Nokea
The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?
- A. Wear a sunscreen with a protection factor of 10 or less when in the sun.
- B. Try to stay out of the sun between 0300 and 0500 daily.
- C. Perform a thorough skin check monthly.
- D. Remember caps and long sleeves do not help prevent skin cancer.
Correct Answer: C
Rationale: Monthly skin checks detect early skin cancer changes. SPF 10 is inadequate, 0300–0500 is nighttime, and caps/long sleeves are protective.
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Which problem should the nurse identify for the client recently diagnosed with leprosy (Hansen’s disease)?
- A. Social isolation.
- B. Altered body image.
- C. Potential for infection.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Leprosy’s stigma often leads to social isolation, a priority psychosocial problem. Body image, infection, and comfort are secondary.
The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100.8°F. Which condition would the nurse suspect the client is experiencing?
- A. Cellulitis.
- B. Lyme disease.
- C. Impetigo.
- D. Deep vein thrombosis.
Correct Answer: A
Rationale: Redness, edema, heat, and streaks post-puncture suggest cellulitis, a bacterial infection. Lyme disease has a bullseye rash, impetigo is superficial, and DVT lacks skin changes.
Which of the following clients should have his clothing removed immediately?
- A. A 32-year-old man who was burned while working on high-tension wires
- B. A 14-year-old boy who suffered severe smoke inhalation during a fire at school
- C. A 78-year-old man who was burned during a fire that started when the client fell asleep while smoking
- D. A 19-year-old student who spilled chemicals on himself in the chemistry lab at school
Correct Answer: D
Rationale: Clothing must be removed immediately in chemical burns to prevent further skin exposure and damage from the corrosive substance.
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.
Once the victim's blood pressure is stabilized, the best indication of successful response to the initial burn treatment is which assessment finding?
- A. Normal body temperature
- B. Minimal level of pain
- C. Adequate urine output
- D. Ability to perform exercises
Correct Answer: C
Rationale: Adequate urine output indicates successful fluid resuscitation.