Nokea
Which finding of the client's biographical data most likely contributed to developing skin cancer?
- A. The client is a chronic cigarette smoker.
- B. The client has male pattern baldness.
- C. The client works for a drug manufacturer.
- D. The client bathes with a deodorant soap.
Correct Answer: B
Rationale: Baldness increases scalp sun exposure, a risk factor for skin cancer.
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The nurse observes the unlicensed assistive personnel (UAP) squeezing the 'blackheads' on an elderly client. Which action should the nurse implement first?
- A. Notify the unit manager of witnessing this activity.
- B. Instruct the assistant to stop this behavior.
- C. Demonstrate the correct way to care for the skin.
- D. Complete an incident report regarding the action.
Correct Answer: B
Rationale: Stopping the UAP prevents harm from inappropriate skin manipulation. Notification, demonstration, and reporting follow.
After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?
- A. Wrap ice in a washcloth and put it on the burn area.
- B. Come to the ED so a doctor can assess your fingers.
- C. Run cool water over the burned area on your fingers.
- D. Apply an antibiotic skin ointment to prevent infection.
Correct Answer: C
Rationale: Ice causes vasoconstriction and can worsen the tissue damage. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing.
The nurse is planning care for a newly burned client. What is the priority nursing observation to be made during the first 48 hours after the burn?
- A. Hourly blood pressure
- B. Assessment of skin color and capillary refill
- C. Hourly urine measurement
- D. Frequent assessment for pain
Correct Answer: C
Rationale: Hourly urine measurement is critical in the first 48 hours to monitor fluid resuscitation effectiveness and prevent hypovolemic shock.
Which other assessment finding is most indicative of an infection in the external ear?
- A. Foul-smelling drainage
- B. Scarred tympanic membrane
- C. Diminished hearing
- D. Enlarged lymph nodes
Correct Answer: A
Rationale: Foul-smelling drainage is a hallmark of external ear infections.
The nurse is caring for the immobile client who is at risk for developing pressure ulcers. Which food should the nurse recommend?
- A. Assorted fruit salad
- B. Oatmeal with raisins
- C. Baked chicken breast
- D. Lettuce and tomato salad
Correct Answer: C
Rationale: Chicken is a high-protein food. Proteins are needed to help meet the body's needs for tissue repair and to maintain skin integrity. Fruit salad, oatmeal, and lettuce salad are high-fiber or carbohydrate foods, not high in protein.