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The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
- A. Cyst
- B. Papule
- C. Pustule
- D. Vesicle
Correct Answer: D
Rationale: A vesicle is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid. Serous fluid is a clear, watery fluid that can accumulate within the vesicle. Vesicles are commonly seen in conditions such as herpes simplex virus infections (cold sores) and contact dermatitis. It is important for nursing students to understand the characteristics of different skin lesions to accurately assess and provide appropriate care for patients.
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A nurse is directed to administer a hypotonic intravenous solution. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. O.45% sodium chloride
- B. 5% dextrose in water
- C. O.90% sodium chloride
- D. 5% dextrose in normal saline solution
Correct Answer: C
Rationale: Hypotonic solutions have lower osmolarity compared to the intracellular fluid, causing water to move into the cells by osmosis. This can lead to further swelling of the cells in the body. In the case of hypovolemia, the body is already experiencing a deficit of fluid and electrolytes, so administering a hypotonic solution like 0.90% sodium chloride would further exacerbate cellular swelling and potentially lead to cellular damage. Therefore, using 0.90% sodium chloride as a compensatory mechanism for hypovolemia would not be appropriate.
Which of the following instructions should Nurse Cheryl include in her teaching plan for the parents of Reggie with otitis media?
- A. Placing the child in the supine position to bottle-feed
- B. Giving prescribed amoxicillin (Amoxil) on an empty stomach
- C. Cleaning the inside of the ear canals with cotton swabs
- D. Avoiding contact with people who have upper respiratory tract infections
Correct Answer: D
Rationale: Nurse Cheryl should include in her teaching plan for Reggie's parents to avoid contact with people who have upper respiratory tract infections. Otitis media is often caused by upper respiratory infections, and exposure to individuals with such infections can increase the risk of exacerbating Reggie's condition or causing recurrent infections. Implementing measures to minimize exposure can help prevent further complications and promote faster recovery for Reggie. Placing the child in the supine position to bottle-feed may increase the likelihood of fluid entering the middle ear, worsening the otitis media. Giving amoxicillin on an empty stomach is not recommended as it can cause gastrointestinal upset and reduce absorption; instead, it should be given with food to enhance efficacy. Cleaning the inside of the ear canals with cotton swabs can be harmful and may cause damage or introduce infection, making it an inappropriate practice in managing otitis media.
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective individual coping related to diabetes mellitus?
- A. Recent weight gain of 20 lb
- B. Skipping insulin doses during illness
- C. Failure to monitor blood glucose
- D. Crying whenever diabetes is levels mentioned
Correct Answer: D
Rationale: Crying whenever diabetes is mentioned indicates a maladaptive coping mechanism, which can be a sign of ineffective individual coping related to diabetes mellitus. Coping with a chronic condition like diabetes can be overwhelming, and excessive emotional distress may hinder the client's ability to effectively manage their disease. It is important for the nurse to identify maladaptive coping strategies in order to provide appropriate interventions and support for the client.
A 72-year-old chemist has left lower lobe pneumonia. His nurse checks his oxygen saturation and the result is 86%. Which of the ff. actions by the nurse is best?
- A. Call the physician for an order for oxygen.
- B. No action necessary; this is a normal SaO
Correct Answer: A
Rationale: An oxygen saturation (SaO2) level of 86% is significantly below the normal range of 95-100%. This indicates hypoxemia, which means the body is not getting enough oxygen. In a patient with pneumonia, low oxygen saturation can lead to further respiratory compromise and potential organ damage. Therefore, it is essential for the nurse to notify the physician promptly to obtain an order for supplemental oxygen to correct the hypoxemia and improve the patient's oxygen saturation levels. Delay in addressing low oxygen levels can have serious consequences for the patient's health and recovery.
A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic is the priority for this class?
- A. Appropriate use of car seat restraints
- B. Safety crossing the street
- C. Helmet use when riding a bicycle
- D. Poison control numbers
Correct Answer: A
Rationale: The safety topic that is the priority for the nurse's accident prevention class for parents of toddlers is the appropriate use of car seat restraints. Car accidents are one of the leading causes of injuries and deaths among children, and proper car seat usage is crucial in protecting toddlers during car rides. Following the guidelines for car seat installation and usage can significantly reduce the risk of injury or death in the event of a car accident. Therefore, ensuring that parents understand and implement proper car seat restraint practices is essential in promoting the safety of toddlers. While the other safety topics are also important, the risk of injury or death in car accidents is higher compared to other accidents for toddlers, making car seat safety a priority.