Nokea
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: A wound with eschar covering the bed is unstageable because the depth cannot be assessed until the eschar is removed.
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A client with obsessive compulsive personality disorder annoys his coworkers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
- A. Helping the client develop a plan for changing his behavior
- B. Contracting with him for the time he spends on a task
- C. Avoiding a discussion of his annoying behavior because it will only make him worse
- D. Encouraging him to set a time schedule and deadlines for himself
Correct Answer: D
Rationale: Setting a time schedule helps the client manage perfectionistic tendencies by structuring tasks, reducing preoccupation with trivial details.
A client is being discharged on Coumadin after hospitalization for a deep vein thrombosis. The nurse recognizes that which food would be restricted while the client is on this medication?
- A. Lettuce
- B. Apples
- C. Potatoes
- D. Macaroni
Correct Answer: A
Rationale: Lettuce, especially leafy greens, is high in vitamin K, which can antagonize Coumadin's anticoagulant effect, requiring dietary restriction or monitoring.
Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
- A. Obeying adults is seen as correct behavior.
- B. Showing respect for parents is seen as important.
- C. Pleasing others is viewed as good behavior.
- D. Behavior is determined by consequences.
Correct Answer: D
Rationale: Kohlberg's preconventional stage for preschoolers involves moral decisions based on consequences, such as avoiding punishment or gaining rewards.
A home health nurse visits a 7-year-old boy on neutropenic precautions. His mother cares for him during the day. Which of the following statements by the mother indicates a need for further teaching?
- A. I will call the doctor if my son has a temperature above 38°C.'
- B. My son should protect his skin by showering every other day instead of daily.'
- C. His aunt cannot visit until 3 weeks have passed since her flu shot.'
- D. I will need to throw out the flowers he got as a get-well gift.'
Correct Answer: C
Rationale: Live vaccines (e.g., nasal flu vaccine) require a 3-week wait, but the standard flu shot is inactivated, posing no risk. The other statements are correct for neutropenic precautions.
A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
- A. Lie prone and let her feet hang over the mattress edge
- B. Lie supine, with her feet rotated inward
- C. Lie on her right side and point her toes downward
- D. Lie on her left side and allow her feet to remain in a neutral position
Correct Answer: A
Rationale: Lying prone with feet hanging over the mattress edge promotes knee extension, helping to prevent or reduce flexion contractures in rheumatoid arthritis.