A client has been diagnosed with herpes zoster present on the upper right side of the torso, extending around to the client's back. Which client statement indicates the need for further teaching regarding this diagnosis?

At least I know that when the rash is gone I won't have any more pain to deal with

I should use proper hand hygiene techniques to avoid spreading the virus

This infection is caused by the same virus that causes chicken pox

This is probably why I had stabbing pain on my upper back before I broke out with a rash

Answer and Explanation

The Correct Answer is A

Choice A reason: This statement indicates the need for further teaching, as it shows that the client does not understand the possible complication of postherpetic neuralgia, which is a chronic pain condition that can persist for months or years after the rash heals. The nurse should explain to the client that some people may experience this condition and that there are treatments available to manage the pain.

Choice B reason: This statement does not indicate the need for further teaching, as it shows that the client understands the importance of preventing the transmission of the virus to others, especially those who have not had chicken pox or the vaccine. The nurse should reinforce this behavior and remind the client to cover the rash with a dressing and avoid contact with pregnant women, newborns, and immunocompromised people.

Choice C reason: This statement does not indicate the need for further teaching, as it shows that the client knows the etiology of the infection. The nurse should confirm that the client is correct and explain that the virus remains dormant in the nerve cells after the initial infection and can reactivate later in life due to stress, aging, or other factors.

Choice D reason: This statement does not indicate the need for further teaching, as it shows that the client recognizes the prodromal symptom of the infection. The nurse should acknowledge that the client is correct and explain that the pain is caused by the inflammation of the nerve fibers where the virus resides. The nurse should also ask the client about the severity and frequency of the pain and provide appropriate interventions.

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Correct Answer is D

Explanation

Choice A reason: Performing a neurovascular assessment of the extremity daily is not enough. The nurse should perform this assessment every 2 to 4 hours to monitor for signs of impaired circulation or nerve function.

Choice B reason: Assessing the client's skin condition under the boot weekly is not enough. The nurse should assess the skin under the boot at least once a day to prevent skin breakdown and infection.

Choice C reason: Increasing the traction if the client complains of increased pain is not appropriate. The nurse should not adjust the traction without a provider's order. Increasing the traction could cause more damage to the fracture site or the surrounding tissues.

Choice D reason: Ensuring that the traction weights do not touch the floor is the correct action. The nurse should make sure that the weights are hanging freely and not resting on anything. This ensures that the traction is applied continuously and evenly.

A. Transferring from sitting to standing position B. Straining during a bowel movement C. Bending down to put socks on D. Turning in bed with an abductor pillow in place E. Crossing the legs or ankles

Correct Answer is C

Explanation

Choice A reason: Transferring from sitting to standing position is not a high-risk activity for hip dislocation, as long as the client follows the proper precautions, such as keeping the operated leg slightly forward, using a chair with armrests, and avoiding twisting or pivoting the hip.

Choice B reason: Straining during a bowel movement is not a direct risk factor for hip dislocation, but it may cause constipation, which is a common problem after surgery. The nurse should educate the client on the importance of adequate hydration, fiber intake, and stool softeners to prevent constipation and reduce the need for straining.

Choice C reason: Bending down to put socks on is a risky activity for hip dislocation, as it violates the hip precautions of avoiding flexing the hip more than 90 degrees, adducting the hip, or internally rotating the hip. The nurse should instruct the client to use assistive devices, such as a sock aid or a long-handled reacher, to put on socks or shoes without bending the hip.

Choice D reason: Turning in bed with an abductor pillow in place is a safe activity for hip dislocation, as the abductor pillow helps to maintain the alignment and stability of the hip joint. The nurse should teach the client to use the abductor pillow while in bed for the first few weeks after surgery, and to turn from side to side with the assistance of a caregiver.

Choice E reason: Crossing the legs or ankles is a dangerous activity for hip dislocation, as it causes the hip to move out of its normal position. The nurse should remind the client to keep the legs apart at all times, and to use a pillow or a wedge between the legs when lying on the side.

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A client has been diagnosed with herpes zoster present on the upper right side of the torso, extending around to the client's back. Which client statement indicates the need for further teaching regarding this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a fractured hip and is in Buck's traction prior to surgical repair. What should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is reviewing a client's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?

Correct Answer is C

Explanation

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