Nokea
The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
- A. Impaired cognition.
- B. Altered nutrition.
- C. Self-care deficit.
- D. Altered coping.
Correct Answer: B
Rationale: Altered nutrition is critical in stage IV ulcers to support wound healing. Cognition, self-care, and coping are secondary in advanced wounds.
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The nurse is caring for a client with complaints of a rash and itching on the face for one (1) week. Which intervention should the nurse implement first?
- A. Check for the presence of hirsutism on the face.
- B. Use the Wood’s light to visualize the rash under the black light.
- C. Determine what OTC medications the client has used on the rash.
- D. Ask the client to describe when the rash first appeared.
Correct Answer: D
Rationale: Determining rash onset provides critical history for diagnosis. Hirsutism, Wood’s light, and OTC medication history are secondary.
The experienced nurse is supervising the new nurse. The nurse should intervene if observing the new nurse performing which intervention?
- A. Applying skin lotion to the face, feet, and hands of the client with pemphigus
- B. Applying a skin emollient to the arms and legs of the client with scleroderma
- C. Informing the client with herpes simplex that the lesions are contagious until crusted
- D. Telling the client that ultraviolet light therapy is one option for treating acne vulgaris
Correct Answer: A
Rationale: The skin of a person with pemphigus is so مرور fragile that touching the skin can cause it to tear; the experienced nurse should intervene. In scleroderma, emollients relieve dry, itching skin. Herpes simplex lesions are contagious until crusted. UV light therapy is a treatment option for acne vulgaris.
The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first?
- A. The 34-year-old client who is quadriplegic and cannot move his arms.
- B. The elderly client diagnosed with a CVA who is weak on the right side.
- C. The 78-year-old client with pressure ulcers who has a temperature of 102.3°F.
- D. The young adult who is unhappy with the care that was provided last shift.
Correct Answer: C
Rationale: Fever in a client with pressure ulcers suggests infection, requiring urgent assessment. Quadriplegia, weakness, and dissatisfaction are less acute.
Which statement made to the nurse is the best evidence that the client understands the anticipated outcome of this procedure?
- A. I'm better night vision.
- B. I'll correctly identify colors.
- C. I'll see well without glasses.
- D. I'll use both eyes when reading.
Correct Answer: C
Rationale: LASIK corrects refractive errors, reducing the need for glasses.
Which individual would most likely experience the skin disorder pseudofolliculitis barbae (shaving bumps)?
- A. A male African American soldier.
- B. A female Caucasian hairdresser.
- C. A male Asian food server.
- D. A female Hispanic schoolteacher.
Correct Answer: A
Rationale: Pseudofolliculitis barbae is common in African American males due to curly hair causing ingrown hairs post-shaving. Other groups are less affected.