A client reports to the hospital with skin lesions. Upon physical examination, the nurse notices
circumscribed elevations of the skin, measuring about
... [Show More] 0.5 × 0.5 cm. The lesions are filled with serous
fluid. What is the suspected cause of these skin lesions?
Multiple selection question
Venous stasis ulcer
Arterial insufficiency
Staphylococcal infection
Herpes simplex infection
Herpes simplex infection
Circumscribed elevated skin lesions filled with serous fluid smaller than 1 cm are called vesicles. Vesicles
are found in conditions such as herpes simplex infection and chicken pox. Venous stasis ulcers are
characterized by deep loss of skin surface that extends to the dermis and is associated with frequent
bleeding. The appearance of shiny and translucent skin with loss of normal furrow indicates arterial
insufficiency. In a staphylococcal infection, the skin lesion is similar to that of vesicle, but is filled with
pus instead of serous fluid.
A client with a history of stabbing pain in the eyes and blurring and gradual loss of vision is examined by
an ophthalmologist, a neurologist, and an internist, all of whom find no organic cause. When eye
complaints increase, the client is admitted to a mental health unit. What is the priority nursing
intervention?
Multiple choice question
Encouraging involvement in group activities
Requesting a description of the eye discomfort
Exploring feelings about possible impending blindness
Focusing on daily activities while avoiding discussion of the eye discomfort
Focusing on daily activities while avoiding discussion of the eye discomfort
The client's eye problems are a conversion reaction. Avoiding discussion of the physical problems
prevents the client from using this topic to avoid an exploration of feelings. Focusing on the safe topic of
activities may eventually progress to a discussion of emotion-laden topics such as feelings. It is too early
for encouraging involvement in group activities; the client is too introspective to become involved with
group activities at this time. Focusing on the physical problem allows the client to avoid feelings. The
data do not indicate that the client has an organic problem and is going blind.
A mother complains that her three year old still performs thumb sucking. What should the nurse suggest
to the mother?
Multiple selection question
"Try to engage child in more play activities."
"Try to identify if the child is experiencing stress."
"Consult a pediatrician immediately because this habit can be harmful to your child."
"Be strict with the child whenever he or she sucks his or her thumb.
"Try to engage child in more play activities." [Show Less]