Nokea
Which problem should the nurse identify for the client recently diagnosed with leprosy (Hansen’s disease)?
- A. Social isolation.
- B. Altered body image.
- C. Potential for infection.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Leprosy’s stigma often leads to social isolation, a priority psychosocial problem. Body image, infection, and comfort are secondary.
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Aside from blood on the anterior end of the packing, what other sign or symptom would suggest that the client is bleeding from the operative area?
- A. Frequent swallowing
- B. Impaired appetite
- C. Slight hoarseness
- D. Diminished hearing
Correct Answer: A
Rationale: Frequent swallowing may indicate blood trickling down the throat.
The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?
- A. Wear a sunscreen with a protection factor of 10 or less when in the sun.
- B. Try to stay out of the sun between 0300 and 0500 daily.
- C. Perform a thorough skin check monthly.
- D. Remember caps and long sleeves do not help prevent skin cancer.
Correct Answer: C
Rationale: Monthly skin checks detect early skin cancer changes. SPF 10 is inadequate, 0300–0500 is nighttime, and caps/long sleeves are protective.
The nurse is explaining facelift (rhytidectomy) surgery to the client and describing the site where the incision is most commonly made. Place an X on the site where the incision most commonly used for rhytidectomy is made.
- A. An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face.
Correct Answer: A
Rationale: An incision either in front or in back of the ear is made during rhytidectomy to remove excess skin and treat muscle laxity of the face. Incisions in the forehead and periorbital area are for blepharoplasty and browlift. Head and neck reconstruction utilizes the chin site.
When examining the electrical burn on the victim, which assessment is most important for the nurse to determine?
- A. The entry and exit wound sites
- B. Degree of skin discoloration
- C. Amount of eschar on the wound bed
- D. Characteristics of wound drainage
Correct Answer: A
Rationale: Identifying entry and exit sites assesses the extent of internal tissue damage.
When describing the examination procedure to the client, which statement by the nurse is most accurate?
- A. You'll read words that are the size of newsprint.
- B. You'll read letters from a distance of 20 feet to mears.
- C. You'll look at a color picture and identify an image.
- D. You'll look at a screen and tell me when an object appears.
Correct Answer: B
Rationale: The Snellen chart involves reading letters from 20 feet to assess visual acuity.