Nokea
The nurse is assessing the client newly diagnosed with psoriasis. Which findings should the nurse expect? Select all that apply.
- A. Pruritus at the affected areas
- B. Nailbeds that are pink and clear
- C. Stringy, oily hair that falls out in clumps
- D. Lesions appear as red plaques with silvery scales
- E. Affected areas at elbows, knees, scalp, palms, or soles
Correct Answer: A,D,E
Rationale: Itching is a common symptom of psoriasis. Psoriatic patches are red, scaly plaques with silvery scales and occur most often on elbows, knees, scalp, palms, and soles. Nail involvement may include thickening, discoloration, and pitting; pink and clear describes normal nailbeds. Hair is dry and brittle, not oily.
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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.
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.
The nurse is providing postoperative care for the client with a split-thickness skin graft on the burn wound at the sole of the right foot. Which is appropriate care for this client?
- A. Immobilization of the graft site
- B. Weight-bearing exercises to the graft site
- C. Assist client out of bed as much as tolerated
- D. Maintain right leg in a dependent position
Correct Answer: A
Rationale: The graft must be immobilized so that it can remain in place and be able to revascularize. The client cannot place weight on the graft site. Bearing weight causes trauma. A dependent position impairs circulation and may cause further tissue injury.
The middle-aged client has had two (2) lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include?
- A. Teach the client that there is no more risk for cancer.
- B. Refer the client to a prosthesis specialist for prosthesis.
- C. Instruct the client how to apply sunscreen to the area.
- D. Demonstrate care of the surgical site.
Correct Answer: D
Rationale: Surgical site care prevents infection and promotes healing. Ongoing cancer risk remains, prostheses are irrelevant, and sunscreen is secondary post-surgery.
After instilling medication into the client's ear, which nursing instruction is most appropriate?
- A. Keep your head tilted for 5 minutes.
- B. Pack a cotton ball tightly in your ear.
- C. Do not blow your nose for at least 1 hour.
- D. Wipe the excess medication from the ear.
Correct Answer: A
Rationale: Keeping the head tilted allows the medication to stay in contact with the ear canal.