Nokea
Which client would most likely be at risk for the development of a carbuncle?
- A. The young male who is just beginning to shave.
- B. The female with a fair complexion.
- C. The male who works out in the gym daily.
- D. The female diagnosed with diabetes mellitus.
Correct Answer: D
Rationale: Diabetes increases infection risk, including carbuncles, due to impaired immunity. Shaving, fair skin, and exercise are less significant.
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Shortly before each debridement, which nursing intervention is essential?
- A. Keeping the client in a fasting state
- B. Witnessing a signed consent form
- C. Administering a prescribed analgesic
- D. Weighing the client on a bed scale
Correct Answer: C
Rationale: Analgesics are essential to manage pain during debridement.
The nurse knows that the client who underwent a stapedectomy understands the discharge instructions when the client identifies which activity to avoid for the next 6 months?
- A. Listening to music
- B. Flying in an airplane
- C. Driving an automobile
- D. Singing in the choir
Correct Answer: B
Rationale: Pressure changes during flying can disrupt healing after a stapedectomy.
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.
The nurse is caring for the client with the pressure ulcer illustrated. Which stage should the nurse document?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: C
Rationale: Stage III pressure ulcer is full-thickness skin loss that extends to the subcutaneous fat, but not fascia; bone, tendon, and muscle are not visible. Stage I is intact but red and nonblanching. Stage II involves a break in the skin with partial-thickness loss. Stage IV is full-thickness loss with exposed muscle and bone.
When the nurse prepares the client for the myringotomy, which statement best explains the purpose of the procedure?
- A. A myringotomy prevents permanent hearing loss.
- B. A myringotomy provides a pathway for drainage.
- C. A myringotomy aids in administering medications.
- D. A myringotomy maintains motion of the ear bones.
Correct Answer: B
Rationale: A myringotomy creates an opening for fluid drainage, relieving pressure.