Nokea
The nurse is caring for the client with the pressure ulcer illustrated. Which stage should the nurse document?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: C
Rationale: Stage III pressure ulcer is full-thickness skin loss that extends to the subcutaneous fat, but not fascia; bone, tendon, and muscle are not visible. Stage I is intact but red and nonblanching. Stage II involves a break in the skin with partial-thickness loss. Stage IV is full-thickness loss with exposed muscle and bone.
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Which health teaching instruction given by the nurse is most important for a client with conjunctivitis?
- A. Eat a well-balanced, nutritious diet with plenty of fluids.
- B. Always wear dark sunglasses when in bright light.
- C. Do not share towels or washcloths with family members.
- D. Avoid all aspirin-containing products.
Correct Answer: C
Rationale: Preventing the spread of conjunctivitis involves avoiding shared items like towels.
Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion?
- A. The client will express feelings of fear.
- B. The client will ask questions about the diagnosis.
- C. The client will state a diminished level of pain.
- D. The client will demonstrate care of the operative site.
Correct Answer: D
Rationale: Demonstrating operative site care ensures healing and prevents infection, a physiological outcome. Fear, questions, and pain are psychosocial or secondary.
When irrigating the client's eyes, which technique describes the best way to direct the flow of irrigating solution?
- A. Directly onto the corneal surface
- B. Away from the inner canthus
- C. Within the anterior chamber
- D. Toward the nasolacrimal duct
Correct Answer: B
Rationale: Directing the flow away from the inner canthus (from outer to inner) prevents contamination of the unaffected eye.
Which client would most likely be at risk for the development of a carbuncle?
- A. The young male who is just beginning to shave.
- B. The female with a fair complexion.
- C. The male who works out in the gym daily.
- D. The female diagnosed with diabetes mellitus.
Correct Answer: D
Rationale: Diabetes increases infection risk, including carbuncles, due to impaired immunity. Shaving, fair skin, and exercise are less significant.
Which subjective symptom is the client most likely to report to the nurse?
- A. Burning
- B. Pressure
- C. Vertigo
- D. Pain
Correct Answer: C
Rationale: Vertigo is a hallmark symptom of Meniere's disease due to inner ear fluid imbalance.