Nokea
The nurse is preparing the client scheduled for a dermabrasion. Which information should the nurse include while teaching the client?
- A. Erythema will go away within 24 hours.
- B. Do not change the dressing until seen by the HCP.
- C. Stay out of extreme cold or heat situations.
- D. Avoid direct sunlight for three (3) days.
Correct Answer: C
Rationale: Avoiding extreme temperatures protects healing skin post-dermabrasion. Erythema persists longer, dressings may be changed, and sunlight avoidance lasts weeks.
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The client who is debilitated and has developed multiple pressure ulcers complains to the nurse during a dressing change that he is 'tired of it all.' Which is the nurse’s best therapeutic response?
- A. These wounds can heal if we get enough protein into you.'
- B. Are you tired of the treatments and needing to be cared for?'
- C. Why would you say that? We are doing our best.'
- D. Have you made out an advance directive to let the HCP know your wishes?'
Correct Answer: B
Rationale: Reflecting the client’s feelings encourages discussion, addressing emotional distress. Protein focus, defensiveness, or advance directives dismiss the client’s emotions.
Which nursing action is most appropriate at this time?
- A. Obtaining the client's pulse and blood pressure
- B. Monitoring the client for respiratory distress
- C. Identifying the client's next of kin
- D. Determining the extent of the burn
Correct Answer: B
Rationale: Burns to the chest and neck risk airway compromise, requiring respiratory monitoring.
The nurse is caring for the client who is diagnosed with a carbuncle. Which home measures should the nurse discuss? Select all that apply.
- A. Leave the draining lesion open to the air so it dries.
- B. Use strict hand washing to prevent cross-contamination.
- C. Cover the mattress and pillows with plastic covers.
- D. Apply ice to the affected area 20 minutes twice daily.
- E. Wash all linens, towels, and clothing after each use.
- F. Remove all throw rugs to prevent tripping or falls.
Correct Answer: B,C,E
Rationale: Treatments for an infected lesion should include strict hand washing to prevent cross-contamination. Covering mattress and pillows with plastic covers and washing all linens, towels, and clothing after each use will prevent cross-contamination. Leaving the lesion open to air is not advised; a dressing is needed. Applying ice or removing throw rugs does not pertain to carbuncle treatment.
Which expected outcome should the nurse include in the plan of care for the client diagnosed with seborrheic dermatitis?
- A. The client will have no further outbreaks.
- B. The client will follow medical protocol.
- C. The client will shampoo three (3) times a week.
- D. The client will apply bacitracin twice daily.
Correct Answer: B
Rationale: Following medical protocol ensures effective management of seborrheic dermatitis. No outbreaks is unrealistic, shampoo frequency varies, and bacitracin is for bacterial infections.
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.