Nokea
The nurse is assessing the client. Which findings should the nurse associate with herpes zoster?
- A. Serous drainage and pus
- B. Nodular lesions and burning
- C. Painful vesicles and pruritus
- D. Macule lesions and petechiae
Correct Answer: C
Rationale: The nurse should associate pain and pruritus (itching) with herpes zoster. Herpes zoster follows the path of peripheral sensory nerves; symptoms come from the nerve involvement. Serous drainage and pus indicate infection of vesicles. Nodular lesions are not associated, though burning may occur. Macule lesions may occur early, but petechiae are not associated.
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The nurse assesses that the client with partial-thickness burns over 50% of the total body surface area (TBSA) has gained weight and has generalized edema after the first 24 hours. The nurse should consider that the edema and weight gain are most likely related to which physiological processes?
- A. Elevated serum sodium and potassium levels
- B. Increased hemoglobin and hematocrit levels
- C. Excess intravenous fluid volume replacement
- D. Leakage of plasma into the interstitial space
Correct Answer: D
Rationale: Initially after a severe burn injury there is a loss of capillary integrity and a shift of fluid, sodium, and protein from the intravascular to the interstitial spaces. The body compensates for this interstitial hemoconcentration by retaining more fluid. Sodium is lost due to diuresis, and existing sodium tends to be diluted by an influx of fluid, so serum sodium levels will be decreased, not increased. Hgb and Hct levels may change in severe burns, but they are the result of the fluid shift, not the cause. Fluid volume deficit (not excess) is a major risk during this phase.
The 55-year-old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox?
- A. Deep vein thrombosis.
- B. Varicella pneumonia.
- C. Pericarditis.
- D. Scarring of the skin.
Correct Answer: B
Rationale: Varicella pneumonia is a serious complication in adults with chickenpox, especially older adults. DVT, pericarditis, and scarring are less common.
When instilling prescribed medication into the ear of an adult, which is the correct technique for the nurse to use to straighten the ear canal?
- A. Pull the ear upward and backward.
- B. Pull the ear upward and forward.
- C. Pull the ear downward and backward.
Correct Answer: A
Rationale: Pulling the ear upward and backward straightens the adult ear canal.
Which health teaching instruction given by the nurse is most important for a client with conjunctivitis?
- A. Eat a well-balanced, nutritious diet with plenty of fluids.
- B. Always wear dark sunglasses when in bright light.
- C. Do not share towels or washcloths with family members.
- D. Avoid all aspirin-containing products.
Correct Answer: C
Rationale: Preventing the spread of conjunctivitis involves avoiding shared items like towels.
When irrigating the client's eyes, which technique describes the best way to direct the flow of irrigating solution?
- A. Directly onto the corneal surface
- B. Away from the inner canthus
- C. Within the anterior chamber
- D. Toward the nasolacrimal duct
Correct Answer: B
Rationale: Directing the flow away from the inner canthus (from outer to inner) prevents contamination of the unaffected eye.