questions

what is the purpose of the wood's light?

"It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.

what interventions are used for a child with MRSA?

-administration of vancomycin -contact isolation -administration of mupirocin ointment to the nares

examples of passive aggressive behavior by a patient using immature defense mechanisms

-being hostile after agreeing to follow unit rules -avoiding completing tasks when asked by the boss at work

what are clinical manifestations of osteomyelitis ?

-complaints of localized pain -swelling -warmth -tenderness -unusual odor -sometimes elevated temp

what are the advantages of external fixation for the immobilization of fractures?

-it leads to minimal blood loss -it allows for early ambulation -it promotes healing

Which fungal infection is commonly referred to as athlete's foot? 1 Tinea pedis 2 Tinea cruris 3 Tinea corporis 4 Tinea unguium

1

Which rationale would explain the reason a client abuses alcohol? 1 To blunt reality 2 To precipitate euphoria 3 To promote social interaction 4 To stimulate the central nervous system

1 Clients abuse alcohol to blunt reality. Alcohol, by depressing the central nervous system and distorting or altering reality, reduces anxiety. Alcohol depresses the central nervous system; it may cause lability of mood, impaired judgment, and aggressive actions rather than euphoria. Although alcohol is used as a social lubricant, clients with alcohol use disorder frequently drink in isolation.

Which component of skin maintains optimal barrier function? 1 Keratin 2 Melanin 3 Collagen 4 Adipose tissue

1 Keratin is a protein produced by keratinocytes that helps maintain optimal barrier function. Melanin pigment is produced by melanocytes and gives color to the skin. Collagen is a protein produced by fibroblasts. Its production is increased during tissue injury and helps form scar tissue. Adipose tissue is the subcutaneous fat that insulates the body and absorbs shock.

Which position would the nurse encourage for the client who had an above-the-knee amputation? 1 Functional alignment 2 Extended and abducted 3 Flexed and externally rotated 4 Hip raised when moving

1 Muscles that originate at the vertebrae or pelvic girdle and insert on the femur act to abduct, adduct, flex, extend, and rotate the femur. Functional body alignment should be maintained because it facilitates safe and efficient use of muscle groups for balance and stability.

Which is the most important topic to include in teaching to promote the comfort of a client with a pruritic skin disease? 1 Sleep 2 Exercise 3 Elimination 4 Hand hygiene

1 Pruritic skin diseases often interfere with sleep. Adequate rest increases the client's ability to tolerate the itching, thereby decreasing the damage to the skin. Exercise and elimination are not specifically associated with the discomfort of a client with a pruritic skin disease. Hand hygiene is an infection control measure.

Which action would the nurse take for a client with panic disorder who jumps when spoken to, reports feeling uneasy, and says, "It's as though something bad is going to happen"? 1 Stay with the client to be a calming presence. 2 Encourage the client to communicate with the staff. 3 Allow the client to set the parameters for the interaction. 4 Help the client understand the cause of the feelings described.

1 The nurse would stay with the client to be a calming presence. Fear can be overwhelming; the nurse's presence provides protection from possible escalating anxiety. The client's anxiety level is interfering with the ability to communicate; anxiety must be reduced first before the nurse would encourage the client to communicate with the staff. The client's anxiety level is so high that sufficient emotional energy to set parameters is not available. Helping the client understand the cause of the feelings he or she describes may increase the client's anxiety at this time.

Which intervention would be essential for the nurse to take for a hyperactive client? 1 Using a firm but caring and consistent approach 2 Anticipating and physically controlling the hyperactivity 3 Allowing the client to choose the activities in which to participate 4 Letting the client know that the staff will not tolerate overactive behavior

1 Using a firm but caring and consistent approach will help reduce the client's anxiety, thereby reducing hyperactivity. It is not possible to physically control hyperactivity. The client is not capable of choosing activities at this time. The staff would know how to deal with overactive behavior; the client may not be capable of controlling overactive behavior.

what % of permethrin is used for lice ?

1, OTC

Which strategies would the nurse apply when vaccinating a child to decrease pain and anxiety? Select all that apply. One, some, or all responses may be correct. 1 Applying a topical anesthetic 2 Injecting the most painful vaccine last 3 Holding the child upright during the vaccination 4 Administering intramuscular injections rapidly without prior aspiration 5 Administering acetaminophen or ibuprofen after vaccination

1,2,3,4

What is Maslow's hierarchy of needs?

1. Physiological needs 2. Safety and Security needs 3. Love and Belonging Needs (relationships) 4. Self esteem 5. self actualization

Lymphocyte normal range

1500-3000

Prealbumin normal range

16-40 mg/dL

Which skin infection would cause facial paralysis? 1 Candidiasis 2 Herpes zoster 3 Herpes simplex 4 Dermatophytosis

2 Facial paralysis is the clinical sign of Bell palsy, a complication of the herpes zoster infection. This is seen when the trigeminal nerve is infected by the varicella-zoster virus. Candidiasis is a fungal infection not associated with Bell palsy. Herpes simplex is a viral infection and may not cause Bell palsy. Dermatophytosis is also a fungal infection not associated with Bell palsy.

Which response would the nurse expect from a client with antisocial personality disorder? 1 "I need a lot of help with my troubles." 2 "Society makes people follow rules that don't apply to me." 3 "This might help me straighten out my life." 4 "I don't like to be around other people for long periods of time."

2 The antisocial client is incapable of accepting responsibility for self-created problems and blames society for the behavior.

Which finding would the nurse observe in a client with conversion disorder who is unable to move the right arm? 1 Feeling depressed 2 Appearing composed 3 Demonstrating free-floating anxiety 4 Exhibiting tension when discussing symptoms

2 The client would appear composed. The client with a conversion disorder literally converts the anxiety to the symptom. Once the symptom develops, it serves as a defense against the anxiety and the client is diagnostically almost anxiety free.

Which approach would the nurse use for a client with Alzheimer disease who expresses fear and anxiety upon admission to a long-term care facility? 1 Exploring the reasons for the concerns 2 Reassuring the client with the presence of 1 or 2 staff members 3 Providing the client with a written schedule of planned interactions 4 Explaining to the client why the admission to the facility is necessary

2 The nurse would reassure the client with the presence of 1 or 2 staff members. The client needs reassurance, because forgetfulness blocks previous explanations; the presence of 1 or 2 staff members serves as a support system. This client will be unable to explain the reasons for the concerns because of the short-term memory loss from Alzheimer disease. The client will not be able to decode a written schedule; the client needs reassurance. This client will not remember the explanation for admission to the facility.

A client has a basal cell carcinoma that is scheduled to be removed. The client expresses concerns that the cancer has metastasized. Which is the best response by the nurse? 1 "You are a low surgical risk." 2 "I can understand how you must feel." 3 "Basal cell tumors usually do not spread." 4 "The primary health care provider probably caught it just in time."

3

Which action would the nurse take to minimize agitation in a disturbed client? 1 Ensure constant staff contact. 2 Increase environmental sensory stimulation. 3 Limit unnecessary interactions with the client. 4 Discuss the reasons for the client's suspicions.

3 Limiting unnecessary interactions will decrease stimulation and therefore agitation. Constant client and staff contact increases stimulation and agitation. Increasing environmental sensory stimulation bombards the client's sensorium and increases agitation. Not all disturbed clients are suspicious. This client is unlikely to benefit from a discussion of suspicions at this time.

Which recommendations would the nurse include in a client's discharge instructions regarding a home skincare program for psoriasis? 1 "Shower twice a day with mild soap and warm water." 2 "Soak the affected areas in hot water on a daily basis." 3 "Apply an alcohol free, moisturizing lotion several times a day." 4 "Cover affected areas when in contact with others."

3 Moisturizing lotions provide an occlusive film on the skin surface so that usual water loss through the skin is limited, thereby allowing the trapped water to hydrate the stratum corneum. Clients should not excessively expose the skin to water, particularly hot water, increases irritation and scaling. Psoriasis is not a communicable disease and affected areas do not need covering when in contact with others.

A client with generalized anxiety disorder presents with restlessness and fatigue. Which additional clinical manifestation would the nurse monitor for? 1 Hoarding 2 Panic attacks 3 Excessive worry 4 Fear of leaving the house

3 The nurse would monitor for excessive worry. Generalized anxiety disorder is the manifestation of both physical and cognitive symptoms of chronic or excessive anxiety/worry.

Albumin normal range

3.5-5 g/dL

A client who uses ritualistic behavior taps other clients on the shoulders three times as part of the ritual. Which rationale best explains the client's behavior? 1 Client demonstrates blurred personal identity 2 Client has poor control of sudden urges 3 Client has a disturbance in spatial boundaries 4 Client has limited ability to adapt to stressors

4 Ineffective coping is the impairment of a person's adaptive behaviors and problem-solving abilities in meeting life's demands; ritualistic behavior is an impaired type of coping. Additional assessment would be needed to determine if the client has problems with personal identity, impulse control, or spatial boundaries.

For a client who is increasingly agitated, which immediate nursing intervention is most likely to increase anxiety? 1 Being assertive 2 Responding early 3 Providing choices 4 Teaching relaxation

4 Once the client is agitated, teaching will not be effective. Learning requires attention and participation; failure to learn will increase the client's anxiety.

what % of permethrin is used for scabies?

5, prescription needed

how long does it take an SSRI to become effective in a new patient ?

8-12 weeks

What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the childs mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. b. Clean the rash vigorously with Betadine three times a day. c. Notify the physician for any itching. d. Keep the child home from school until the lesions are healed.

A

A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action would the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

A A client's medical alert bracelet or any other jewelry would be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.

When assessing the child with atopic dermatitis, the nurse should ask the parents about a history of a. Asthma b. Nephrosis c. Lower respiratory tract infections d. Neurotoxicity

A Most children with atopic dermatitis have a family history of asthma, hay fever, or atopic dermatitis, and up to 80% of children with atopic dermatitis have asthma or allergic rhinitis.

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse respond? a. "Skeletal traction will assist in realigning your fractured bone." b. "This treatment will prevent future complications and back pain." c. "Traction decreases muscle spasms that occur with a fracture." d. "This type of traction minimizes damage as a result of fracture treatment."

A Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.

Which statement by the mother of an adolescent being discharged after spinal fusion for severe scoliosis indicates the need for further teaching? a. I am glad we chose surgery. Now it is all over and done. b. Ill see you in a month; well be back fairly regularly. c. I have to pick up some more T-shirts on the way home. d. Those exercises the physical therapist showed us were not too hard.

A Spinal fusion requires long-term follow-up to assess the stability of the spinal correction.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action would the nurse take? a. Request a prescription for permethrin. b. Administer an antihistamine. c. Assess the client's airway. d. Apply gloves to minimize friction.

A The client's presentation is most likely to be scabies, a contagious mite infestation. The drugs used to treat this infestation are ivermectin and permethrin. The nurse would contact the primary care provider to request a prescription for one of the medications.

A rehabilitation nurse assesses a client upon admission. Which assessments would the nurse complete to determine actual or potential interruption in skin and tissue integrity? (Select all that apply.) a. Oxygen saturation b. Cognitive abilities c. Functional mobility d. Spiritual needs e. Urinary output f. Nutrition

A,B,C,E,F

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia

A,C,D Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

Where do the lesions of atopic dermatitis most commonly occur in the infant? Select all that apply. a. Cheeks b. Buttocks c. Extensor surfaces of arms and legs d. Back e. Trunk

A,C,E The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities.

A nurse plans care for a client who is immobile. Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the client's heels off the bed surfaces

A,D,F (reposition every hour while in chair)

A nurse cares for a client who reports discomfort related to eczematous dermatitis. Which nonpharmacologic comfort measures would the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with colloidal oatmeal e. Back rub with baby oil

ANS: A, D For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse would implement cool, moist compresses and tepid baths with additives such as colloidal oatmeal.

labile behavior would be seen in which cluster personality disorder?

B -changing rapidly and often

A rehabilitation nurse in a skilled nursing facility (SNF) cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise would the nurse implement? a. Passive range of motion b. Active range of motion c. Resistive range of motion d. Aerobic exercise

B Active range of motion is a part of a restorative nursing program. Active range of motion will promote strength, range of motion, and independence with activities of daily living.

A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago reports burning pain and tingling in the affected foot. For which potential complication would the nurse anticipate? a. Delayed bone healing b. Complex regional pain syndrome c. Peripheral neuropathy d. Compartment syndrome

B Burning pain and tingling that occurs weeks or months after a fracture or other trauma may indicate complex regional pain syndrome. Compartment syndrome tends to occur within days of the initial injury

A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention would the nurse implement to prevent skin breakdown? a. Place pillows under the client's heels. b. Have the client do wheelchair push-ups. c. Perform wound care as prescribed. d. Massage the client's calves and feet with lotion

B Clients who sit for prolonged periods in a wheelchair would perform wheelchair push-ups for at least 20 seconds every hour. Chair-bound clients also need to be repositioned at least every 1 to 2 hours. The lower legs, where the wheelchair could rub against the legs, also need to be assessed.

A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action? a. Pain of 4 on a scale of 0-10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

B The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a. "Have you eaten a large amount of chocolate lately?" b. "Have you been under a lot of stress lately?" c. "Have you recently used a public shower?" d. "Have you been out of the country recently?" e. "Have you recently had any other health problems?" f. "Have you changed any medications recently?"

B, E, F Outbreaks of psoriasis can be induced by stress, environmental triggers, certain medications, skin injuries, infections, smoking, alcohol use, and obesity

Parents of a child with lice infestation should be instructed carefully in the use of antilice products because of which potential side effect?

Because of the danger of absorption through the skin and potential for neurotoxicity, antilice treatment must be used with caution. A child with many open lesions can absorb enough to cause seizures.

avoidant personality disorder is which cluster ?

C

Which type of fractures describes traumatic separation of cranial sutures? a. Basilar b. Linear c. Commuted d. Depressed

C Commuted skull fractures include fragmentation of the bone or a multiple fracture line

A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? Select all that apply. a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. e. Combs and brushes should be boiled in water for at least 10 minutes.

C,D,E An over-the-counter pediculicide, permethrin 1% (Nix, Elimite, Acticin), kills head lice and eggs with one application and has residual activity (i.e., it stays in the hair after treatment) for 10 days. Nix crme rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes.

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching? a. "This drug should help decrease my tremors and help me move better." b. "I need to change positions slowly to prevent dizziness or falls." c. "I should take the drug at the same time each day for the best effect." d. "I know the drug will probably make help me prevent constipation."

D Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it does not work to prevent constipation. This class of drugs can cause orthostatic hypotension and should be taken at the same time every day.

An older client who fell at home is admitted to the emergency department and reports pain in her left groin and behind her left knee. What action would the nurse anticipate? a. Administer IV push morphine. b. Prepare for application of a leg cast. c. Begin oxygen at 6 L/min via mask. d. Obtain a left hip x-ray

D The location of the client's pain indicates a possible fractured hip and therefore an x-ray of the hip is needed

A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? a. Hypertension b. Diarrhea c. Infection d. Hematuria

D The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse would also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia.

A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound? a. Wet-to-damp saline moistened gauze b. None, the wound is left open to the air c. A transparent film d. Multi-fiber superabsorbent dressing

D This pressure injury requires a superabsorbent dressing that will collect the exudate but not stick to the wound itself

what medication would be used to treat a fungal infection?

Ketoconazole

Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs who has what disease?

Parkinson's

A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound and change the dressing every day because it costs too much for supplies. How should the nurse respond? a. You can use tap water instead of sterile saline to clean your wound. b. If you dont clean the wound properly, you could end up in the hospital. c. Sterile procedure is necessary to keep this wound from getting infected. d. Good hand hygiene is the only thing that really matters with wound care.

a For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration

A patient in the emergency department has no physical injuries but exhibits disorganized behavior and incoherence after minor traffic accident. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurses office, furnished with chairs, files, magazines, and bookcases

a Individuals who are experiencing severe to panic-level anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move.

A patient has a fear of public speaking. The nurse should be aware that social anxiety disorders (social phobias) are often treated with which type of medication? a. Beta-blockers b. Antipsychotic medications c. Tricyclic antidepressant agents d. Monoamine oxidase inhibitors

a propranolol

what kind of dressing provides mechanical removal of necrotic tissue?

a wet-to-damp gauze

___________, _________, and ___________ counts all give information related to nutritional status. The ________________ count is a more specific indicator of nutritional status than is the albumin count

albumin, prealbumin, lymphocyte prealbumin

what is the greatest respiratory complication of Parkinson's disease ?

aspiration, so keep the head of the bed at 30 degrees or greater

When taking a history on a child with a possible diagnosis of cellulitis, what should be the priority nursing assessment to help establish a diagnosis?

assess for any recent infections or signs of infection because cellulitis may follow an upper respiratory infection, sinusitis, Otis media, or tooth abscess.

Clumsy movements, loss of coordination, equilibrium, and kinesthetic sense occur in what kind of CP?

ataxic CP

Slow, writhing, uncontrolled, involuntary movements occur with what kind of CP?

athetoid or dyskinetic CP

A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patients anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

b All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving to begin

The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a."How do you feel about what happened to you as a child? b."How do you feel about what is going on right now?" c."Remember a time when you were calm." d."Tap your hands until the feeling goes away."

b Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training.

A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurses comments and asks, What are they going to do? Assessment findings include a tremulous voice, respirations 28 breaths per minute, and pulse rate 110 beats per minute. What is the patients level of anxiety? a. Mild b. Moderate c. Severe d. Panic

b Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

Which factor should the nurse include when teaching a parent about the care of a newborn in a Pavlik harness for hip dysplasia? a. The harness may be removed with every diaper change. b. The harness is used to maintain the infants hips in flexion and abduction and external rotation. c. The harness is only the first step of treatment. d. The harness is worn for 2 weeks.

b The harness must be worn for 23 hours per day and should be removed only according to the physicians recommendation. Hips that remain unstable become progressively more deformed as maturity takes place.The harness is used to maintain the infants hips in flexion and external rotation to allow the hips (femoral head and acetabulum) to mold and grow normally.With early diagnosis and treatment, the Pavlik harness is often the only treatment necessary.The length of treatment is determined by radiographic documentation of the maturity of the hips.

cellulitis is a _________ infection

bacterial

what is the key difference between OCD and OCPD?

behaviors in people with OCD can fluctuate at different times, behaviors in people with OCPD are consistent over time

What is burn shock?

burn shock describes the loss of fluid from the intravascular space as a result of burn injury causes leaking capillaries requires crystalloid infusion

what is complex regional pain syndrome?

burning pain and tingling that occurs weeks or months after a fracture or other trauma

what is a long acting antianxiety medication?

buspirone

For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control.

c Calm, brief, directive verbal interaction can help the patient gain control of the overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus learning relaxation techniques is virtually impossible. Administering an anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other, less-restrictive measures are proven ineffective.

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, The nurse manager had a headache the day I was interviewed. Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting

c Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others.

A person has minor physical injuries after an automobile accident. The person is unable to focus and says, I feel like something awful is going to happen. This person has nausea, dizziness, tachycardia, and hyperventilation. What is this persons level of anxiety? a. Mild b. Moderate c. Severe d. Panic

c The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic-level anxiety demonstrates significantly disturbed behavior and may lose touch with reality.

individuals with antisocial disorder are

callous, deceitful, and impulsive

what medical conditions are most commonly associated with anxiety?

cancer, COPD, dysrhythmias, encephalitis, hyperthyroidism

Small red papules with peripheral scaling in a sharply demarcated area involving the anterior thighs, lower abdomen, and perineum are characteristic of primary ___________

candidiasis

what is indicative of a possible wound infection?

change in appearance change in texture change in color change in drainage change in size of wound (except after debridement)

what is an example of normal anxiety?

changing study habits to earn better grades after initially failing a test

what temperatures makes poison ivy feel better?

cold

a boy who has fractured his forearm is unable to extend his fingers. this may indicate what ?

compartmental syndrome

what is the most common problem faced by rehabilitation patients ?

constipation

what is the unconscious transformation of anxiety into a physical symptom?

conversion

After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching? a. Ill apply cortisone cream to reduce the inflammation. b. Ill apply a clean dressing after squeezing out the pus. c. Ill keep my arm down at my side to prevent spread. d. Ill cleanse the area prior to applying antibiotic cream.

d Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.

The pediatric nurse understands that cellulitis is most often caused by a. Herpes zoster b. Candida albicans c. Human papillomavirus d. Streptococcus or Staphylococcus organisms

d Streptococcus, Staphylococcus, and Haemophilus influenzae are the organisms usually responsible for cellulitis.

which skin layer supports the exchange of heat and oxygen?

dermis (capillaries and lymph vessels)

what is nystatin CREAM used for?

diaper rash caused by candida

emollients and moisturizers (lotion) are used for

dry skin in psoriasis

typical characteristics of cluster C disorders

eccentric behavior suspicious irrational

what is another name for atopic dermatitis?

eczema

which body area is most commonly affected by psoriasis?

elbow

because patients diagnosed with obsessive-compulsive disorder become overly involved in rituals, what should the nurse do to help the patient develop more effective coping strategies?

encourage the patient to participate in social activities -daily activities and involvement with other people prevent the constant focus on anxiety and its symptoms

what is a closed reduction?

ends of the bones are manually pulled and realigned and is the most common NONSURGICAL method for managing a simple fracture

________ ______________ is also common in clients with Parkinson disease and is associated with the autonomic nervous system's response

excessive perspiration

upper extremity fractures most often result from what?

falls

The client with a healing _______ needs supplements of vitamins B and C and a high-protein, high-calorie diet.

fracture

what involves the replacement of dead tissue with scar tissue that aids in healing?

granulation

Physical therapists help clients to achieve self-management by focusing on _______ __________

gross mobility

what makes cellulitis worse ?

hydrocortisone cream

what is contraindicated in the treatment of a child with cellulitis ?

ice packs to relive swelling-will decrease circulation to the affected area and inhibit the healing process

A client with Parkinson disease reports problems with bowel elimination. Which instruction should the nurse provide for the client?

increase residue in the diet -Increasing residue in the diet produces bulk, which stimulates defecation; the muscles used in defecation are weak in clients with Parkinson disease.

what is the first phase of wound healing and how long does it last ?

inflammatory phase, 3 to 5 days

What is the introjection defense mechanism?

integrating the beliefs and values of another individual into one's own ego structure

__________ is identified by a red macerated area of sharp demarcation in the groin folds. It can also develop in the gluteal and neck folds.

intertrigo

children integrating their parents value system into the process of conscience formation is an example of what ?

introjection

A shiny, parchment-like erythematous rash on the buttocks, medial thighs, mons pubis, and scrotum, but not in the folds, is suggestive of

irritant contact dermatitis.

what is the primary problem of contact dermatitis?

itching

what is a characteristic of a patient with antisocial personality ?

lack of remorse when confronted with the results of their thoughtless, irresponsible behavior toward others

how does exercise help with anxiety ?

lowers tension, releases endorphins, distraction

which additional problem is most important for the nurse to assess in a patient newly diagnosed with GAD?

major depressive disorder

A ________ face and _________ are common in clients with Parkinson disease.

masklike, drooling

The child with _____ ________ requires long-term follow-up to determine whether the curve will progress or remain stable

mild scoliosis

what kind of dressing is used for a stage 3 pressure injury that has copious amounts of exudate?

multi-fiber superabsorbent dressing that will collect the exudate but not stick to wound itself

Carbidopa-levodopa is prescribed for a client with Parkinson disease. The nurse assesses for which adverse responses associated with this medication?

nausea and emotional changes Nausea and vomiting may occur; this reflects a central emetic reaction to levodopa. Changes in affect, mood, and behavior are related to the toxic effects of carbidopa-levodopa. Insomnia, tremors, and agitation are side effects that may occur, not lethargy. Tachycardia and palpitations, not bradycardia, occur. Anemia and leukopenia, not polycythemia, are adverse reactions.

what personality disorders have evidence of genetic links?

obsessive compulsive, antisocial, and schizotypal

what is the most serious complication of skeletal traction?

osteomyelitis-inflammation of bone and bone marrow

which type of anxiety may be associated with delusional/disturbed thinking ?

panic-level anxiety

Prior to administering antibiotics, the nurse obtains the ___________ ___________. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known.

prescribed cultures

_____________ is the hallmark of _____________

projection, blaming

what is the primary clinical manifestation of scabies?

pruritus

_____________ _____________ manifests as thick reddened papules covered by white scales.

psoriasis vulgaris (chronic disorder)

what is an example of reaction formation?

recovered smoker preaches about the dangers of secondhand smoke -keeps unacceptable feelings out of awareness by using opposite behavior

______________ ______________ work to help clients continue or develop hobbies or interests.

recreational therapist

the affected area from cellulitis looks like...

red, hot, tender, and indurated

what is the most common fracture in the adult population?

rib

what viral infection is associated with fetal anomalies?

rubella virus can cross the placenta

impetigo tends to heal without

scarring

________ is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis

scoliosis

_________ ___________ __________the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The childs muscles are very tight and any stimuli may cause a sudden jerking movement

spastic cerebral palsy

__________ _____________pathologists evaluate and retrain clients with speech, language, or swallowing problems.

speech language

what kind of fracture occurs after minimal trauma to a bone that has been weakened by a disease ?

spontaneous (pathologic)

people with OCD need to regularly be assessed for what?

suicide

what should parents be taught about the administration of Nystatin to their infant with thrush (oral candidiasis) ?

swab nystatin SUSPENSION onto the oral mucus membranes, rubbing it onto the gums and tongue, after feedings, every 6 hours, until 3 to 4 days after symptoms have disappeared

what is the most commonly used cast on a broken limb?

synthetic cast-dry and set fast

Which purpose would the nurse explain to a client as the reason for using Buck traction before surgery?

to immobilize the fracture -A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain, and edema.

___________ ____________are characteristic of rigid/tremor/atonic cerebral palsy

tremulous movements

how do you know a child has adequate perfusion with severe burns?

urinary output-reflects the adequacy of end-organ perfusion

do you use heat or cold for cellulitis?

warm compress because more blood flow to the area brings more WBC to help get rid of infection moist heat for muscle and joint

what treatment is indicated for a child with cellulitis?

warm soaks applied every 4 hours while the child is awake to increase circulation to the infected area, relieve pain, and promote healing.