Nokea
The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital?
- A. Complete the Braden Scale.
- B. Monitor the client on a Glasgow Coma Scale.
- C. Assess for Babinski’s sign.
- D. Initiate a Brudzinski flow sheet.
Correct Answer: A
Rationale: The Braden Scale assesses pressure ulcer risk, guiding interventions. Glasgow, Babinski, and Brudzinski are neurological, not relevant to ulcers.
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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.
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.
When planning the child's discharge, what nursing instruction is most appropriate for the nurse to provide the parent concerning the cotton ball in the client's ear canal?
- A. Leave the cotton ball in place until it is saturated.
- B. Keep the cotton ball placed loosely within the ear canal.
- C. Remove the cotton ball in peroxide before insertion.
- D. Remove the cotton ball when the cotton becomes dry.
Correct Answer: B
Rationale: A loosely placed cotton ball protects the ear without causing pressure.
After instilling medication into the client's ear, which nursing instruction is most appropriate?
- A. Keep your head tilted for 5 minutes.
- B. Pack a cotton ball tightly in your ear.
- C. Do not blow your nose for at least 1 hour.
- D. Wipe the excess medication from the ear.
Correct Answer: A
Rationale: Keeping the head tilted allows the medication to stay in contact with the ear canal.
Which information provided by the nurse will best prepare the client for the caloric test?
- A. Cold water and warm water will be instilled into each of the ears.
- B. You will wear earphones through which sounds are transmitted.
- C. The room will be darkened, and scalp electrodes will be attached to the head.
- D. Your blood will be drawn from a vein and examined microscopically.
Correct Answer: A
Rationale: The caloric test involves instilling water to assess vestibular function.