Nokea
The nurse is caring for a client one (1) day postoperative for facial reconstruction. Which intervention should the nurse implement?
- A. Provide all activities of daily living.
- B. Allow the client to voice fears and concerns.
- C. Monitor nutritional food and fluid intake.
- D. Assess signs and symptoms of infection.
Correct Answer: D
Rationale: Assessing for infection is critical post-facial reconstruction to prevent complications. ADL provision, voicing concerns, and nutrition are secondary.
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The client is receiving UV light treatments for psoriasis along with methoxsalen, a photosensitizing agent. What precaution should be followed the first day after treatment?
- A. Wear ultraviolet B-protective sunglasses.
- B. Avoid applying skin ointments and lotions.
- C. Check for elevated temperature every 4 hours.
- D. Stop treatments if skin redness or erythema occurs.
Correct Answer: A
Rationale: Treatment with methoxsalen (Uvadex) enhances sensitivity of the eyes to sunlight. Sunglasses that provide UVB protection need to be worn for at least 24 hours following treatments. Skin ointments may be prescribed. Temperature monitoring is not needed. Redness and erythema are normal responses.
The nurse is caring for the immobile client who is at risk for developing pressure ulcers. Which food should the nurse recommend?
- A. Assorted fruit salad
- B. Oatmeal with raisins
- C. Baked chicken breast
- D. Lettuce and tomato salad
Correct Answer: C
Rationale: Chicken is a high-protein food. Proteins are needed to help meet the body's needs for tissue repair and to maintain skin integrity. Fruit salad, oatmeal, and lettuce salad are high-fiber or carbohydrate foods, not high in protein.
Which assessment finding is commonly noted when the intraocular pressure (IOP) of a client with angle-closure glaucoma becomes dangerously high?
- A. Spots in the visual field
- B. Severe eye pain
- C. Pinpoint pupils
- D. Bulging eyes
Correct Answer: B
Rationale: Acute angle-closure glaucoma causes severe eye pain due to rapidly elevated IOP.
The client is scheduled for application of a cadaver homograph to a burn on the forearm. Which comment by the client demonstrates an accurate understanding of this procedure?
- A. The graft donor site from my right upper thigh shouldn't take too long to heal.
- B. I know this graft will only be a temporary measure to protect and help heal my arm.
- C. I am glad that there is no risk of me getting a blood-borne disease with this type of graft.
- D. If this graft doesn't permanently take, then I'll need to select another graft donor site.
Correct Answer: B
Rationale: A cadaver skin graft is a type of temporary graft, also called a biological dressing, and it is used to protect the damaged skin and promote healing and epithelialization. A cadaver skin graft does not use the client's own skin, so there is no donor site. There is a risk of transmitting blood-borne infections with cadaver grafts. The graft is not permanent, so no further donor site selection is needed.
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.