Nokea
The nurse is preparing the plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care?
- A. Apply a thin dusting with Mycostatin, an antifungal powder, over the area.
- B. Cover the area with an occlusive dressing after applying a steroid cream.
- C. Administer acyclovir, an antiviral medication, to the affected areas six (6) times a day.
- D. Teach the client the risks and hazards of implanted radiation therapy.
Correct Answer: B
Rationale: Occlusive dressings with steroids enhance absorption, treating psoriasis. Mycostatin is for fungal infections, acyclovir is for viral infections, and radiation is irrelevant.
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The nurse completes teaching the client with a second-degree burn about silver sulfadiazine. Which client statements should indicate to the nurse that the teaching was effective? Select all that apply.
- A. I apply the cream only to the opened areas of the burned area.
- B. Silver sulfadiazine will prevent an infection of the burned area.
- C. I never should apply a dressing after applying silver sulfadiazine.
- D. I use a tongue blade to remove the old ointment before reapplying.
- E. The cream is dark colored and cannot be removed with water.
Correct Answer: A,B
Rationale: Silver sulfadiazine (Silvadene) is only applied to opened areas; this statement indicates client understanding of the instructions. Silver sulfadiazine is used to reduce/prevent bacterial growth and thus an infection; this statement indicates client understanding of the instructions. Dressings can be applied but are not necessary; this statement does not indicate client understanding. Removal of old ointment with a tongue blade can damage new granulation tissue; this statement does not indicate client understanding. The cream is white in color and water-soluble; if it darkens it should not be used; this statement does not indicate client understanding.
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 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 client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse?
- A. The client has bilaterally weak radial pulses.
- B. The client is able to move the left fingers.
- C. The client has a CRT less than three (3) seconds.
- D. The client is unable to remove the wedding ring.
Correct Answer: D
Rationale: Inability to remove a ring in cellulitis suggests severe edema, risking compartment syndrome, requiring immediate intervention. Weak pulses, finger movement, and normal CRT are less urgent.
The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate?
- A. Gently palpate the affected area using sterile gloves.
- B. Apply vinegar to the affected area to identify the scabies.
- C. Use a magnifying glass and a penlight to visualize the skin.
- D. Obtain a Doppler to assess the movement of the mites.
Correct Answer: C
Rationale: Magnifying glass and penlight visualize scabies burrows and mites. Palpation is unnecessary, vinegar is irrelevant, and Doppler is for vascular assessment.