Nokea
Which response by the nurse is best at this time?
- A. I'm sure you will look absolutely gorgeous.
- B. I didn't think you were unattractive before.
- C. Your face is swollen with bruises around the eyes.
- D. Your personality is more important than your looks.
Correct Answer: C
Rationale: An honest response about expected swelling prepares the client for recovery.
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It is most appropriate for the nurse to monitor a client for which potential problem?
- A. Infection
- B. Hyperthermia
- C. Depression
- D. Malnutrition
Correct Answer: A
Rationale: Open exposure increases infection risk due to exposed tissue.
The client receives treatment for uncomplicated lower-extremity cellulitis. The nurse notes improvement in the client's condition when which observation is noted on assessment?
- A. Decreased swelling in the lower extremity
- B. Strong dorsalis pedis pulses felt bilaterally
- C. Increased erythema in the lower extremity
- D. White blood cell (WBC) count 14,000/mm3
Correct Answer: A
Rationale: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Observing a decrease in swelling is evidence of improvement. Circulation is not involved with cellulitis, so pedal pulses are unaffected. Increased erythema indicates worsening. A WBC of 14,000/mm3 is elevated, indicating infection.
The female client admitted for an unrelated diagnosis asks the nurse to check her back because 'it itches all the time in that one spot.' When the nurse assesses the client’s back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first?
- A. Notify the HCP to check the lesion on rounds.
- B. Measure the lesion and note the color.
- C. Apply lotion to the lesion.
- D. Instruct the client to make sure the HCP checks the lesion.
Correct Answer: B
Rationale: Measuring and documenting the lesion provides baseline data for HCP evaluation. Notification, lotion, or client instruction are secondary.
The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority?
- A. Impaired cognition.
- B. Altered nutrition.
- C. Self-care deficit.
- D. Altered coping.
Correct Answer: B
Rationale: Altered nutrition is critical in stage IV ulcers to support wound healing. Cognition, self-care, and coping are secondary in advanced wounds.
The nurse should instill the eyedrops into which part of the client's eye?
- A. Onto the cornea
- B. The three carnaus
- C. At the outer canthus
- D. In the lower conjunctival sac
Correct Answer: D
Rationale: Instilling drops in the lower conjunctival sac ensures proper distribution and minimizes corneal irritation.