Nokea
The nurse is preparing the plan of care for a client diagnosed with Stevens-Johnson syndrome. Which interventions should the nurse include? Select all that apply.
- A. Monitor intake and output every eight (8) hours.
- B. Assess breath sounds and rate every four (4) hours.
- C. Assess vesicles, erosions, and crusts frequently.
- D. Perform the whisper test for auditory changes daily.
- E. Assess orientation to person, place, and time every shift.
Correct Answer: A,B,C,E
Rationale: Monitoring I&O, breath sounds, skin lesions, and orientation address SJS complications (fluid loss, respiratory issues, skin breakdown, neurological changes). Whisper test is irrelevant.
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The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220 pounds and the order reads 10 mg per kilogram per day to be administered in equally divided doses every six (6) hours. How many milligrams will be administered in one dose?
Correct Answer: 250
Rationale: 220 lbs ÷ 2.2 = 100 kg; 10 mg/kg/day = 1000 mg/day; 1000 mg ÷ 4 doses = 250 mg/dose.
If a client with a middle ear infection reports the following symptoms, the blood pressure and 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.
The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis?
- A. Appearance of red, elevated plaques with silvery white scales.
- B. A burning, prickling row of vesicles located along the torso.
- C. Raised, flesh-colored papules with a rough surface area.
- D. An overgrowth of tissue with an excessive amount of collagen.
Correct Answer: A
Rationale: Red plaques with silvery scales are characteristic of psoriasis. Vesicles suggest herpes zoster, papules suggest warts, and collagen overgrowth suggests keloids.
When the nurse applies mafenide acetate cream to the burn wound, the nurse should recognize which of the following as its chief disadvantage?
- A. Skin discoloration
- B. Pain on application
- C. Unpleasant odor
- D. Contact dermatitis
Correct Answer: B
Rationale: Mafenide acetate causes significant pain upon application.
If a client who has recently experienced diminished hearing takes medications from each of the following drug categories, which one is most likely to have affected the client's hearing?
- A. Nonsteroidal anti-inflammatory drug
- B. Beta-adrenergic blocker
- C. Aminoglycoside antibiotic
- D. Histamine-2 (H2) antagonist
Correct Answer: C
Rationale: Aminoglycosides are ototoxic and can cause hearing loss.