Nokea
Which laboratory test should the nurse monitor to identify an allergic reaction for the client diagnosed with contact dermatitis?
- A. IgA.
- B. IgD.
- C. IgE.
- D. IgG.
Correct Answer: C
Rationale: IgE mediates allergic reactions, elevated in contact dermatitis. IgA, IgD, and IgG are less relevant.
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The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?
- A. Replace fluids and electrolytes.
- B. Prevent contractures of extremities.
- C. Monitor urine output hourly.
- D. Prepare to assist with an escharotomy.
Correct Answer: A
Rationale: Massive fluid loss in 65% burns requires immediate fluid and electrolyte replacement to prevent shock. Contracture prevention, urine monitoring, and escharotomy are secondary after fluid resuscitation.
When the nurse applies mafenide acetate cream to the burn wound, the nurse should recognize which of the following as its chief disadvantage?
- A. Skin discoloration
- B. Pain on application
- C. Unpleasant odor
- D. Contact dermatitis
Correct Answer: B
Rationale: Mafenide acetate causes significant pain upon application.
The nurse is assessing the client diagnosed with psoriasis. Which data would support that diagnosis?
- A. Appearance of red, elevated plaques with silvery white scales.
- B. A burning, prickling row of vesicles located along the torso.
- C. Raised, flesh-colored papules with a rough surface area.
- D. An overgrowth of tissue with an excessive amount of collagen.
Correct Answer: A
Rationale: Red plaques with silvery scales are characteristic of psoriasis. Vesicles suggest herpes zoster, papules suggest warts, and collagen overgrowth suggests keloids.
The client mentions all of the following to the nurse. Which of the following should the client be encouraged to report to the physician immediately?
- A. A small mole on the right thigh that has looked the same ever since the client can remember
- B. A pigmented area that is pink-red in color and has been present since birth
- C. Three small warts on the right hand that have been present for some time
- D. A black and purple mole that is growing larger and has a funny shape
Correct Answer: D
Rationale: A growing, irregularly shaped, and discolored mole may indicate melanoma, requiring immediate medical evaluation.
Which common ailment should the nurse instruct the client who underwent a stapedectomy to immediately report to the physician?
- A. The common cold
- B. A sore throat
- C. A productive cough
- D. Conjunctivitis
Correct Answer: A
Rationale: A cold can lead to middle ear pressure changes, risking surgical complications.