The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and healing promotion. The nurse determines that the client has understood the teaching by observing the client:
A. perform range-of-motion exercises.
B. avoid placing body weight on the healing site.
C. elevate body parts that are susceptible to edema.
D. demonstrate the technique for massaging the wound site.
ANS: B
A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care?
A. Ensuring that the family knows that impetigo is not contagious
B. Teaching about the safe and effective use of topical corticosteroids
C. Teaching about the importance of maintaining high standards of hygiene
D. Ensuring that the family knows how to safely burst the child's vesicles
ANS: C
An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care?
A. Avoid the application of skin emollients
B. Apply antibiotic ointment, as prescribed, following baths
C. Avoid using hot water during the client's baths
D. Administer acetaminophen four times daily as prescribed
ANS: C
An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury?
A. I
B. II
C. III
D. IV
ANS: D
While performing an initial assessment of a client admitted with appendicitis, the nurse observes an elevated blue-black lesion on the client's ear. The nurse knows that this lesion is consistent with what type of skin cancer?
A. Basal cell carcinoma
B. Squamous cell carcinoma
C. Dermatofibroma
D. Malignant melanoma
ANS: D