When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?

Administering systemic antibiotics as ordered.

Placing mitts on the client's hands.

Continuing to administer antibiotics for 21 days as ordered.

Applying topical antibiotics as ordered.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Administering systemic antibiotics is essential to treat the underlying bacterial infection causing severe impetigo. This intervention helps reduce infection spread and promotes healing.

Choice B rationale

Placing mitts on the client's hands may prevent scratching, which can worsen impetigo, but it is not the primary treatment for the infection itself. Antibiotic therapy is more crucial.

Choice C rationale

Continuing antibiotics for 21 days is not a standard duration for impetigo treatment. The treatment duration typically ranges from 7 to 10 days, depending on the severity and response to treatment.

Choice D rationale

Topical antibiotics are used for mild cases of impetigo. For severe impetigo, systemic antibiotics are more appropriate and effective in managing the infection.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Documenting wound size includes measuring the length, width, and depth of the wound to track the healing process and plan appropriate interventions.

Choice B rationale

The wound bed should be assessed for tissue type (granulation, slough, or eschar), color, and the presence of any exudate or infection.

Choice C rationale

The periwound skin is the area around the wound which should be assessed for color, temperature, swelling, and signs of maceration or excoriation.

Choice D rationale

Pattern of eruption is more relevant to dermatological conditions such as rashes or lesions, and not a primary focus for documenting acute open wounds.

A. Cushing triad. B. Decreased level of consciousness (LOC). C. Headache. D. Coma.

Correct Answer is B

Explanation

Choice A rationale

Cushing triad is a late sign of increased ICP, characterized by bradycardia, hypertension, and irregular respirations, appearing after other symptoms like decreased LOC.

Choice B rationale

Decreased LOC is one of the earliest signs of increased ICP as it reflects the brain's response to pressure changes, alerting the need for immediate intervention.

Choice C rationale

Headache can be an early sign but is not as sensitive or specific as changes in LOC when assessing for increased ICP.

Choice D rationale

Coma is a late sign of significantly increased ICP, indicating severe brain dysfunction, often following initial symptoms like decreased LOC.

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When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse documenting an acute open wound should include which characteristics? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

What is one of the earliest signs of increased intracranial pressure (ICP)?

Correct Answer is B

Explanation

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