Chronic Final

the nurse is providing dietary teaching to a client receiving a high protein diet while recovering from an acute episode of colitis, which would the nurse include in the rationale for this client?

repairs tissues

A young client has been diagnosed with tinea corporis (ringworm), but the mother would like the child to return to school. To avoid spreading the infection, what does the nurse suggest to the mother?

"Keep the site covered with a bandage."

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required?

"A tanning bed will supply the ultraviolet light I need." Ultraviolet radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients.

A client with a bacterial skin infection is being taught home care for treatment of this infection. Which statement by the client indicates a need for further teaching?

"I may stop using the topical antibiotic when the lesions disappear." The statement by the client that, "I may stop using the topical antibiotic when the lesions disappear," indicates the need for further teaching. The antibiotic should be used for the time prescribed and not just until the lesions seem to be resolved

Which statement by a client with psoriasis indicates that teaching about the condition has been effective?

"I should practice good handwashing technique." Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection. Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.

In teaching a client about primary prevention of skin cancer, which instruction does the nurse include?

Avoid sun exposure between 11 a.m. and 3 p.m." The nurse teaches the client that the sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time.

The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include?

Avoiding or reducing skin exposure to sunlight Avoiding or reducing one's exposure to the sun is the most important prevention technique.

A client has an odorous, purulent wound. How does the nurse best support this client?

Changes the dressing frequently The nurse knows that frequent dressing changes help with healing and help the client feel clean. This is the best method of support for this client

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first?

Clean and dry the client's skin.

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus infection. The nurse plans to include which instruction in the client's teaching plan?

Cover the infected area with a clean, dry bandage. The nurse includes the instruction that the infected area should be covered with a clean, dry bandage to prevent the spread of infection.

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home?

Determines whether the client can reach the affected area Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to independently perform frequent dressing changes at home.

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response?

Encourages participation in care of the wound The nurse's best response is to encourage client participation in wound care. This gives the client a sense of autonomy.

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant?

Every 2 hours, reposition a client who has had a stroke and is incontinent. The nurse can delegate repositioning a client to a nursing assistant.

The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy? Hyperbaric oxygen Nutrition therapy Topical growth factors vacuum assisted wound closure

Hyperbaric Oxygen

A client with diabetes presents to the ER with a 3 hour history of profound weakness and nervousness. According to the spouse, the client became confused shortly after self administering the morning dose of 10 units of regular insulin and 25 units of NPH insulin. The client had a light breakfast and no additional intake since that time. What condition would the nurse identify as the likely cause of the clients sings and symptoms?

Hypoglycemia: found in diabetic clients who take insulin and miss a meal

The nurse is teaching a client who has loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy does the nurse include in the client's teaching plan?

Lift hips off the chair at least every hour. The daily prevention strategy the nurse includes in the client's teaching plan is that the client will lift the hips off the chair at least every hour to relieve pressure and help prevent pressure ulcers.

The nursing instructor reviews instructions with the nursing student about caring for an older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client?

Massages bony prominences Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears.

A client has had a melanoma lesion removed. For secondary prevention, what is most important for the nurse to teach the client?

Perform a total skin self-examination monthly with a partner.

An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for?

Pressure ulcer development This client is at risk for developing pressure ulcers related to protein deficiency if he or she remains bedridden

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II?

Promote mobility and/or frequent repositioning. Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer.Reddened areas should never be massaged.

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention?

Second Second-intention healing is characterized by a cavitylike defect frequently found in chronic pressure ulcers. This involves gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss.

The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration?

Serum albumin Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.

which finding is an indication of an ulcer perforation in a client with PUD?

Tachycardia, hypotension, rigid abdomen, nausea and vomiting, back and shoulder pain

The nurse is caring for a client who has several infected lesions on both arms. The client is afebrile and does not have enlarged regional lymph nodes. The nurse notifies the provider who will most likely order which medication?

Topical mupirocin Topical mupirocin is an antibiotic that is most likely to be ordered for a client with a mild bacterial skin infection without fever or lymphadenopathy. Recurrent or severe infections may be treated with oral amoxicillin. Clients with methicillin-resistant Staphylococcus aureus infections should be treated with oral linezolid or clindamycin or intravenous vancomycin if the infection is severe.

The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. What precaution will the nurse take while performing this dressing change?

Wearing disposable gloves The nurse will wear disposable gloves. Disposable gloves are necessary when changing a dressing on a wound infected with MRSA to prevent transmission to others.

1. Which are appropriate nursing interventions for a client who has poor personal hygiene? (Select all that apply.) a. Obtain a social history. b. Assist the client with bathing. c. Tell the client that he or she smells badly. d. Consult social services to assess the client's living conditions. e. Teach client and family members how to help with personal hygiene. f. Notify the health care provider of any suspected drug or alcohol addiction. g. Assess for poor cognitive function or physical limitations that might interfere with grooming. h. Instruct the client and family to use rubbing alcohol to cleanse skin areas with most visible amount of dirt.

a. Obtain a social history. b. Assist the client with bathing. d. Consult social services to assess the client's living conditions. e. Teach client and family members how to help with personal hygiene. f. Notify the health care provider of any suspected drug or alcohol addiction. g. Assess for poor cognitive function or physical limitations that might interfere with grooming.

1. What is the appropriate nursing response when a client asks, "What is a punch biopsy"? a. "The healthcare provider will use a scalpel to remove a portion of the skin." b. "A circular cutting instrument will be used to remove a small plug of tissue." c. "A deep specimen of skin will be taken, and then the health care provider will suture this area closed." d. "A local anesthetic will be injected before a razor blade is moved parallel to the skin's surface to obtain a sample."

b. "A circular cutting instrument will be used to remove a small plug of tissue."

1. While performing skin assessment on an elderly client, the nurse observes an isolated brownish-purple lesion with irregular borders on the anterior chest wall. The lesion feels slightly raised on palpation and crusted blood is visible at the lower edge. Which is the appropriate nursing intervention? a. Wash the lesion gently with warm water to remove the crusts and teach not to pick it. b. Document lesion's location, size, and characteristics and request a dermatology consult. c. Reassure that the lesion is a common occurrence with aging, especially in sun-exposed areas. d. Ask the client about exposure to new lotions or perfumes that could cause an allergic reaction.

b. Document lesion's location, size, and characteristics and request a dermatology consult.

Causes of peritonitis

bowel obstruction, appendicitis, external penetrating wound, peritoneal dialysis

which information to promote self management would the nurse provide to a client being discharged with a new ileostomy?

change the appliance every 4-7 days and cleanse skin to prevent irritation clients should drink 3000ml of fluid in 24 hours avoid all alcohol should be emptied when its 1/3 full avoid nuts and seeds

a nurse is eliciting a health history from a client with ulcerative colitis, which factor would the nurse consider to be most likely associated to the clients colitis?

genetic predisposition

which assessment parameter is used to determine the severity of blood loss in a client with an upper GI bleed?

hematocrit, hemoglobin, platelet count, oxygen saturation, BUN

which information would the nurse provide a client with a new colostomy about managing the appliance?

measure the stoma once a week and cut the stoma opening 1/8-1/16 inch larger than the stoma so the wafer does not cut into the stoma - antifungal cream or powder is used for fungal rashes - soap should not be used on peristomal area to prevent drying

a client is admitted to the hospital with a diagnosis of Chron's disease, which is important for the nurse to include in the teaching plan for the client?

meeting nutritional needs

the nurse is caring for a client with a new colostomy, which client outcome is most important for achievement of long range goals, associated with adjusting to a new colostomy?

readiness to accept an altered body function

which hormone would the nurse identify as inhibiting insulin and glucagon secretion?

somatostatin

Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer?

the pain occurs 1-2 hours after having a meal