inside such as the interior of the blood vessel. Epithelial are on the outside or coating of walls.
The nurse is caring for a client in need of a blood transfusion. The client's family member wants to be considered to donate blood. The nurse notes that the family member has several tattoos and asks the family member when and where the last tattoo was obtained. If the family member obtained the last tattoo on February 14, 2021, in a state that does not regulate tattoo facilities, after which date would the family member be eligible to donate blood?
- A. After February 28, 2021
- B. After May 14, 2021
- C. After March 14, 2021
- D. After April 14, 2021
Correct Answer: B
Rationale: The American Red Cross (2021) rejects potential blood donors who have received a tattoo within 3 months if the tattoo was applied in a state that does not regulate tattoo facilities. Therefore, the earliest that the client's family member would be able to give blood is May 14, 2021. Two weeks, 1 month, and 2 months are insufficient amounts of time to wait after receiving a tattoo in a state that does not regulate tattoo facilities.
The nurse is working at a podiatrist's office. Which assessment finding is characteristic to the acquisition of onychomycosis in women?
- A. Clipping nails too closely
- B. Soaking hands in detergent
- C. Wearing artificial nails.
- D. Filing nails even with the fingers
Correct Answer: C
Rationale: The nurse is correct to instruct the client that onychomycosis is frequently found in the fingernails of women wearing artificial nails. Unsanitary cleansing of nail-application utensils between customers in salons seems to be the mode of transmission. Clipping nails too closely can cause discomfort. Soaking hands in detergent and filing nails even with the fingers do not cause onychomycosis.
The nurse is caring for an older adult client who has developed chapped and itchy skin. Which nursing intervention included in this client's plan of care should the nurse alter?
- A. Use of a gait belt for ambulation
- B. Maintenance of foam pad on wheelchair
- C. Daily bathing with warm-hot water
- D. Applying lanolin ointment
Correct Answer: C
Rationale: When the client develops dry and itchy skin, the nurse should alter the client's plan of care with respect to bathing. Hot water will dry the skin further. Due to a decrease in epidermal replacement rates, excessive drying of an older person's skin can lead to pruritus, dryness, and infection. Lanolin ointment is good to apply to dry skin because it helps moisturize so this should be kept in the plan. The nurse would not alter the plan of using a gait belt for ambulation or using a foam pad on the wheelchair.
The school nurse is instructing a parent in the care and elimination of lice from their child's hair. The parent brings all of the products for care in a bag. Which contents are not appropriate for use?
- A. Shampoo and conditioner
- B. Permethrin (Nix)
- C. Plastic fine-toothed comb
- D. New hair clips
Correct Answer: A
Rationale: The nurse is correct to instruct the parent to avoid shampoo and conditioner because this coats the hair and protects the nits. Nix and a fine-toothed comb are recommended. New hair clips may be used once the infestation is gone.
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