The nurse is caring for a patient with lesions on the skin. Which of the following assessment findings would cause the nurse to suspect scabies?
Reddish brown dots at the base of hairs
Large, fluid-filled blisters
Gray blue macules on the thighs and axillae
Short, wavy, brownish black lines
The Correct Answer is D
A. Reddish brown dots at the base of hairs:
Suggestive of lice/nits, not scabies.
B. Large, fluid-filled blisters:
Could indicate bullous impetigo or burns, not typical of scabies.
C. Gray blue macules on the thighs and axillae:
These may be seen in pubic lice, but not scabies.
D. Short, wavy, brownish black lines:
These are burrows made by the scabies mite, often seen in web spaces, wrists, or axillae.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Adequate Tissue Perfusion
While this important in burn management, it is not typically classified as a priority nursing diagnosis in the early stages of treatment.
B. Risk for infection
Burned skin is a lost barrier to pathogens, increasing infection risk.
C. Impaired Gas Exchange
Especially in cases of inhalation injury, airway swelling or carbon monoxide exposure can impair gas exchange.
D. Acute Pain
Burns cause significant pain that requires management for comfort and healing.
E. Fluid Volume Deficit
Burns result in fluid shifts and capillary leakage, leading to hypovolemia.
Correct Answer is B
Explanation
A. Perform hourly neurological assessments on the client:
Important, but not the first action. Neurological symptoms may improve with oxygenation.
B. Administer oxygen to the client at 100%:
CO binds to hemoglobin with a higher affinity than oxygen. 100% oxygen displaces CO and is the priority intervention to reduce hypoxia.
C. Institute seizure precautions for the client:
Useful if the client becomes neurologically compromised, but not the priority over oxygenation.
D. Provide ondansetron IV to the client for nausea:
Nausea can occur in CO poisoning, but treating hypoxia is the priority.
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