Nokea
The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse?
- A. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch.
- B. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally.
- C. The skin covering the coccyx is intact but the client complains of pain in the area.
- D. The coccyx wound extends to the subcutaneous layer and there is drainage.
Correct Answer: D
Rationale: Extension to the subcutaneous layer with drainage indicates progression to stage III or IV, worsening the ulcer. Smaller size, blisters, or pain are less severe.
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The nurse is teaching a class on how to prevent Lyme disease. Which intervention should be included in the discussion?
- A. Instruct the clients to wear dark clothes when hunting.
- B. Use a sunscreen of at least SPF 30 when outside.
- C. Avoid dense undergrowth when in a wooded area.
- D. Do not use any type of insect repellant when deer hunting.
Correct Answer: C
Rationale: Avoiding dense undergrowth reduces tick exposure, preventing Lyme disease. Dark clothes attract ticks, sunscreen is irrelevant, and insect repellent is recommended.
The nurse is teaching a 24-year-old female with severe cystic acne who is prescribed a systemic retinoic acid drug. Which question is priority?
- A. Are you sexually active?
- B. Are you allergic to vitamin A?
- C. Is your skin dry or sensitive?
- D. Can you take the drug as scheduled?
Correct Answer: A
Rationale: A systemic retinoic acid drug is teratogenic. A sexually active female must be instructed to practice birth control while taking this class of drugs, to avoid pregnancy. Allergy, skin sensitivity, and adherence are important but not the priority.
The client is receiving UV light treatments for psoriasis along with methoxsalen, a photosensitizing agent. What precaution should be followed the first day after treatment?
- A. Wear ultraviolet B-protective sunglasses.
- B. Avoid applying skin ointments and lotions.
- C. Check for elevated temperature every 4 hours.
- D. Stop treatments if skin redness or erythema occurs.
Correct Answer: A
Rationale: Treatment with methoxsalen (Uvadex) enhances sensitivity of the eyes to sunlight. Sunglasses that provide UVB protection need to be worn for at least 24 hours following treatments. Skin ointments may be prescribed. Temperature monitoring is not needed. Redness and erythema are normal responses.
Which statement made by the client to the nurse best indicates an understanding of when cataract surgery is needed?
- A. I'll need surgery when my loss of vision really interferes with my activities.
- B. I'll need surgery when I can't control the pain anymore with eyedrops.
- C. I'll need surgery when I start to feel self-conscious about my appearance.
- D. I'll need surgery when my cataracts are at their maximum density.
Correct Answer: A
Rationale: Surgery is indicated when vision loss significantly impacts daily activities.
The client had an allergic reaction to poison oak two (2) weeks ago. He has returned to the clinic with severe itching and weeping vesicles on the arms and legs. Which intervention should the nurse implement?
- A. Obtain a sample of the drainage for culture and sensitivities.
- B. Determine any allergic reactions to any medications taken recently.
- C. Inquire how the poison ivy/oak plants were destroyed.
- D. Assess for any temperature elevation since the last visit to the clinic.
Correct Answer: D
Rationale: Fever suggests secondary infection in persistent poison oak dermatitis, requiring assessment. Cultures, medication allergies, and plant destruction are secondary.