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The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychosocial problem of 'fear.' Which nursing interventions should be included in the plan of care?
- A. Explain to the client that the fears are unfounded.
- B. Encourage the client to verbalize the feeling of being afraid.
- C. Have the HCP discuss the client’s fear with the client.
- D. Instruct the client regarding all planned procedures.
Correct Answer: B
Rationale: Verbalizing fear helps address anxiety and promotes coping. Dismissing fears, deferring to HCP, or procedure instruction are less therapeutic.
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When a foreign body becomes embedded in a client's eye, which nursing action should be taken first before referring the client for emergency treatment?
- A. Remove the object with forceps.
- B. Ask the person to blink rapidly.
- C. Instill antibiotic ointment.
- D. Loosely patch both eyes.
Correct Answer: D
Rationale: Patching both eyes prevents eye movement, reducing further damage until emergency treatment is received.
The nurse who documents the burn injury is accurate in identifying the full-thickness burns as having what appearance?
- A. White and leathery
- B. Pink and blistered
- C. Red and painful
- D. Mottled and wet
Correct Answer: A
Rationale: Full-thickness burns appear white, leathery, and painless due to nerve destruction.
Before the client leaves the emergency department, which nursing instruction is most appropriate?
- A. Advise the client to limit dietary intake of fluids.
- B. Tell the client to sleep in a recliner or with the head up.
- C. Show the client how to take the carotid pulse at hourly intervals.
- D. Warn the client to avoid blowing the nose for several hours.
Correct Answer: D
Rationale: Avoiding nose blowing prevents dislodging clots and restarting bleeding.
The nurse is planning the care of a client diagnosed with psoriasis. Which psychosocial problem should be included in the plan?
- A. Alteration in comfort.
- B. Altered body image.
- C. Anxiety.
- D. Altered family processes.
Correct Answer: B
Rationale: Psoriasis’s visible plaques often cause body image disturbance. Comfort, anxiety, and family processes are secondary.
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.