The male client diagnosed with a stage 4 pressure ulcer on the coccyx area is being treated with an autolytic medication for debridement and an occlusive dressing. The wife asks about a foul odor. Which statement is the nurse's best response?

Correct Answer: C

Rationale: The correct answer is C: 'The odor is an expected reaction to the pressure dressing.' The rationale is that in the scenario provided, the male client is being treated with an occlusive dressing for the pressure ulcer. Occlusive dressings can sometimes lead to a foul odor due to the accumulation of exudate and bacteria under the dressing, which is a normal part of the healing process. The nurse's response should reassure the wife that the odor is expected and not necessarily indicative of an infection. Option A: 'I will contact your husband's doctor when he makes rounds.' This response does not address the wife's concern about the foul odor and delays providing necessary information. Option B: 'The odor is secondary to an infection and he is taking antibiotics.' This response assumes an infection without proper assessment and may mislead the wife about the cause of the odor. Option D: 'I am sorry the odor bothers you. We will bathe your husband.' This response does not address the underlying cause

Correct Answer: A

Rationale: The correct answer is A because actinic keratosis lesions typically present as scaly, rough patches on the skin. This is due to the abnormal thickening of the outer layer of the skin caused by sun damage. Choice B is incorrect as actinic keratosis is more common in individuals with fair skin due to their increased sensitivity to UV radiation. Choice C is incorrect as the key microscopic feature of actinic keratosis is the presence of dysplastic cells, not atypical dividing cells in the prickle cell layer. Choice D is incorrect as actinic keratosis can progress to squamous cell carcinoma, not basal cell carcinoma.

Correct Answer: A

Rationale: Rationale for Correct Answer (A): Lipomas are indeed the commonest benign tumors, typically composed of adipose (fat) tissue. They are usually slow-growing and painless. This statement accurately reflects the characteristic of lipomas. Summary of Incorrect Choices: B: Lipomas are not more common in males; they occur with equal frequency in both males and females. C: While lipomas can arise in various connective tissues, they most commonly develop in subcutaneous fat. D: Lipomas can occur in various locations, including the palm, sole of foot, and scalp, although they are more commonly found in other areas.

Correct Answer: B

Rationale: The Rule of Nines is a method used to estimate the total body surface area affected by burns in adults. It divides the body into regions, each representing 9% or multiples of 9% of the total body surface area. This helps determine the severity of the burn and guide treatment. Choice B is correct as it accurately reflects the application of the Rule of Nines in assessing burn percentage in adults. Choices A, C, and D are incorrect as the Rule of Nines specifically applies to adults and not children, and it does not refer to the depth of a burn but rather the extent of the burn injury.

Correct Answer: C

Rationale: The correct answer is C: Tachypnea (RR 26). Tachypnea, an increased respiratory rate, is a systemic manifestation of an inflammatory response due to the body's attempt to deliver more oxygen to tissues during inflammation. Erythema (choice A) is localized redness, pain (choice B) is a common symptom of inflammation at the site, and edema (choice D) is localized swelling, not a systemic response. Tachypnea is a systemic sign that reflects the body's overall response to inflammation.