A client who is suffering from an allergic reaction asks the nurse what can be done about the itching. Which of the following will the nurse provide to the client?
Try to avoid scratching
Apply a moist cool compress
Use alcohol to cleanse the area
Use a wooden stick to scratch lesions
Avoid hot air
Correct Answer : A,B,E
Choice A Reason: This is a correct choice. Trying to avoid scratching is an advice that the nurse will provide to the client, as it prevents further damage and infection of the skin. Scratching can break the skin barrier and introduce bacteria or fungi into the wound, leading to inflammation and complications.
Choice B Reason: This is a correct choice. Applying a moist cool compress is an advice that the nurse will provide to the client, as it soothes and relieves itching and swelling. A moist cool compress can reduce inflammation and histamine release, which are responsible for allergic symptoms.
Choice C Reason: This is an incorrect choice. Using alcohol to cleanse the area is not an advice that the nurse will provide to the client, as it irritates and dries out the skin. Alcohol can strip away the natural oils and moisture from the skin, making it more prone to cracking and itching.
Choice D Reason: This is an incorrect choice. Using a wooden stick to scratch lesions is not an advice that the nurse will provide to the client, as it causes more harm than good. A wooden stick can injure or infect the skin, as well as spread the allergen or irritant to other areas.
Choice E Reason: This is a correct choice. Avoiding hot air is an advice that the nurse will provide to the client, as it aggravates itching and inflammation. Hot air can increase blood flow and histamine release, which are responsible for allergic symptoms. The client should also avoid hot water or showers, as they can have the same effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.
Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.
Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.
Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because observing the client swallowing small sips of water before assisting with feeding may not reduce the risk of aspiration pneumonia. Water is a thin liquid that can easily enter the lungs if the client has impaired swallowing or cough reflexes. The nurse should assess the client's need for thickened liquids or pureed foods and use a swallow screening tool to determine the appropriate consistency and amount of food and fluids.
Choice B Reason: This is incorrect because turning on the television for the client during meals may increase the risk of aspiration pneumonia. Television can distract the client from focusing on chewing and swallowing and cause them to eat too fast or too much. The nurse should provide a quiet and calm environment for the client during meals and encourage them to eat slowly and carefully.
Choice C Reason: This is incorrect because instructing the client to tilt their head back while swallowing may increase the risk of aspiration pneumonia. Tilting the head back can open the airway and allow food or fluids to enter the lungs. The nurse should instruct the client to tilt their head forward or tuck their chin while swallowing, which can close the airway and prevent aspiration.
Choice D Reason: This is correct because sitting the client upright 90 degrees then assisting the client with feeding can reduce the risk of aspiration pneumonia. Sitting upright can help gravity move food and fluids down the esophagus and away from the lungs. The nurse should also keep the client upright for at least 30 minutes after eating and drinking to prevent regurgitation and aspiration.
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