Nokea
The nurse is assessing the client for possible scabies infestation. Which findings should the nurse expect?
- A. Serosanguineous drainage and fever
- B. Malaise and local edema
- C. Itching and papule-like rash
- D. Macule rash and blisters
Correct Answer: C
Rationale: The most common symptoms of a scabies infestation are itching and papule rash. Serosanguineous drainage and fever or malaise and edema occur with wound infections. Macule rash and blisters may occur with allergic reactions.
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After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?
- A. Wrap ice in a washcloth and put it on the burn area.
- B. Come to the ED so a doctor can assess your fingers.
- C. Run cool water over the burned area on your fingers.
- D. Apply an antibiotic skin ointment to prevent infection.
Correct Answer: C
Rationale: Ice causes vasoconstriction and can worsen the tissue damage. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing.
The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?
- A. This surgery will create a skin flap to cover my wounds.'
- B. This surgery will get all the old black tissue out of the wound so it can heal.'
- C. The surgery is important to allow oxygen to get to the tissue for healing to occur.'
- D. Stool will come out an opening in my abdomen so it won’t get in the sore.'
Correct Answer: D
Rationale: Fecal diversion (colostomy) prevents stool contamination of coccyx ulcers, aiding healing. Skin flaps, debridement, and oxygen delivery are unrelated to this surgery.
The health department nurse is caring for the client who has leprosy (Hansen’s disease). Which assessment data indicate the client is experiencing a complication of the disease?
- A. Elevated temperature at night.
- B. Brownish-black discoloration to the skin.
- C. Reduced skin sensation in the lesions.
- D. A high count of mycobacteria in the culture.
Correct Answer: C
Rationale: Reduced sensation in lesions indicates nerve damage, a leprosy complication. Night fevers, discoloration, and bacterial load are less specific.
The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
- A. Instruct the clients to wear dark clothes when hunting.
- B. Use a sunscreen of at least SPF 30 when outside.
- C. Avoid dense undergrowth when in a wooded area.
- D. Do not use any type of insect repellant when deer hunting.
Correct Answer: C
Rationale: Avoiding dense undergrowth reduces tick exposure, preventing Lyme disease. Dark clothes attract ticks, sunscreen is irrelevant, and insect repellent is recommended.
Which information is most appropriate to include in the discharge instructions for the client who has undergone a cataract extraction?Select all that apply.
- A. Avoid bending over from the waist.
- B. Sleep with the head slightly elevated.
- C. Wash hands before applying eye drops
- D. Sleep with the head elevated
Correct Answer: A,B,C,D
Rationale: Avoiding bending and elevating the head reduce intraocular pressure and promote healing.