Nokea
Which type of capillary hemangioma is described by the following: this is a common blemish on the head and neck of a newborn child and rapidly disappears spontaneously
- A. Strawberry naevus
- B. Port-wine stain
- C. Campbell de Morgan spots
- D. Spider naevus
Correct Answer: A
Rationale: Strawberry nevus typically appears on the head and neck of newborns and tends to disappear spontaneously.
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Which diagnostic test should the nurse expect to rule out osteoarthritis?
- A. Full-body MRI scan
- B. Serum studies for synovial fluid amount
- C. X-ray of the affected joints
- D. Serum erythrocyte sedimentation rate
Correct Answer: C
Rationale: X-rays reveal joint space narrowing characteristic of OA.
The nurse notes a thickening and hardening of the skin from continued irritation on an individual who is wheelchair-bound. What term should the nurse use to describe this finding?
- A. Crust
- B. Papule
- C. Excoriation
- D. Lichenification
Correct Answer: D
Rationale: Lichenification is thickened, hardened skin. A crust is a scab formed by dried serum. A papule is a raised solid lesion. Excoriation is a traumatic abrasion.
The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon?
- A. A total of 100 mL of red drainage in the autotransfusion drainage system.
- B. Pain relief after using the patient-controlled analgesia (PCA) pump.
- C. Cool toes, distal pulses palpable, and pale nailbeds bilaterally.
- D. Urinary output of 60 mL of clear yellow urine in three (3) hours.
Correct Answer: C
Rationale: Cool toes and pale nailbeds suggest possible circulatory compromise, warranting immediate reporting.
A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain?
- A. History of sun exposure by the patient
- B. Method of birth control used by the patient
- C. Length of time the patient has used fluorouracil
- D. Appearance of the treated areas on the patients face
Correct Answer: B
Rationale: Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable birth control has the most potential for serious adverse medication effects.
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: Infection is the priority due to the extensive loss of skin barrier, increasing susceptibility to pathogens in severe burns.