The home health nurse has identified a series of concerns while providing services to a client. During one of the visits, the nurse becomes concerned about criminal activity in the home. What initial action by the nurse is most appropriate?

Correct Answer: C

Rationale: The most appropriate initial action for the nurse in this scenario is to leave the home. This is the correct answer because the nurse's safety should be the top priority. By leaving the potentially dangerous situation, the nurse can ensure their own well-being and then take appropriate steps to address the concerns. Dialing 911 or advising the client to leave the home could escalate the situation and put the nurse at risk. Contacting the physician may not provide immediate assistance in this urgent situation. In summary, leaving the home allows the nurse to prioritize safety and seek help or resources to address the concerns in a safer environment.

Correct Answer: D

Rationale: The correct diagnosis is D: Vulvar carcinoma. In a 60-year-old female with small red lesions on the vulva, vulvar carcinoma is the most likely cause due to the age group and presentation. Vulvar carcinoma commonly presents as red, white, or pigmented lesions, and its incidence increases with age. Herpes simplex (choice A) typically presents with vesicles and ulcers, not red lesions. Primary syphilis (choice B) presents with a painless chancre, while secondary syphilis (choice C) presents with a rash that typically involves the palms and soles. These choices are less likely based on the client's age, lesion appearance, and clinical findings.

Correct Answer: B

Rationale: The correct answer is B: Use pulse oximetry to assess the client's oxygen saturation. The bluish tinge, known as cyanosis, indicates decreased oxygen saturation in the blood. Using pulse oximetry will provide objective data on the client's oxygen levels. This is crucial in determining the severity of hypoxemia and guiding further interventions. Choice A: Asking about medications is not the immediate priority when cyanosis is detected. Medications may be relevant but do not address the urgent need for assessing oxygen saturation. Choice C: Auscultating lung fields is important in assessing respiratory status, but it does not directly address the need to determine the client's oxygen saturation level. Choice D: Palpating pulses can provide information on perfusion, but it does not directly assess the client's oxygenation status, which is the immediate concern when cyanosis is present.

Correct Answer: C

Rationale: The correct answer is C because a white blood cell count of 23,000/mm³ indicates a potential infection. Elevated WBC count is a common sign of infection as the body responds to pathogens. The other choices are incorrect because: A: Blood cultures pending do not necessarily indicate a wound infection. B: Thin, serous wound drainage is normal in some cases and does not always indicate infection. D: Decrease in wound size is a positive sign of healing, not infection. In summary, the client with an elevated WBC count should be evaluated for a wound infection due to the potential indication of an inflammatory response.

Correct Answer: A

Rationale: The correct answer is A: Cool, moist compresses. This nonpharmacologic measure helps to soothe eczematous dermatitis by reducing inflammation, itching, and discomfort. Cool compresses provide relief by constricting blood vessels and reducing swelling. Moist compresses help to hydrate the skin and prevent further irritation. Summary: B: Topical corticosteroids are pharmacologic agents used to treat eczematous dermatitis by reducing inflammation. They are not nonpharmacologic comfort measures. C: Heating pad can exacerbate eczematous dermatitis by increasing inflammation and itching. It is not recommended for this condition. D: Tepid bath with cornstarch may provide some relief for eczematous dermatitis, but cool, moist compresses are more effective in soothing the skin and reducing discomfort.