Nokea
While repositioning the client, the LPN notices a shallow, open ulcer on the sacrum with partial-thickness skin loss. What is the classification stage of this ulcer?
- A. Stage I
- B. Stage IV
- C. Stage II
- D. Stage III
Correct Answer: C
Rationale: An ulcer is classified as stage II when the skin is not intact and there is partial-thickness skin loss. An ulcer with full-thickness skin loss would be stage III.
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A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
- A. plantar fasciitis.
- B. hallux valgus.
- C. hammertoe.
- D. Morton's neuroma.
Correct Answer: D
Rationale: Morton's neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as a bunion. Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.
The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse's best response?
- A. I need to find out the client's preferences first.
- B. Shave him only after you have bathed him.
- C. Use the electric razor when you shave him.
- D. Avoid shaving him. I need a doctor's order.
Correct Answer: A
Rationale: A: Removal of facial hair varies based on personal and cultural preferences, which should be assessed first. B: Bathing order is irrelevant without preferences. C: Electric razors are safe but preferences are unknown. D: Shaving does not require a doctor's order.
The client residing in a nursing home has bilateral weak handgrips and visual and hearing deficits. Which interventions should the nurse implement when the client is eating a meal? Select all that apply.
- A. Ask the client's permission to open containers and cut up meats on the food tray.
- B. Obtain special easy-to-hold, built-up silverware for the client to use when eating.
- C. Observe the client, but avoid providing assistance even if the client is frustrated.
- D. Help feed the client if the client is eating too slowly so food does not get too cold.
- E. Ensure that the client wears eyeglasses and hearing aids before starting to eat.
Correct Answer: A,B,E
Rationale: A: Asking permission promotes autonomy. B: Built-up silverware aids weak grips. E: Sensory aids enhance independence. C: Assistance reduces frustration. D: Feeding discourages independence.
Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:
- A. the right to examine and question the bill
- B. the right to reasonable response to requests
- C. the right to refuse treatment
- D. the right to confidentiality
Correct Answer: D
Rationale: The client's concern about costs suggests he may demand to examine the bill, expect reasonable responses, or refuse treatment. Confidentiality, while a right, is unrelated to his stated financial concerns and is not suggested to be breached.
The client began wearing hearing aids 5 weeks earlier. Which statement to the nurse demonstrates that the client is successfully adapting to the hearing aids?
- A. I need to wear the hearing aids only when I go out in public.
- B. I clean my ears with a cotton-tipped swab before I insert them.
- C. I place the hearing aids in the protective box to store them at night.
- D. I soak the plastic parts of the hearing aids in mild soap and water weekly.
Correct Answer: C
Rationale: C: Hearing aids are expensive and delicate, and they should be stored in a protective container in a dry, safe place. A: Hearing aids should be worn daily to adjust to their use. B: Cotton-tipped swabs should not be inserted into the ear canal due to possible injury and infection. D: Hearing aids should be kept dry except when cleaning the ear mold with mild soap and water.