Nokea
The nurse writes the nursing diagnosis 'impaired skin integrity related to open burn wounds.' Which intervention would be appropriate for this nursing diagnosis?
- A. Provide analgesia before pain becomes severe.
- B. Clean the client’s wounds, body, and hair daily.
- C. Screen visitors for respiratory infections.
- D. Encourage visitors to bring plants and flowers.
Correct Answer: B
Rationale: Daily wound cleaning prevents infection and promotes healing, addressing impaired skin integrity. Analgesia addresses pain, visitor screening is for infection control, and plants increase infection risk.
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The client is diagnosed with acne vulgaris. Which psychosocial problem is priority?
- A. Impaired skin integrity.
- B. Ineffective grieving.
- C. Body image disturbance.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Acne vulgaris often causes body image disturbance, especially in adolescents, due to visible lesions. Skin integrity, grieving, and knowledge are secondary.
The nurse identifies the concept of impaired skin integrity for a pediatric client diagnosed with impetigo on the arms. Which interventions should the nurse implement?
- A. Teach the parents to ensure the child takes all the prescribed antibiotics.
- B. Give the parents a written excuse so the child can go back to school.
- C. Encourage the parents to bathe the child in an oatmeal bath for the itching.
- D. Apply topical lidocaine before debriding the crusts from the lesions.
Correct Answer: A
Rationale: Completing antibiotics ensures impetigo resolution, addressing skin integrity. School return requires clearance, oatmeal baths are for comfort, and lidocaine is unnecessary.
The nurse is caring for the client with psoriasis taking methotrexate. Which laboratory tests are most important for the nurse to monitor? Select all that apply.
- A. Serum potassium level
- B. Liver function tests
- C. Serum glucose level
- D. Arterial blood gases
- E. White blood cells
Correct Answer: B,E
Rationale: The nurse should monitor liver function tests because methotrexate (Trexall) is metabolized by the liver, and a side effect is hepatotoxicity. The nurse should monitor WBCs because a side effect of methotrexate use is leukopenia. Methotrexate has no effect on serum potassium unless complications arise. Glucose monitoring is needed only if the client is diabetic. ABGs are not prescribed for routine monitoring.
The school nurse is assessing a teacher who has pediculosis. Which statement by the teacher makes the nurse suspect that the teacher did not comply with the instructions that were discussed in the classroom with the children?
- A. I used the comb to remove all the nits.'
- B. I washed my hair with Kwell shampoo.'
- C. I removed all the sheets from my bed.'
- D. I had to fix my daughter’s hair with my brush.'
Correct Answer: D
Rationale: Sharing a brush risks reinfestation with lice, indicating noncompliance. Combing nits, using Kwell, and washing sheets are correct.
The nurse is concerned that a very dark-skinned African American client may be developing a pressure ulcer on the heel. What should the nurse do to assess for the presence of tissue injury?
- A. Turn on all of the fluorescent lights in the client's room before inspection.
- B. Apply pressure to the heel, remove the pressure, and observe for blanching.
- C. Check to see if the area of pressure appears darker than the surrounding skin.
- D. Ask about pain and check the heel for redness, edema, and cracks in the tissue.
Correct Answer: C
Rationale: In a dark-skinned client, injured skin may appear darker than surrounding skin. Natural or halogen light should be used, as fluorescent light produces a bluish tone. Dark skin does not blanch. Red tones are absent in very dark-skinned persons; inflammation may appear purplish-blue or violet.