Nokea
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.
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The elderly client diagnosed with poison ivy is prescribed a Solu-Medrol (a steroid) dose pack. Which intervention should the nurse teach the client?
- A. Tell the client to return to the office in one (1) week for blood levels.
- B. Instruct the client to take the medication exactly as prescribed.
- C. Explain the medication should be taken on an empty stomach.
- D. Teach to stop the medication immediately if side effects occur.
Correct Answer: B
Rationale: Taking steroids as prescribed ensures efficacy and minimizes risks. Blood levels are unnecessary, food reduces GI upset, and abrupt stopping is harmful.
Cimetidine [Tagamet] is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client?
- A. To prevent infection
- B. To restore electrolyte balance
- C. To promote renal function
- D. To prevent Curling's ulcers
Correct Answer: D
Rationale: Cimetidine is used to prevent Curling’s ulcers, stress-induced gastric ulcers common in severe burn clients due to increased gastric acid production.
The nurse is caring for the client with problems of anxiety and confusion in the critical phase of burn injury. Which interventions should the nurse implement? Select all that apply.
- A. Repeat orientation statements of person, place, and time.
- B. Turn and reposition the client at least every 2 hours.
- C. Place familiar objects from home near the client.
- D. Implement a schedule for regular sleep-wake cycles.
- E. Control distractions by keeping the room door closed.
- F. Encourage the client to write notes to family members.
Correct Answer: A,C,D
Rationale: Reiterating statements of orientation to the client decreases confusion. Familiar objects reduce anxiety when clients are in unfamiliar surroundings. Employing a regular schedule for sleep-wake cycles assists in decreasing confusion and anxiety. Turning and repositioning improves circulation and aeration but does not affect confusion. Closing the door of the room may increase client anxiety. In the acute phase of burns, the client is too ill to write notes to family members.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP?
- A. Stock the rooms with the equipment needed.
- B. Weigh the clients and position the clients for the examination.
- C. Discuss problems the client has experienced since the previous visit.
- D. Take the biopsy specimens to the laboratory.
Correct Answer: C
Rationale: Discussing client problems requires nursing judgment, outside UAP scope. Stocking, weighing/positioning, and transporting specimens are appropriate.
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.