Nokea
The nurse is concerned that a very dark-skinned African American client may be developing a pressure ulcer on the heel. What should the nurse do to assess for the presence of tissue injury?
- A. Turn on all of the fluorescent lights in the client's room before inspection.
- B. Apply pressure to the heel, remove the pressure, and observe for blanching.
- C. Check to see if the area of pressure appears darker than the surrounding skin.
- D. Ask about pain and check the heel for redness, edema, and cracks in the tissue.
Correct Answer: C
Rationale: In a dark-skinned client, injured skin may appear darker than surrounding skin. Natural or halogen light should be used, as fluorescent light produces a bluish tone. Dark skin does not blanch. Red tones are absent in very dark-skinned persons; inflammation may appear purplish-blue or violet.
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The nurse is explaining facelift (rhytidectomy) surgery to the client and describing the site where the incision is most commonly made. Place an X on the site where the incision most commonly used for rhytidectomy is made.
- A. An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face.
Correct Answer: A
Rationale: An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face. Incisions in the forehead and periorbital area are for blepharoplasty and browlift. Head and neck reconstruction utilizes the chin site.
A client who has just been diagnosed with psoriasis asks the nurse what should be done to prevent family members from getting the condition. What should the nurse include when responding to this question?
- A. Showering daily with antiseptic soap should be sufficient.
- B. Wearing clothing over the affected part and washing clothes separately from the rest of the family are all that is necessary.
- C. Psoriasis is not contagious, so no special precautions are necessary.
- D. Psoriasis is transmitted primarily by direct contact with the skin.
Correct Answer: C
Rationale: Psoriasis is a non-contagious autoimmune condition, so no precautions are needed to prevent transmission to family members.
The nurse writes the nursing diagnosis 'impaired skin integrity related to open burn wounds.' Which intervention would be appropriate for this nursing diagnosis?
- A. Provide analgesia before pain becomes severe.
- B. Clean the client’s wounds, body, and hair daily.
- C. Screen visitors for respiratory infections.
- D. Encourage visitors to bring plants and flowers.
Correct Answer: B
Rationale: Daily wound cleaning prevents infection and promotes healing, addressing impaired skin integrity. Analgesia addresses pain, visitor screening is for infection control, and plants increase infection risk.
The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?
- A. Wear a sunscreen with a protection factor of 10 or less when in the sun.
- B. Try to stay out of the sun between 0300 and 0500 daily.
- C. Perform a thorough skin check monthly.
- D. Remember caps and long sleeves do not help prevent skin cancer.
Correct Answer: C
Rationale: Monthly skin checks detect early skin cancer changes. SPF 10 is inadequate, 0300–0500 is nighttime, and caps/long sleeves are protective.
Which nursing intervention is most appropriate to include in the care plan of an anxious client who is blind or has the eyes patched?
- A. Touch the client before speaking.
- B. Explain what you plan to do beforehand.
- C. Stand in front of the client when speaking.
- D. Leave the room lights on at all times.
Correct Answer: B
Rationale: Explaining actions beforehand reduces anxiety by preparing the client for what to expect.