Nokea
The nurse suspects that the client's anxiety is due to fear that nursing care will intensify symptoms. Which nursing intervention is most appropriate to add to the care plan?
- A. Let the client suggest ways to carry out care.
- B. Discontinue nursing care measures at this time.
- C. Restrict care to nutrition and elimination only.
- D. Carry out nursing activities quickly and efficiently.
Correct Answer: A
Rationale: Involving the client in care decisions reduces anxiety by providing control.
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The nurse is assessing the client newly diagnosed with psoriasis. Which findings should the nurse expect? Select all that apply.
- A. Pruritus at the affected areas
- B. Nailbeds that are pink and clear
- C. Stringy, oily hair that falls out in clumps
- D. Lesions appear as red plaques with silvery scales
- E. Affected areas at elbows, knees, scalp, palms, or soles
Correct Answer: A,D,E
Rationale: Itching is a common symptom of psoriasis. Psoriatic patches are red, scaly plaques with silvery scales and occur most often on elbows, knees, scalp, palms, and soles. Nail involvement may include thickening, discoloration, and pitting; pink and clear describes normal nailbeds. Hair is dry and brittle, not oily.
The nurse is assessing the client with atopic dermatitis. Which finding should the nurse expect?
- A. Patchy loss of skin pigmentation called vitiligo.
- B. Trichotillomania, a type of hair loss from compulsive pulling and/or twisting of the hair.
- C. Blistering, redness, and a white patch between the fingers, characteristic of candidiasis.
- D. Atopic dermatitis, which is characterized by redness and irregular, scaly lesions.
Correct Answer: D
Rationale: Atopic dermatitis is characterized by redness and irregular, scaly lesions. Vitiligo shows patchy loss of pigmentation. Trichotillomania involves hair loss from compulsive pulling. Candidiasis shows blistering, redness, and white patches.
Which of the parent's statements indicates a need for further teaching?
- A. Lice are gone if I don't see any one day after treatment.
- B. I've washed all the bed linens in soap, hot water, and bleach.
- C. None of my children shares each other's combs or brushes.
- D. Once there is an outbreak, all students should be inspected.
Correct Answer: A
Rationale: Lice treatment requires follow-up to ensure all nits are eradicated.
The nurse is caring for a person who has severe poison ivy. Soaks with Burrow's solution are ordered. What is the primary reason for using Burrow's solution soaks?
- A. To disinfect the wound
- B. To prevent pain from the lesions
- C. To stop the pruritus associated with the condition
- D. To help dry the oozing lesions
Correct Answer: C
Rationale: Burrow’s solution soaks relieve pruritus (itching) in poison ivy by soothing the skin and reducing inflammation.
The nurse is determining the IV fluid needs for the 50-kg client with partial-thickness burns to 40% total body surface area (TBSA). Using the Parkland formula (4 mL X weight in kg X % TBSA burn = 24-hour IV fluid volume replacement; half given in first 8 hours), how many mL of IV fluid are needed during the first 8 hours after injury? mL of IV fluid (Record your answer as a whole number.)
- A. 4000
Correct Answer: A
Rationale: Use the Parkland formula provided: 4.0 mL at 50 kg = 200 mL; 200 mL × 40% TBSA burn = 8000 mL. Half of 8000 mL, or 4000 mL, is given in the first 8 hours after the burn.