A nurse is examining a skin infection on a client's lower left leg. Findings include edema, erythema, tenderness, and the client reports pain. The nurse should identify that these findings indicate which of the following?
Herpes zoster
Dermatophytosis
Contact dermatitis
Cellulitis
The Correct Answer is D
A) Herpes zoster
This condition, also known as shingles, is characterized by a painful, blistering rash that follows a nerve path. It typically presents as grouped vesicles rather than generalized edema and erythema, making it unlikely in this case.
B) Dermatophytosis
Commonly known as ringworm, this fungal infection usually causes a scaly, ring-shaped rash. It does not typically present with significant edema or erythema as seen with cellulitis, and tenderness is less common.
C) Contact dermatitis
This allergic or irritant reaction usually causes itching, redness, and rash after contact with a substance. While it can cause erythema and pain, it is less likely to cause the significant edema and tenderness observed in cellulitis.
D) Cellulitis
Cellulitis is a bacterial skin infection characterized by edema, erythema, tenderness, and pain. These symptoms align with the nurse’s findings, indicating an inflammatory response in the deeper layers of the skin, often requiring antibiotic treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Double-bag the client's trash before removing it from the room: Double-bagging trash is typically recommended for patients with highly contagious and severe infectious diseases, such as those requiring contact precautions. Influenza, while contagious, does not necessitate this level of precaution.
B) Place the client in a negative air pressure room with 6 to 12 air exchanges per hour: Negative air pressure rooms are used for airborne diseases like tuberculosis or measles, which can spread through the air over long distances. Influenza primarily spreads through respiratory droplets, so this precaution is not necessary.
C) Ensure all air in the client's room is filtered through a HEPA filter: HEPA filters are used for airborne pathogens to filter out infectious particles. Since influenza spreads via respiratory droplets rather than airborne particles, this level of air filtration is not required.
D) Wear a surgical mask when within 1 m (3 ft) of the client: Influenza spreads through respiratory droplets, which can travel up to about 1 meter (3 feet) when a person coughs or sneezes. Wearing a surgical mask within this distance helps prevent inhalation of these droplets, making it the appropriate precaution for influenza.
Correct Answer is D
Explanation
A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.
B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.
C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.
D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.
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