Nokea
The nurse is assessing a young mother who came to the clinic complaining of sores on her skin. Which assessment data would support that the client has chickenpox?
- A. Crops of lesions that have pus and reddened base.
- B. Oval scaling lesions that occur on the legs and arms.
- C. Severe itching of the scalp with tiny eggs visible.
- D. Ringed red lesions on the face, neck, trunk, and extremities.
Correct Answer: A
Rationale: Crops of pustular lesions with a red base are characteristic of chickenpox. Scaling lesions, scalp eggs, and ringed lesions suggest other conditions.
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The nurse correctly hands the physician which solution?
- A. Povidone-iodine (Betadine)
- B. Gentian violet
- C. Will have to remove my prosthesis for cleaning.
- D. Fluorescein
Correct Answer: D
Rationale: Fluorescein is used to stain the cornea to detect foreign bodies or injuries.
A severely burned client is to be admitted from the emergency department. What type of room should the nurse prepare for the client?
- A. A semi-private room with a noninfectious client
- B. A room with a postoperative client
- C. An isolation room
- D. A private room with a private bath
Correct Answer: C
Rationale: An isolation room is necessary to reduce the risk of infection, a major complication in burn clients due to compromised skin barriers.
The nurse suspects that the client's anxiety is due to fear that nursing care will intensify symptoms. Which nursing intervention is most appropriate to add to the care plan?
- A. Let the client suggest ways to carry out care.
- B. Discontinue nursing care measures at this time.
- C. Restrict care to nutrition and elimination only.
- D. Carry out nursing activities quickly and efficiently.
Correct Answer: A
Rationale: Involving the client in care decisions reduces anxiety by providing control.
Which statement would the nurse expect the client to report when looking at an object without wearing corrective glasses or contact lenses?
- A. I see near objects more clearly.
- B. I see a blurry area in front of me.
- C. I see far objects more clearly.
- D. I see two of the same object.
Correct Answer: B
Rationale: Astigmatism causes blurry or distorted vision due to irregular corneal curvature.
Before leaving the room, which of the following nursing access to the nurse's place, the client's place.
- A. The nurse straightens the client's linens.
- B. The nurse informs the client when leaving the room.
- C. The nurse offers to give the client a back rub.
- D. The nurse shares some current events with the client.
Correct Answer: B
Rationale: Informing the client when leaving reduces anxiety and enhances safety.