Nokea
When assessing the client's skin the nurse notices a rounded area of hair loss with redness, pustules, and scales that appear greenish-yellow when exposed to a black light (Wood's lamp). The nurse should plan to implement treatment for which condition?
- A. Lyme disease
- B. Fungal infection
- C. Anaerobic infection
- D. Contact dermatitis
Correct Answer: B
Rationale: A fungal infection that manifests on the scalp with red, scaly lesions and hair loss will appear either greenish-yellow or bluish-green under a Wood's lamp. Lyme disease produces a bull's-eye rash that does not fluoresce. Anaerobic infections have diffuse redness and do not fluoresce. Contact dermatitis does not display a discrete, rounded area of hair loss or fluoresce.
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The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first?
- A. The client scheduled for a skin biopsy who is crying.
- B. The client who had surgery three (3) hours ago and is sleeping.
- C. The client who needs to void prior to discharge.
- D. The client who has received discharge instructions and is ready to go home.
Correct Answer: A
Rationale: Crying suggests emotional distress or pain, requiring immediate assessment. Sleeping, voiding, and discharge-ready clients are stable.
The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220 pounds and the order reads 10 mg per kilogram per day to be administered in equally divided doses every six (6) hours. How many milligrams will be administered in one dose?
Correct Answer: 250
Rationale: 220 lbs ÷ 2.2 = 100 kg; 10 mg/kg/day = 1000 mg/day; 1000 mg ÷ 4 doses = 250 mg/dose.
The elderly client is admitted from the long-term care facility diagnosed with congestive heart failure. The client complains of severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client’s fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data?
- A. Tinea capitis.
- B. Herpes simplex 2.
- C. Scabies.
- D. Psoriasis.
Correct Answer: C
Rationale: Itching and threadlike burrows between fingers indicate scabies. Tinea capitis affects the scalp, HSV-2 is genital, and psoriasis causes plaques.
Which standing nursing order should be eliminated from this client's care plan?
- A. Keep the client's bed in a low position at all times.
- B. Urge the client to cough every 2 hours while awake.
- C. Assist the client when ambulating in the hall or room.
Correct Answer: B
Rationale: Coughing is unnecessary and may increase intraocular pressure, risking complications.
Because the immobile client slides down in bed, the nurse is correct to assess for which type of skin injury?
- A. One that results from continuous pressure
- B. One that results from a shearing force
- C. One that results from friction
- D. One that results from agitation in bed
Correct Answer: B
Rationale: Sliding causes shearing forces, damaging skin and underlying tissue.