Nokea
Which response will the nurse most likely observe during the caloric test if the client has Meniere's disease?
- A. Onset of severe symptoms
- B. No response or change in symptoms
- C. Improvement in balance
- D. Aphasia and loss of consciousness
Correct Answer: A
Rationale: Meniere's disease causes an exaggerated response to caloric stimulation.
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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.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority?
- A. High risk for infection.
- B. Ineffective coping.
- C. Impaired physical mobility.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Extensive burns increase infection risk due to loss of skin barrier; this is the priority. Coping, mobility, and knowledge are secondary in acute burn care.
What images will a client with macular degeneration most likely describe seeing?
- A. Objects that are close to the face
- B. Objects that are clear distance
- C. Objects that are in outer peripheral fields
- D. Objects that are in the central field of vision
Correct Answer: C
Rationale: Macular degeneration spares peripheral vision, affecting central vision.
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.
The nurse is caring for clients with second- and third-degree burns. Which medication should the nurse plan to apply topically to treat bacterial and yeast infections?
- A. Bismuth subsalicylate
- B. Gold sodium thiomalate
- C. Silver sulfadiazine
- D. Arsenic trioxide
Correct Answer: C
Rationale: Silver sulfadiazine (Silvadene) is a topical anti-infective agent for prevention and treatment of wound infection in second- and third-degree burn clients. Bismuth subsalicylate (Kaopectate) is an antidiarrheal medication. Gold sodium thiomalate (Aurolate) is used to treat rheumatoid arthritis resistant to conventional therapy. Arsenic trioxide (Trisenox) is an antineoplastic.