Nokea
When assessing a skin lesion, you look for A-asymmetry, B-irregular borders, C-variegated colors, D-diameter, and E-
- A. Edema.
- B. Erythema.
- C. Elevation.
- D. Ever-changing.
Correct Answer: C
Rationale: Elevation is one of the ABCDE criteria for assessing suspicious skin lesions.
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A nurse assesses a client’s pain level as a 5 out of 10 on the pain scale. The order reads for the client to receive morphine. Which of the following five ways of managing pain does the drug morphine fall under?
- A. Altering pain transmission at the level of the spinal cord
- B. Combining analgesics with adjuvant drugs
- C. Blocking brain perception
- D. Interrupting pain-transmitting chemicals at the site of injury
Correct Answer: A
Rationale: The correct answer is A because morphine primarily works by altering pain transmission at the level of the spinal cord by binding to opioid receptors.
What is a typical parasomnia?
- A. Cataplexy
- B. Hypopnea
- C. Sleep apnea
- D. Sleep terrors
Correct Answer: D
Rationale: The correct answer is D. Sleep terrors are a classic example of parasomnias, which are abnormal behaviors during sleep. Cataplexy (A) is associated with narcolepsy, hypopnea (B) refers to shallow breathing, and sleep apnea (C) involves breathing interruptions.
A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:
- A. excoriation.
- B. dehiscence.
- C. decortication.
- D. evisceration.
Correct Answer: D
Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.
What statement by Mr. Ross indicates postural drainage has been effective?
- A. ‘I have been able to eat a little better during the past week.’
- B. ‘I have not gained any during the past week.’
- C. ‘I have not been able to sleep very well at night.’
- D. ‘I have been bringing up lots of sputum when I cough.’
Correct Answer: D
Rationale: Effective postural drainage clears secretions, evidenced by productive coughing.
Mary Thomas presents with red, teary eyes, a runny nose, and a stuffy head. What nursing orders would be recommended?
- A. Antihistamines, aspirin, and cough syrup
- B. Increased fluids, steam inhalation, and rest
- C. Aspirin, cough syrup, and increased fluids
- D. Auscultation and percussion of the chest
Correct Answer: B
Rationale: Hydration, steam inhalation, and rest help alleviate symptoms and promote recovery.