Nokea
Which patient instruction will the nurse reinforce relative to the management of systemic lupus erythematosus (SLE)?
- A. Maintain a balance between rest and activity.
- B. Increase activity to promote mobility.
- C. Increase exposure to the sun to increase vitamin D absorption.
- D. Increase sodium consumption.
Correct Answer: A
Rationale: Balanced rest, activity, and diet will support medication management. It is not necessary to increase activity to promote mobility. Limited sunlight exposure is recommended to prevent photosensitivity. SLE often has kidney involvement, which would require reduction of sodium.
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A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower lip and chin. The nurse believes these lesions most likely are caused by which condition?
- A. chickenpox.
- B. impetigo.
- C. shingles.
- D. herpes simplex type I.
Correct Answer: B
Rationale: Impetigo is seen at all ages but is particularly common in children. The crust is honey-colored and easily removed and is associated with pruritus. The disease is highly contagious and spreads by contact. Chickenpox and shingles are characterized by vesicles and are not honey-colored. Herpes simplex type I is also known as 'cold sores' or 'fever blisters'. Lesions are generally located around and in the mouth.
Several residents in a long term care facility have been diagnosed with herpes zoster. Which resident will require the closest observation for development of complications?
- A. A resident who is sexually active
- B. A resident recovering from a hip fracture
- C. A resident with dementia who requires assistance eating.
- D. A resident who is undergoing chemotherapy for breast cancer
Correct Answer: D
Rationale: The resident who is undergoing chemotherapy is likely to develop a low white blood cell count, and is at the highest risk of complications such as disseminated herpes zoster or severe skin infection from the irritated skin at the lesion sites. A resident who is sexually active is not necessarily at high risk of complications of herpes zoster, (shingles). Neither the resident recovering from a hip fracture or the resident with dementia are as high a risk as the resident undergoing chemotherapy.
Which is the greatest concern during the emergent phase of a burn injury?
- A. joint contractures
- B. Fluid overload
- C. hypovolemic shock.
- D. adrenal failure.
Correct Answer: C
Rationale: Hypovolemic shock is frequently lethal in the emergent period of a severe burn because of the transfer of fluids into the interstitial tissue from the circulating volume. Joint contractures and fluid overload occur during later phases of the burn injury. Adrenal failure is not associated with the emergent period of a severe burn.
Which is a nursing intervention and patient teaching item for the treatment of head lice and scabies?
- A. Clothing, linens, and bath articles thoroughly cleaned in hot water
- B. Stress nature and transmission of the disease
- C. Special carbohydrate diet to promote healing
- D. Complete isolation from the public
- E. removal of pets from the home
Correct Answer: A,B
Rationale: Identify involved contacts while stressing importance of preventing transmission of disease. Washable and clothing items should be cleaned in hot water to prevent reinfection. No special diet is required. Isolation is not necessary once medical management is completed. It is not necessary to remove pets from the home.
When providing the open method of treatment for a patient who is 52 years old with burns to the lower extremities, which does the nurse expect to see included in the nursing plan?
- A. Change the dressing using good medical asepsis.
- B. Provide an analgesic immediately after the dressing change.
- C. Perform circulation checks every 2 to 4 hours.
- D. Keep the room temperature at 85°F (29.4°C) to prevent chilling.
Correct Answer: D
Rationale: Chilling may be controlled by keeping the room temperature at 85°F (29.4°C). The open method of burn injury treatment does not involve dressings; the wound is left undressed. Strict surgical protocol is observed and analgesia should be given before the treatment. Circulation is not restricted if the wound area is left open.