Nokea
The nurse is caring for the client diagnosed with contact dermatitis. Which collaborative intervention should the nurse implement?
- A. Encourage the use of support stockings.
- B. Administer a topical anti-inflammatory cream.
- C. Remove scales frequently by shampooing.
- D. Shampoo with lindane 1%, an antiparasitic, weekly.
Correct Answer: B
Rationale: Topical anti-inflammatory cream (e.g., steroids) treats contact dermatitis. Stockings, scale removal, and lindane are irrelevant.
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The nurse is caring for the client at increased risk for developing pressure ulcers. Which measure should the nurse take to limit shearing forces?
- A. Padding the client's sacrum and heels
- B. Obtaining an alternating air pressure mattress
- C. Using a lifting device when turning the client
- D. Keeping the head of bed lower than 30 degrees
Correct Answer: D
Rationale: Keeping the HOB higher than 30 degrees increases the shearing forces to the shoulders, sacrum, and heels. Padding and air mattresses reduce tissue pressure but not shearing forces. Using a lift sheet helps reduce friction but not shearing forces.
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
- A. Complete the Braden Scale.
- B. Monitor the client on a Glasgow Coma Scale.
- C. Assess for Babinski’s sign.
- D. Initiate a Brudzinski flow sheet.
Correct Answer: A
Rationale: The Braden Scale assesses pressure ulcer risk, guiding interventions. Glasgow, Babinski, and Brudzinski are neurological, not relevant to ulcers.
The nurse writes the problem 'impaired skin integrity' for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply.
- A. Turn the client every three (3) to four (4) hours.
- B. Ask the dietitian to consult.
- C. Have the client sign a consent for pictures of the wounds.
- D. Obtain an order for a low air-loss bed.
- E. Elevate the head of the bed at all times.
Correct Answer: B,C,D
Rationale: Dietitian consult, wound photos (with consent), and low air-loss bed address stage IV ulcers. Turning every 3–4 hours is too infrequent, and constant head elevation increases coccyx pressure.
When the client asks the nurse about the purpose of the eye shield, which explanation is best?
- A. The shield keeps foreign substances out of the eye.
- B. The shield protects the eye from accidental trauma.
- C. The shield reduces rapid eye movement when dreaming.
- D. The shield promotes dilation of the pupil at night.
Correct Answer: B
Rationale: The shield prevents accidental trauma to the healing eye during sleep.
When planning the child's discharge, what nursing instruction is most appropriate for the nurse to provide the parent concerning the cotton ball in the client's ear canal?
- A. Leave the cotton ball in place until it is saturated.
- B. Keep the cotton ball placed loosely within the ear canal.
- C. Remove the cotton ball in peroxide before insertion.
- D. Remove the cotton ball when the cotton becomes dry.
Correct Answer: B
Rationale: A loosely placed cotton ball protects the ear without causing pressure.