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The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions?
- A. Use a pillow to keep the heels off the bed when supine.
- B. Order a low air-loss therapy bed immediately.
- C. Prepare to insert a nasogastric feeding tube.
- D. Order an occupational therapy consult for strength training.
Correct Answer: A
Rationale: Heel elevation prevents pressure ulcers in paralyzed clients. Low air-loss beds require HCP orders, NG tubes are premature, and OT is for rehabilitation, not immediate care.
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Of the following information provided by the client to the nurse, which factor is most likely to cause a retinal detachment?
- A. The client is younger than age 40.
- B. The client fell and struck the head.
- C. The client has multiple allergies.
- D. The client is being treated for glaucoma.
Correct Answer: B
Rationale: Trauma, such as a head injury, is a common cause of retinal detachment.
The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers?
- A. Constant perineal moisture.
- B. Ability of the clients to reposition themselves.
- C. Decreased elasticity of the skin.
- D. Impaired cardiovascular perfusion of the periphery.
Correct Answer: A
Rationale: Perineal moisture is modifiable through hygiene and barriers, reducing ulcer risk. Repositioning ability, skin elasticity, and perfusion are less modifiable.
The nurse is planning care for the client with a Stage II pressure ulcer on the ball of the right foot. Which interventions should the nurse include in this client's care? Select all that apply.
- A. Obtain cultures of the wound daily.
- B. Clean vigorously to remove dead tissue.
- C. Cover with a protective dressing.
- D. Reposition at least every two hours.
- E. Elevate the right heel completely off the bed.
Correct Answer: C,D,E
Rationale: The dressing protects the underlying wound and provides a moist environment for healing. The client should be repositioned at least every 2 hours. Positioning devices are utilized to keep the load or pressure off the wound. Daily wound cultures are unnecessary, as all wounds contain bacteria. The wound should be cleansed gently to prevent further tissue trauma.
The school nurse is discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, 'How can I prevent getting impetigo?' Which statement would be the most appropriate response?
- A. Wash your hands after using the bathroom.'
- B. Do not touch any affected areas without gloves.'
- C. Apply a topical antibiotic to your hands.'
- D. Keep the child with impetigo isolated in the room.'
Correct Answer: B
Rationale: Avoiding contact with impetigo lesions without gloves prevents transmission. Handwashing is general, topical antibiotics are for treatment, and isolation is excessive.
If a client with a middle ear infection reports the following symptoms, which one suggests that the infection has spread to the inner ear?
- A. Temporal headaches
- B. A sore throat
- C. Nasal congestion
- D. Postural dizziness
Correct Answer: D
Rationale: Postural dizziness suggests inner ear involvement, such as labyrinthitis.