Nokea
The school nurse is teaching parents about head lice. What statement regarding the transmission of lice would the nurse identify as a myth?
- A. Lice can be spread by sharing of hats, caps, and combs
- B. Lice can jump from one individual to another.
- C. Lice need to be removed from the hair with a fine comb.
- D. Lice can be seen without magnification.
Correct Answer: B
Rationale: The nurse is correct to identify that lice cannot jump from one individual to another. Direct contact is needed for transmission. The other options are factual statements.
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A client enters the walk-in clinic stating that there is an itchy, red, warm, raised rash on the left forearm. The nurse documents when the rash developed and what the client was doing when it appeared. Allergic dermatitis is diagnosed. Which instruction is most important to prevent further problems?
- A. Instruct on the use of topical ointment.
- B. Advise against scratching the rash.
- C. Instruct on eliminating further allergen exposure.
- D. Instruct on washing the skin.
Correct Answer: C
Rationale: It is important to instruct on the use of topical ointment, if prescribed, and to keep the area clean and dry. It is also important to advise against scratching the rash. By scratching the itchy rash, the client can open the skin and develop an infection. Staphylococcus aureus is the most common skin infection. To prevent further problems, the client must avoid further exposure to the allergen.
A client asks the nurse what psoriasis is. What is the best answer?
- A. It is a chronic, infectious inflammatory disease.
- B. It is characterized by patches of redness covered with silvery scales.
- C. A cure is possible with prompt treatment.
- D. The onset typically occurs in young children.
Correct Answer: B
Rationale: Psoriasis is characterized by patches of erythema covered with silvery scales, usually on the extensor surfaces of the elbows, knees, trunk, and scalp. It is a chronic non-infectious inflammatory disease. Psoriasis has no cure. The onset is in young- and middle-adulthood.
What is the cause of shingles?
- A. Parasitic fungi
- B. Itch mite
- C. Reactivated virus
- D. Hormonal change
Correct Answer: C
Rationale: Several skin disorders involve an infecting agent. Scabies is caused by an itch mite. Parasitic fungi cause dermatophytosis in the skin, scalp, and nails. Shingles is caused by a reactivated virus. Hormonal change is not the cause of shingles.
The nurse is caring for an older adult client who has developed chapped and itchy skin. Which nursing intervention included in this client's plan of care should the nurse alter?
- A. Use of a gait belt for ambulation
- B. Maintenance of foam pad on wheelchair
- C. Daily bathing with warm-hot water
- D. Applying lanolin ointment
Correct Answer: C
Rationale: When the client develops dry and itchy skin, the nurse should alter the client's plan of care with respect to bathing. Hot water will dry the skin further. Due to a decrease in epidermal replacement rates, excessive drying of an older person's skin can lead to pruritus, dryness, and infection. Lanolin ointment is good to apply to dry skin because it helps moisturize so this should be kept in the plan. The nurse would not alter the plan of using a gait belt for ambulation or using a foam pad on the wheelchair.
The nurse is preparing to care for a client's new tattoo. Which action would the nurse take first?
- A. Cover the new tattoo with antibiotic ointment.
- B. Wash hands prior to gloving.
- C. Place a sterile gauze dressing over the tattoo.
- D. Teach the client to use a sunscreen (SPF 30) while in the sun.
Correct Answer: B
Rationale: As with any wound care, the nurse performs hand hygiene prior to donning gloves. The nurse is then ready to care for the newly tattooed skin. Antibiotic ointment is applied each day for 5 days. A sterile dressing is used to cover the tattoo for the first 12 hours. Sunscreen is good protection for the tattoo but not as part of a new tattoo treatment regimen.