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While performing a skin assessment on an older adult, the nurse notices a number of irregular round brownish-colored lesions on the client's hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?
- A. Apply a topical antibiotic ointment.
- B. Monitor the lesions for changes.
- C. Advise the client to use sunscreen.
- D. Refer the client for a skin lesion biopsy.
Correct Answer: D
Rationale: Referral for a skin biopsy is necessary to rule out potential malignancy of irregular skin lesions. Applying a topical antibiotic ointment (Choice A) is not indicated for irregular pigmented lesions. Monitoring the lesions for changes (Choice B) may delay appropriate intervention if malignancy is present. Advising the client to use sunscreen (Choice C) is important for sun protection but is not the priority when irregular lesions are present.
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While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem?
- A. Irritation of nerve endings
- B. Diminished blood flow
- C. Ischemic tissue changes
- D. Compression of a nerve
Correct Answer: D
Rationale: The correct answer is D: Compression of a nerve. In carpal tunnel syndrome, pain arises from the compression of the median nerve within the carpal tunnel. This compression leads to symptoms such as pain, numbness, and tingling in the hand and arm. Choices A, B, and C are incorrect because carpal tunnel syndrome pain is primarily caused by the physical compression of the nerve, rather than irritation of nerve endings, diminished blood flow, or ischemic tissue changes.
Which pathology is associated with an asthma condition?
- A. Chronic dilation and inflammation of the bronchi.
- B. Recurrent spasms of the airways accompanied by edema and mucus production.
- C. Progressive loss of lung function due to destruction of alveolar walls.
- D. Infection of the lung parenchyma.
Correct Answer: B
Rationale: The correct answer is B: Recurrent spasms of the airways accompanied by edema and mucus production. Asthma is characterized by bronchospasms, inflammation, swelling of the airways, and increased mucus production. This leads to airway constriction, making it difficult to breathe. Choices A, C, and D do not represent the typical pathology seen in asthma. Chronic dilation and inflammation of the bronchi (Choice A) is more characteristic of bronchiectasis, progressive loss of lung function due to destruction of alveolar walls (Choice C) is seen in conditions like emphysema, and infection of the lung parenchyma (Choice D) is more related to conditions like pneumonia.
When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?
- A. Impaired body image
- B. Skin impairment
- C. Nutritional deficit
- D. Injury
Correct Answer: B
Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.
Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?
- A. Cerebral palsy
- B. Hydrocephalus
- C. Meningitis
- D. Neuroblastoma
Correct Answer: B
Rationale: Hydrocephalus is the additional congenital malformation expected in 80% of infants with a myelomeningocele. Myelomeningocele is commonly associated with hydrocephalus due to the abnormal accumulation of cerebrospinal fluid in the brain. Cerebral palsy (Choice A) is a motor disorder but not typically associated with myelomeningocele. Meningitis (Choice C) is an infection of the meninges and is not a congenital malformation. Neuroblastoma (Choice D) is a type of cancer that originates in immature nerve cells and is not a typical association with myelomeningocele.
When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep?
- A. Right side-lying
- B. Left side-lying
- C. Prone
- D. Supine
Correct Answer: D
Rationale: The correct answer is D, supine. The American Academy of Pediatrics recommends placing infants on their back, or supine, to sleep as it has been shown to reduce the risk of SIDS. Choices A, B, and C are incorrect because placing infants on their right side, left side, or prone (on their stomach) respectively are not recommended sleeping positions due to the increased risk of SIDS associated with those positions.