Nokea
Which response by the nurse is best in this situation?
- A. Gravity helps to reattach the separated retina.
- B. I'm very small to be a reasonable, and I'm very
- C. I can get you a sedative if it's hard to lie still.
- D. The doctor knows what's best for you, and you should listen.
Correct Answer: A
Rationale: Bed rest uses gravity to aid retinal reattachment.
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The client is scheduled for application of a cadaver homograph to a burn on the forearm. Which comment by the client demonstrates an accurate understanding of this procedure?
- A. The graft donor site from my right upper thigh shouldn't take too long to heal.
- B. I know this graft will only be a temporary measure to protect and help heal my arm.
- C. I am glad that there is no risk of me getting a blood-borne disease with this type of graft.
- D. If this graft doesn't permanently take, then I'll need to select another graft donor site.
Correct Answer: B
Rationale: A cadaver skin graft is a type of temporary graft, also called a biological dressing, and it is used to protect the damaged skin and promote healing and epithelialization. A cadaver skin graft does not use the client's own skin, so there is no donor site. There is a risk of transmitting blood-borne infections with cadaver grafts. The graft is not permanent, so no further donor site selection is needed.
The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement?
- A. This surgery will create a skin flap to cover my wounds.'
- B. This surgery will get all the old black tissue out of the wound so it can heal.'
- C. The surgery is important to allow oxygen to get to the tissue for healing to occur.'
- D. Stool will come out an opening in my abdomen so it won’t get in the sore.'
Correct Answer: D
Rationale: Fecal diversion (colostomy) prevents stool contamination of coccyx ulcers, aiding healing. Skin flaps, debridement, and oxygen delivery are unrelated to this surgery.
The nurse is assessing the client for possible scabies infestation. Which findings should the nurse expect?
- A. Serosanguineous drainage and fever
- B. Malaise and local edema
- C. Itching and papule-like rash
- D. Macule rash and blisters
Correct Answer: C
Rationale: The most common symptoms of a scabies infestation are itching and papule rash. Serosanguineous drainage and fever or malaise and edema occur with wound infections. Macule rash and blisters may occur with allergic reactions.
The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychosocial problem of 'fear.' Which nursing interventions should be included in the plan of care?
- A. Explain to the client that the fears are unfounded.
- B. Encourage the client to verbalize the feeling of being afraid.
- C. Have the HCP discuss the client’s fear with the client.
- D. Instruct the client regarding all planned procedures.
Correct Answer: B
Rationale: Verbalizing fear helps address anxiety and promotes coping. Dismissing fears, deferring to HCP, or procedure instruction are less therapeutic.
When examining the client's skin, which finding would the nurse expect to observe?
- A. Weeping skin lesions on the trunk of the body.
- B. Red skin patches covered with silvery scales.
- C. A red rash containing raised pustules.
Correct Answer: B
Rationale: Psoriasis presents with red patches and silvery scales.