Nokea
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.
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An electrician was wearing a glove that had a hole in it when he grabbed a 'hot' wire. His coworkers came to him immediately and called the rescue squad. When the industrial nurse reached him, the electric current had been shut off. What action should the nurse take initially?
- A. Dress the entrance and exit wounds
- B. Check respirations and pulse rate
- C. Remove clothing from the burned area
- D. Roll him in a blanket
Correct Answer: B
Rationale: Checking respirations and pulse rate is the initial action to assess for life-threatening complications, such as cardiac arrhythmias, common in electrical burns.
When developing nursing care plans, the nurse is careful to classify which type of wound as a chronic wound?
- A. A gunshot wound with tissue damage
- B. A slow-healing diabetic foot ulcer
- C. A stage I pressure ulcer on the coccyx
- D. A 7-day-old infected surgical wound
Correct Answer: B
Rationale: Diabetic foot ulcers heal slowly, classifying them as chronic.
Which statement is the best indication that the client understands the purpose of wearing the pressure garment?
- A. It prevents subsequent wound infection.
- B. It prevents exposure to the sun.
- C. It reduces the severity of scar formation.
- D. It reduces the potential for social rejection.
Correct Answer: C
Rationale: Pressure garments minimize hypertrophic scarring.
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client’s mental health?
- A. Encourage the client to stay at home as much as possible.
- B. Discuss the importance of not relying on the family for needs.
- C. Tell the client to remember that changes in lifestyle take time.
- D. Instruct the client to discuss feelings only with the therapist.
Correct Answer: C
Rationale: Acknowledging lifestyle changes promotes mental health by fostering realistic expectations. Isolation, independence from family, or limiting discussions hinder recovery.
The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse?
- A. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch.
- B. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally.
- C. The skin covering the coccyx is intact but the client complains of pain in the area.
- D. The coccyx wound extends to the subcutaneous layer and there is drainage.
Correct Answer: D
Rationale: Extension to the subcutaneous layer with drainage indicates progression to stage III or IV, worsening the ulcer. Smaller size, blisters, or pain are less severe.