Nokea
Which information about pruritus should the nurse include? Select all that apply.
- A. Cool environments increase itching.
- B. Use of soap increases itching.
- C. Use hot water to rinse off soap.
- D. Apply mild skin lotion for hydration.
- E. Blot gently, but completely dry the skin.
Correct Answer: B,D,E
Rationale: Soap, mild lotion, and gentle drying reduce pruritus. Cool environments decrease itching, and hot water worsens it.
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The nurse is obtaining a preoperative health history on the client scheduled for revision of facial scars. Which client comment indicates an increased risk for a poor cosmetic outcome?
- A. I haven't had anything to eat or drink since 10 pm last night.
- B. I'm nervous about surgery; what if the surgery doesn't work?
- C. My high blood pressure is controlled with lisinopril.
- D. I plan to continue taking diclofenac for pain control.
Correct Answer: D
Rationale: Diclofenac (Voltaren) is an NSAID; increased bleeding tendency and increased sensitivity to sunlight are side effects that may inhibit achieving optimal cosmetic outcomes. Fasting is standard practice. Nervousness does not affect cosmetic outcomes. Controlled hypertension poses no significant risk.
What is the best evidence that the antibiotic the nurse is administering for the treatment of acute otitis media is having a therapeutic effect?
- A. The ear feels less warm to the touch.
- B. Ear drainage is thin and watery.
- C. Ear discomfort is relieved.
Correct Answer: C
Rationale: Relief of ear discomfort indicates the infection is responding to treatment.
The nurse is teaching a class on the prevention of cancer. Which information should be included regarding how to reduce the risk of skin cancer?
- A. Avoid prolonged exposure to the sun.
- B. Shower immediately after being outdoors.
- C. Avoid strong perfumes, hand creams, and body lotions.
- D. After being in the woods or in tall grass, check for ticks.
Correct Answer: A
Rationale: Avoiding prolonged sun exposure reduces ultraviolet radiation damage, a primary risk factor for skin cancer.
The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first?
- A. The 34-year-old client who is quadriplegic and cannot move his arms.
- B. The elderly client diagnosed with a CVA who is weak on the right side.
- C. The 78-year-old client with pressure ulcers who has a temperature of 102.3°F.
- D. The young adult who is unhappy with the care that was provided last shift.
Correct Answer: C
Rationale: Fever in a client with pressure ulcers suggests infection, requiring urgent assessment. Quadriplegia, weakness, and dissatisfaction are less acute.
The client is complaining of burning, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement?
- A. Transfer the client to the ED for a cardiac work-up.
- B. Inform the client that the nurse can’t see anything.
- C. Administer a nonnarcotic analgesic to the client.
- D. Ask the client if he or she has ever had chickenpox.
Correct Answer: D
Rationale: Burning pain along dermatomes without visible lesions suggests early herpes zoster, linked to prior chickenpox. Cardiac work-up, dismissal, or analgesics are premature.