Nokea
The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
- A. Instruct the clients to wear dark clothes when hunting.
- B. Use a sunscreen of at least SPF 30 when outside.
- C. Avoid dense undergrowth when in a wooded area.
- D. Do not use any type of insect repellant when deer hunting.
Correct Answer: C
Rationale: Avoiding dense undergrowth reduces tick exposure, preventing Lyme disease. Dark clothes attract ticks, sunscreen is irrelevant, and insect repellent is recommended.
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The nurse is assessing the client for possible scabies infestation. Which findings should the nurse expect?
- A. Serosanguineous drainage and fever
- B. Malaise and local edema
- C. Itching and papule-like rash
- D. Macule rash and blisters
Correct Answer: C
Rationale: The most common symptoms of a scabies infestation are itching and papule rash. Serosanguineous drainage and fever or malaise and edema occur with wound infections. Macule rash and blisters may occur with allergic reactions.
The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse?
- A. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch.
- B. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally.
- C. The skin covering the coccyx is intact but the client complains of pain in the area.
- D. The coccyx wound extends to the subcutaneous layer and there is drainage.
Correct Answer: D
Rationale: Extension to the subcutaneous layer with drainage indicates progression to stage III or IV, worsening the ulcer. Smaller size, blisters, or pain are less severe.
After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?
- A. Wrap ice in a washcloth and put it on the burn area.
- B. Come to the ED so a doctor can assess your fingers.
- C. Run cool water over the burned area on your fingers.
- D. Apply an antibiotic skin ointment to prevent infection.
Correct Answer: C
Rationale: Ice causes vasoconstriction and can worsen the tissue damage. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing.
Which response by the nurse is best in this situation?
- A. Gravity helps to reattach the separated retina.
- B. I'm very small to be a reasonable, and I'm very
- C. I can get you a sedative if it's hard to lie still.
- D. The doctor knows what's best for you, and you should listen.
Correct Answer: A
Rationale: Bed rest uses gravity to aid retinal reattachment.
When examining the client's skin, which finding would the nurse expect to observe?
- A. Weeping skin lesions on the trunk of the body.
- B. Red skin patches covered with silvery scales.
- C. A red rash containing raised pustules.
Correct Answer: B
Rationale: Psoriasis presents with red patches and silvery scales.