The nurse admits a client to the emergency department after a motor vehicle accident. Which is the nurse most likely to identify on the client's skin?
1. Scaly, oozing area with erythema
2. Rough, flaky, cracked skin surface
3. Denuded area with delayed oozing
4. A skin eruption resulting from overexposure
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3. The nurse is most likely to find abrasions on the client's skin resulting from the accident because an abrasion is an area of skin where the epidermis has been scraped away, or denuded. These areas of denuded skin can start to bleed mildly but usually have delayed oozing of serous fluid.
1. Contact dermatitis is indicated by scaly, oozing, reddened skin.
2. Dry skin is rough and flaky and can be cracked.
4. Skin eruptions from overexposure are called rashes.
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Which instruction will the nurse include when teaching a client newly prescribed chlorothiazide (Diuril)?
1. "It is all right to have a glass of wine with this medication." 2. "Avoid foods high in potassium while you are taking this medication." 3. "Be sure to include lots of salt in your diet." 4. "Take the medication early in the morning."
The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the LI section of this format?
1. In order to avoid causing anxiety, limit the amount of information given to clients regarding adverse sexual side effects of treatments or medications. 2. Give the client accurate but concise information in regard to any sexual questions that might be asked. 3. Start information using slang terms to refer to sexual body parts because the client is not likely to know the proper terms. 4. Review current research literature associated with the sexual concerns of the client and partner.
The postpartum home care client asks the nurse why the visit is taking place. Which response is best? "We make home care visits to:
1. "Reinforce any teaching that you didn't quite grasp in the hospital." 2. "Verify that both you and the baby are safe and doing well." 3. "Provide a service that leads to better statistical outcomes." 4. "Thoroughly assess your baby to make sure he is growing."
The client has chronic obstructive pulmonary disease (COPD). Which does the nurse expect to find on physical assessment of the client? (Select all that apply.)
1. Wheezing 2. Hypercapnia 3. Upright posture 4. Small lung fields 5. Diminished chest excursion 6. Anteroposterior ratio of 1:1