Nokea
The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis?
- A. Appearance of red, elevated plaques with silvery white scales.
- B. A burning, prickling row of vesicles located along the torso.
- C. Raised, flesh-colored papules with a rough surface area.
- D. An overgrowth of tissue with an excessive amount of collagen.
Correct Answer: A
Rationale: Red plaques with silvery scales are characteristic of psoriasis. Vesicles suggest herpes zoster, papules suggest warts, and collagen overgrowth suggests keloids.
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The experienced nurse is observing the new nurse administer medications. Which actions by the new nurse require the experienced nurse to intervene? Select all that apply.
- A. Applies tretinoin to an open wound on the face of the client with acne
- B. Withholds isotretinoin until the client's pregnancy status is known
- C. Withholds fluorouracil because the client's papules of actinic keratosis are worse
- D. Waits two hours after the client bathes and uses lotion to apply tacrolimus
- E. Tells the client taking acitretin for psoriasis to prevent pregnancy for a year
Correct Answer: A,C,E
Rationale: Tretinoin (Retin-A) should not be applied to open wounds; the experienced nurse should intervene. Actinic keratosis treatment using fluorouracil (Carac) causes the affected area to become worse before getting better; the medication should not be withheld. When taking acitretin (Soriatane), the client should not become pregnant for three years following treatment. Withholding isotretinoin until pregnancy status is known is appropriate. Waiting two hours to apply tacrolimus after lotion is correct.
The school nurse is discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, 'How can I prevent getting impetigo?' Which statement would be the most appropriate response?
- A. Wash your hands after using the bathroom.'
- B. Do not touch any affected areas without gloves.'
- C. Apply a topical antibiotic to your hands.'
- D. Keep the child with impetigo isolated in the room.'
Correct Answer: B
Rationale: Avoiding contact with impetigo lesions without gloves prevents transmission. Handwashing is general, topical antibiotics are for treatment, and isolation is excessive.
When the nurse applies mafenide acetate cream to the burn wound, the nurse should recognize which of the following as its chief disadvantage?
- A. Skin discoloration
- B. Pain on application
- C. Unpleasant odor
- D. Contact dermatitis
Correct Answer: B
Rationale: Mafenide acetate causes significant pain upon application.
The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first?
- A. The client scheduled for a skin biopsy who is crying.
- B. The client who had surgery three (3) hours ago and is sleeping.
- C. The client who needs to void prior to discharge.
- D. The client who has received discharge instructions and is ready to go home.
Correct Answer: A
Rationale: Crying suggests emotional distress or pain, requiring immediate assessment. Sleeping, voiding, and discharge-ready clients are stable.
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.