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The nurse is caring for an older adult client who has developed chapped and itchy skin. Which nursing intervention included in this client's plan of care should the nurse alter?
- A. Use of a gait belt for ambulation
- B. Maintenance of foam pad on wheelchair
- C. Daily bathing with warm-hot water
- D. Applying lanolin ointment
Correct Answer: C
Rationale: When the client develops dry and itchy skin, the nurse should alter the client's plan of care with respect to bathing. Hot water will dry the skin further. Due to a decrease in epidermal replacement rates, excessive drying of an older person's skin can lead to pruritus, dryness, and infection. Lanolin ointment is good to apply to dry skin because it helps moisturize so this should be kept in the plan. The nurse would not alter the plan of using a gait belt for ambulation or using a foam pad on the wheelchair.
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The nurse is instructing the client on the correct toenail trimming technique when having onychocryptosis. Which instruction made by the nurse is best?
- A. Use scissors and trim the toenails in a semicircle.
- B. Use nail clippers and round the corners on the end.
- C. Tear the nail across, allowing the nail to be removed.
- D. Use nail clippers allowing the ends of the nails to be longer than the toes.
Correct Answer: D
Rationale: The nurse is correct to instruct the client that proper nail trimming for a client with onychocryptosis is to use a nail clipper and allow the ends of the nail to be longer than the end of the toes. The ends of the nails should not be rounded off. The other options are not best for the ingrown toenail condition.
The nurse is caring for a female with progressive hair loss. When instructing the client on typical considerations to promote hair growth, which would be restricted in the client's care?
- A. Conditioner added to the client's hair
- B. Use of a wide-toothed comb
- C. Use of finasteride (Propecia)
- D. Attaching a hair extension
Correct Answer: C
Rationale: The nurse is correct to instruct on the restriction of finasteride (Propecia) for women due to the androgenic inhibitor property. The use of a hair conditioner and wide-toothed comb is encouraged to not break or damage the hair. Attaching a hair extension is common to provide more hair on the head.
The nurse has assessed a client's superficial fungal infection that began in the skin between the toes and has spread to the soles of the feet. How would the nurse document this finding?
- A. Tinea corporis
- B. Tinea capitis
- C. Tinea pedis
- D. Tinea cruris
Correct Answer: C
Rationale: Tinea pedis is an infection that begins in the skin between the toes and spreads to the soles of the feet. Tinea corporis is a skin infection of the body. Tinea capitis invades the hair shaft below the scalp. Tinea cruris is a skin infection of the groin.
A client asks the nurse what psoriasis is. What is the best answer?
- A. It is a chronic, infectious inflammatory disease.
- B. It is characterized by patches of redness covered with silvery scales.
- C. A cure is possible with prompt treatment.
- D. The onset typically occurs in young children.
Correct Answer: B
Rationale: Psoriasis is characterized by patches of erythema covered with silvery scales, usually on the extensor surfaces of the elbows, knees, trunk, and scalp. It is a chronic non-infectious inflammatory disease. Psoriasis has no cure. The onset is in young- and middle-adulthood.
The home health nurse is caring for a client with scabies. When instructing on the proper procedure to wash preworn contaminated clothing, which nursing instruction is essential?
- A. Use commercial grade laundry detergent.
- B. Pretreat clothing where scabies contact existed.
- C. Wash clothes through two laundry cycles.
- D. Use hot water throughout wash cycle.
Correct Answer: D
Rationale: The nurse is correct to instruct the client to use hot water throughout the wash cycle. Using hot water kills scabies and infectious agents on the laundry. If using the correct wash settings, the client does not need to use commercial-grade laundry detergent; the clothing does not need pretreated nor washed through two cycles.