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 encouraging coughing and deep breathing can increase intracranial pressure (ICP), which is the pressure inside the skull that can affect brain function. Coughing and deep breathing can increase blood flow and oxygen demand to the brain, which can worsen cerebral edema. The nurse should suction the patient as needed and maintain a patent airway.
Choice B Reason: This is incorrect because positioning the patient with knees and hips flexed can increase ICP by reducing venous drainage from the head. The nurse should position the patient with neck and body in alignment and avoid extreme flexion or extension of any joints.
Choice C Reason: This is incorrect because performing nursing interventions once an hour can disturb the patient's sleep and increase ICP by stimulating brain activity. The nurse should cluster nursing interventions and provide quiet and dark environment to promote rest and reduce stress.
Choice D Reason: This is correct because keeping the head of the bed elevated to 30 degrees can decrease ICP by facilitating venous drainage from the head and reducing cerebral blood volume. The nurse should monitor the patient's blood pressure and pulse to ensure adequate cerebral perfusion.

Correct Answer is ["A","B","D"]
Explanation
Choice A Reason: This is a correct choice. Standing next to the client when speaking is an action that the nurse should plan to take, as it helps the client hear better and see the nurse's facial expressions and lip movements. The nurse should also speak clearly and slowly, use simple words and sentences, and avoid covering their mouth.
Choice B Reason: This is a correct choice. Guiding the client away from background noise is an action that the nurse should plan to take, as it reduces distractions and interference with hearing. The nurse should also choose a well-lit and quiet place for communication and turn off any unnecessary devices or appliances.
Choice C Reason: This is an incorrect choice. Providing a copy of the instructions printed in Braille is not an action that the nurse should plan to take, as it is not helpful for clients with hearing loss. Braille is a system of raised dots that represents letters and numbers for people who are blind or visually impaired. The nurse should provide a copy of the instructions printed in large font or use pictures or diagrams to supplement verbal information.
Choice D Reason: This is a correct choice. Repeating any phrases that the client misunderstands is an action that the nurse should plan to take, as it ensures comprehension and clarification of important information. The nurse should also ask open-ended questions, encourage feedback, and summarize key points at the end of the conversation.
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