A client who is suffering from an allergic reaction asks the nurse what can be done about the itching. Which of the following will the nurse provide to the client?
Try to avoid scratching
Apply a moist cool compress
Use alcohol to cleanse the area
Use a wooden stick to scratch lesions
Avoid hot air
Correct Answer : A,B,C
Choice A Reason: This is a correct choice. Trying to avoid scratching is an advice that the nurse will provide to the client, as it prevents further damage and infection of the skin. Scratching can break the skin barrier and introduce bacteria or fungi into the wound, leading to inflammation and complications.
Choice B Reason: This is a correct choice. Applying a moist cool compress is an advice that the nurse will provide to the client, as it soothes and relieves itching and swelling. A moist cool compress can reduce inflammation and histamine release, which are responsible for allergic symptoms.
Choice C Reason: This is an incorrect choice. Using alcohol to cleanse the area is not an advice that the nurse will provide to the client, as it irritates and dries out the skin. Alcohol can strip away the natural oils and moisture from the skin, making it more prone to cracking and itching.
Choice D Reason: This is an incorrect choice. Using a wooden stick to scratch lesions is not an advice that the nurse will provide to the client, as it causes more harm than good. A wooden stick can injure or infect the skin, as well as spread the allergen or irritant to other areas.
Choice E Reason: This is a correct choice. Avoiding hot air is an advice that the nurse will provide to the client, as it aggravates itching and inflammation. Hot air can increase blood flow and histamine release, which are responsible for allergic symptoms. The client should also avoid hot water or showers, as they can have the same effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.
Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.
Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.
Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.
Correct Answer is B
Explanation
Choice A Reason: The test is not inconclusive, but rather positive for conductive hearing loss. The Weber test involves placing a vibrating tuning fork on the center of the forehead and asking the client which ear hears the sound louder. It can help differentiate between conductive and sensorineural hearing loss.
Choice B Reason: This is the correct choice. The client has conductive hearing loss, which is a type of hearing loss that occurs when sound waves are blocked or reduced in the outer or middle ear. It can be caused by earwax, infection, fluid, perforation, or trauma. In conductive hearing loss, the Weber test shows lateralization to the affected ear, meaning the sound is heard louder in that ear.
Choice C Reason: The client does not have normal hearing, but rather conductive hearing loss. In normal hearing, the Weber test shows no lateralization, meaning the sound is heard equally in both ears.
Choice D Reason: The client does not have sensorineural hearing loss, but rather conductive hearing loss. Sensorineural hearing loss is a type of hearing loss that occurs when there is damage to the inner ear or auditory nerve. It can be caused by aging, noise exposure, disease, or drugs. In sensorineural hearing loss, the Weber test shows lateralization to the unaffected ear, meaning the sound is heard louder in that ear.
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