Nokea
Which measure is best for the nurse to recommend?
- A. Soak affected body parts in a warm solution that is approximately 100°F (37.8°C).
- B. Massage the affected areas to restore circulation.
- C. Apply a heating pad on the highest setting to the affected body parts.
- D. Flood the affected skin surface with hot water at a temperature of approximately 140°F (60°C).
Correct Answer: A
Rationale: Warm soaking at 100°F promotes rewarming without causing burns.
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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.
The nurse is caring for the client who is diagnosed with a carbuncle. Which home measures should the nurse discuss? Select all that apply.
- A. Leave the draining lesion open to the air so it dries.
- B. Use strict hand washing to prevent cross-contamination.
- C. Cover the mattress and pillows with plastic covers.
- D. Apply ice to the affected area 20 minutes twice daily.
- E. Wash all linens, towels, and clothing after each use.
- F. Remove all throw rugs to prevent tripping or falls.
Correct Answer: B,C,E
Rationale: Treatments for an infected lesion should include strict hand washing to prevent cross-contamination. Covering mattress and pillows with plastic covers and washing all linens, towels, and clothing after each use will prevent cross-contamination. Leaving the lesion open to air is not advised; a dressing is needed. Applying ice or removing throw rugs does not pertain to carbuncle treatment.
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.
Which subjective symptom is the client most likely to report to the nurse?
- A. Burning
- B. Pressure
- C. Vertigo
- D. Pain
Correct Answer: C
Rationale: Vertigo is a hallmark symptom of Meniere's disease due to inner ear fluid imbalance.
What is the scientific rationale for placing lift pads under an immobile client?
- A. The pads will absorb any urinary incontinence and contain stool.
- B. The pads will prevent the client from being diaphoretic.
- C. The pads will keep the staff from workplace injuries such as a pulled muscle.
- D. The pads will help prevent friction shearing when repositioning the client.
Correct Answer: D
Rationale: Lift pads reduce friction and shear during repositioning, preventing skin breakdown. Absorbent pads address incontinence, diaphoresis is unrelated, and staff safety is secondary.