Nokea
When the nurse reviews the client's health history, which symptom is directly related to the development of cataracts?
- A. Gradual loss of vision
- B. Feeling of fullness within the eye
- C. Ocular pain or discomfort
- D. Flashes of light
Correct Answer: A
Rationale: Cataracts cause a gradual loss of vision due to lens opacity.
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The nurse is assessing the client. Which findings should the nurse associate with herpes zoster?
- A. Serous drainage and pus
- B. Nodular lesions and burning
- C. Painful vesicles and pruritus
- D. Macule lesions and petechiae
Correct Answer: C
Rationale: The nurse should associate pain and pruritus (itching) with herpes zoster. Herpes zoster follows the path of peripheral sensory nerves; symptoms come from the nerve involvement. Serous drainage and pus indicate infection of vesicles. Nodular lesions are not associated, though burning may occur. Macule lesions may occur early, but petechiae are not associated.
The nurse administered morphine sulfate, a narcotic analgesic, IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client complains the pain decreased to a '5' on a 1-to-10 scale. Which intervention should the nurse implement?
- A. Turn on soft music and shut the blinds.
- B. Apply warm, moist heat to the lesions.
- C. Notify the HCP for more pain medication.
- D. Encourage the client to ambulate with assistance.
Correct Answer: A
Rationale: Soft music and dim lighting provide nonpharmacologic pain relief for herpes zoster. Heat may worsen pain, more medication is premature, and ambulation is unrelated.
When the client asks about the cause of shingles, the nurse answers correctly with which cause of the disease?
- A. The reactivation of a dormant virus
- B. A vector insect such as a tick
- C. A toxin from a bacterial infection
- D. An antibody response to a drug allergen
Correct Answer: A
Rationale: Shingles results from reactivation of the varicella-zoster virus.
The client is being admitted to the ED after a house fire. Place the client's problems in the order of priority in which they should be addressed by the nurse.
- A. Has 48% partial- and full-thickness burn injury
- B. Laceration on the face that has stopped bleeding
- C. Inhalation injury from smoke
- D. History of hypertension
Correct Answer: C,A,B,D
Rationale: Inhalation injury from smoke is the priority problem that should be addressed first to ensure that the client has a patent airway. The 48% partial- and full-thickness burn injury should be addressed next due to fluid loss and pain. The laceration on the face that has stopped bleeding should be addressed next, possibly requiring suturing. History of hypertension can be addressed last, as fluid shifts from the burn are likely to lower BP.
The HCP prescribed Kwell lotion to be applied to the entire body. Which instructions should the nurse teach the client concerning this medication?
- A. Leave the lotion on for two (2) hours after applying it to the body.
- B. Make sure that the skin is completely dry before applying the lotion.
- C. Repeat total body lotion application daily for at least one (1) week.
- D. Put the lotion in the bathwater and soak for at least 20 minutes.
Correct Answer: B
Rationale: Kwell (lindane) is applied to dry skin to maximize efficacy and minimize irritation. Contact time is typically 6–8 hours, daily repetition is excessive, and bathwater use is incorrect.