The nurses assess the client's pain prior to completing a dressing change. The client says his current pain is 5/10, but he has pain of 10/10 when his dressing is changed. What is the priority intervention for this client?

Correct Answer: C

Rationale: In this scenario, the priority intervention for the client experiencing increased pain during a dressing change is option C) Teach the client about nonpharmacological pain control methods. This is the correct choice because the client's pain management needs to be addressed effectively to ensure their comfort and well-being during the dressing change procedure. Option A) Offer the client protein with meals to promote healing is incorrect as it does not directly address the immediate issue of managing the client's pain during the dressing change. Option B) Remove the old dressing with clean gloves is also incorrect as it overlooks the need to address the client's pain management before proceeding with the dressing change. Option D) Check medication administration record (MAR) for as needed orders (PRN) is not the priority in this situation as the client's pain needs to be managed promptly during the dressing change, and nonpharmacological methods should be considered first before resorting to medications. Educationally, it is important to understand that assessing and managing a client's pain is a crucial aspect of nursing care. By teaching the client about nonpharmacological pain control methods, nurses empower clients to participate in their own care and enhance their overall comfort and well-being. Effective pain management not only improves the client's experience but also promotes better outcomes and healing.

Correct Answer: A

Rationale: In clients with lupus, a classic symptom that is commonly assessed is the butterfly rash, which appears on the face resembling the shape of a butterfly across the cheeks and bridge of the nose. This rash is a hallmark sign of lupus and is often one of the first visible symptoms to appear. Option B, Chvostek's sign, is actually associated with hypocalcemia and is manifested as facial muscle spasms when the facial nerve is tapped. Option C, Ovid's sign, is a distractor as it is not a recognized medical sign or symptom in relation to lupus or any other condition. Option D, Heberden's nodes, are bony swellings that occur at the distal interphalangeal joints in osteoarthritis, which is not typically associated with lupus. Understanding these distinctions is crucial for healthcare providers to accurately assess and diagnose lupus in patients. Recognizing the key symptoms of lupus, such as the butterfly rash, aids in prompt intervention and management of the condition, ultimately improving patient outcomes.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Cataracts. Cataracts are characterized by a gradual clouding of the lens in the eye, leading to blurred vision. The client's complaint of constantly needing to clean his glasses and the absence of eye pain are indicative of cataracts. Option B) Diabetic retinopathy is unlikely in this case as there is no mention of the client having diabetes, which is a key risk factor for this condition. Option C) Corneal dystrophy affects the cornea, not the lens, and typically presents with symptoms different from those described by the client. Option D) Conjunctivitis is characterized by redness, itching, and discharge in the eye, none of which are mentioned by the client. In an educational context, this question helps reinforce the importance of recognizing common eye disorders based on specific symptoms and history provided by the client. Understanding these distinctions is crucial for effective nursing assessment and intervention in clinical practice.

Correct Answer: A

Rationale: The correct answer is A) The client with AIDS is a susceptible host. This is because individuals with AIDS have a compromised immune system due to the depletion of CD4 T cells, which are crucial in fighting infections. As a result, they are more susceptible to opportunistic infections like pneumonia, which can be caused by pathogens that a healthy person's immune system would normally combat effectively. Option B) The client with AIDS has greater immune defenses is incorrect because, in reality, individuals with AIDS have weakened immune defenses, not greater ones. This is a key characteristic of AIDS - the immune system is compromised, making the individual more vulnerable to infections. Option C) The client with AIDS was not as careful is incorrect and not relevant to the immune response and susceptibility to pneumonia. Carefulness or behavior is not a determining factor in the susceptibility of individuals with AIDS to infections like pneumonia. Option D) The client with AIDS has more portals of entry is incorrect because the number of portals of entry does not directly correlate with susceptibility to pneumonia. The primary factor at play in this scenario is the compromised immune system of the individual with AIDS. In an educational context, understanding why individuals with AIDS are more susceptible to certain infections is crucial in providing appropriate care and support for this population. It highlights the importance of infection control measures, vaccination, and early detection of infections in individuals with compromised immune systems. This knowledge is essential for healthcare professionals working with HIV/AIDS patients to ensure the best possible outcomes for their clients.

Correct Answer: A

Rationale: In this scenario, the most concerning finding when assessing an area of skin over a bony prominence would be option A) Redness. Redness, also known as erythema, indicates localized inflammation and increased blood flow to the area, which can be a sign of early-stage pressure injury or skin breakdown. This finding is concerning because it suggests that tissue damage may be occurring due to prolonged pressure on the skin, leading to compromised blood flow and potential tissue necrosis. Option B) Non-blanching is incorrect because non-blanching erythema is a more severe sign of tissue damage that does not fade when pressure is applied. It indicates more advanced tissue injury compared to blanching erythema, where the redness fades when pressure is relieved. Option C) Blanching is incorrect because blanching erythema is a less concerning finding as the redness fades when pressure is applied, suggesting that the blood flow is still intact and the skin is not yet compromised. Option D) Warmth is incorrect because while warmth can be associated with inflammation, it is a less specific indicator of tissue damage compared to redness, which directly points towards localized inflammation and potential skin breakdown. Educationally, it is crucial for nurses to recognize the early signs of pressure injuries and skin breakdown to prevent complications in patients, especially those with limited mobility or sensory perception. Regular skin assessments, knowledge of risk factors, and prompt intervention are essential in providing quality care and preventing pressure ulcers. Recognizing the significance of skin findings like redness can help nurses take proactive measures to prevent further tissue damage and promote skin integrity.