Question

A client with generalized pruritus is admitted to your unit. Which of the following nursing interventions is most appropriate to alleviate the client's discomfort?

Answer 1

Correct Answers:

Advise the client to apply lotion to the skin immediately after drying off from a bath.

Rationale :

🟨 Moisturizing immediately after bathing helps seal in hydration, which is vital for clients with pruritus or dry skin.

🟨 Lotions soothe the skin and reduce itching and scratching, preventing skin breakdown and infection.

🟨 Hot showers and abrasive scrubbing can exacerbate skin irritation and worsen pruritus.

🟨 Loose clothing is preferred to avoid friction against sensitive skin.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Administer antiviral medication as prescribed.

Rationale :

🟥 Herpes zoster (shingles) is a viral reactivation of varicella-zoster and requires prompt initiation of antiviral therapy (e.g., acyclovir, valacyclovir).

🟥 Early administration—ideally within 72 hours—helps reduce pain, shorten the duration, and prevent complications like postherpetic neuralgia.

🟥 Covering the rash tightly can worsen pain, and compresses or hydration alone do not address the viral cause.

🟥 This is a priority treatment and a core component of clinical management.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Yes, sexually transmitted diseases are a common cause of male genitourinary tract infections.

Rationale :

🔵 STDs such as chlamydia, gonorrhea, and trichomoniasis frequently lead to urethritis, epididymitis, and prostatitis in males.

🔵 These infections cause burning during urination, discharge, and pelvic discomfort.

🔵 Prompt diagnosis and treatment reduce transmission and complications like infertility.

🔵 Education and screening are essential for public health and prevention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

To detect viral infections, such as herpes simplex or varicella-zoster.

Rationale :

🟩 A Tzanck smear is a diagnostic tool used to identify multinucleated giant cells in vesicular viral infections.

🟩 It is commonly used when herpes simplex or varicella-zoster is suspected.

🟩 While it doesn't distinguish between viral types, it confirms the presence of a viral etiology.

🟩 Not useful for fungal, bacterial, or cancer screening.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Impaired skin Integrity.

Rationale :

🟠 A pressure injury is defined by disruption in skin structure, making impaired skin integrity the most accurate diagnosis.

🟠 It focuses on the physical breakdown and the goal of promoting healing and tissue regeneration.

🟠 Risk for infection or pain may be present, but they are secondary diagnoses.

🟠 This is a direct, problem-focused nursing priority.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

To reduce stimulation and alleviate symptoms like headache and photophobia.

Rationale :

🟣 Meningitis often leads to photophobia, headache, and hypersensitivity to stimuli.

🟣 A dark, quiet room minimizes stimulation and helps manage neurologic symptoms.

🟣 This environment enhances comfort and reduces intracranial irritation.

🟣 Infection control and hydration are also important but not the reason for dark rest.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Ask the client how they would like to be addressed and use their preferred pronouns.

Rationale :

🔶 Respecting gender identity is a cornerstone of patient-centered, culturally sensitive care.

🔶 Asking how a client wants to be addressed builds trust and therapeutic rapport.

🔶 Using chosen pronouns affirms identity and improves mental health outcomes.

🔶 Assumptions based on appearance or record can lead to harm and miscommunication.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Reposition the client every two hours and offload pressure from the sacral area.

Rationale :

🔴 Stage 1 pressure injuries are reversible if pressure is relieved early and consistently.

🔴 Frequent repositioning promotes circulation and prevents progression to deeper injuries.

🔴 Offloading the sacral area reduces ischemia and skin breakdown.

🔴 Massage and harsh cleansers are contraindicated as they worsen damage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Prevent infection by maintaining skin integrity.

Rationale :

🟢 In pemphigus vulgaris, blistering and erosions increase infection risk due to skin barrier loss.

🟢 Nursing care must focus on meticulous skin care, aseptic dressing changes, and infection prevention.

🟢 Secondary goals include hydration and nutrition, but preventing sepsis is paramount.

🟢 Infection is a major cause of morbidity and mortality in these clients.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Wrinkling.
Decreased elasticity.
Reduced moisture retention.

Rationale :

Wrinkling

✔ Wrinkling occurs due to the breakdown of collagen and elastin fibers in the dermis, which are essential for maintaining the skin's structure and smoothness.

✔ With aging, there is less dermal support, leading to skin sagging and visible lines.

✔ Long-term sun exposure (photoaging) also accelerates this process by damaging connective tissue.

✔ Wrinkles are more pronounced in sun-exposed areas such as the face, neck, and hands.

Decreased Elasticity

✔ As we age, elastin fibers degrade and fibroblast activity declines, leading to a loss of skin stretch and recoil ability.

✔ This results in skin that appears loose or hangs, especially around the cheeks, jawline, and upper arms.

✔ The dermal layer thins, which weakens structural integrity and reduces skin resilience.

✔ Decreased elasticity also contributes to slower wound closure and tissue regeneration.

Reduced Moisture Retention

✔ Aging skin produces less sebum and natural moisturizing factors, reducing its ability to retain water.

✔ The epidermal barrier becomes compromised, allowing increased transepidermal water loss (TEWL).

✔ This leads to dry, flaky, and itchy skin, particularly on the lower legs and arms.

✔ Maintaining moisture is vital to prevent cracking, itching, and secondary infections.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Custom: N2100 Summer 25 Exam 5

No.

1 :
A client with generalized pruritus is admitted to your unit. Which of the following nursing interventions is most appropriate to alleviate the client's discomfort?

2 :
A client presents with a painful rash on one side of the torso. The nurse suspects herpes zoster. Which nursing management strategy is most important in this scenario?

3 :
Are sexually transmitted diseases a common cause of male genitourinary tract infections?

4 :
What is a Tzanck smear used for in clinical practice?

5 :
Which of the following is the most appropriate nursing diagnosis for a patient with a pressure injury?

6 :
Why is resting in a dark room recommended for patients with meningitis?

7 :
A 24-year-old client assigned female at birth identifies as non-binary and prefers the pronouns 'they/them.' They are also in a same-sex relationship. As a nurse, what is the most appropriate way to address the client during the initial assessment?

8 :
A client in a long-term care facility has developed a localized area of non-blanchable erythema on their sacrum. Which of the following is the most appropriate nursing intervention for a Stage 1 pressure injury?

9 :
What is a primary nursing goal for a client diagnosed with a blistering disease such as pemphigus vulgaris?

10 :
Which of the following are characteristics of aging skin? (Select All that Apply.)

Connect With Us

Custom: N2100 Summer 25 Exam 5

No.

1 : A client with generalized pruritus is admitted to your unit. Which of the following nursing interventions is most appropriate to alleviate the client's discomfort?

2 : A client presents with a painful rash on one side of the torso. The nurse suspects herpes zoster. Which nursing management strategy is most important in this scenario?

3 : Are sexually transmitted diseases a common cause of male genitourinary tract infections?

4 : What is a Tzanck smear used for in clinical practice?

5 : Which of the following is the most appropriate nursing diagnosis for a patient with a pressure injury?

6 : Why is resting in a dark room recommended for patients with meningitis?

7 : A 24-year-old client assigned female at birth identifies as non-binary and prefers the pronouns 'they/them.' They are also in a same-sex relationship. As a nurse, what is the most appropriate way to address the client during the initial assessment?

8 : A client in a long-term care facility has developed a localized area of non-blanchable erythema on their sacrum. Which of the following is the most appropriate nursing intervention for a Stage 1 pressure injury?

9 : What is a primary nursing goal for a client diagnosed with a blistering disease such as pemphigus vulgaris?

10 : Which of the following are characteristics of aging skin? (Select All that Apply.)

1 :
A client with generalized pruritus is admitted to your unit. Which of the following nursing interventions is most appropriate to alleviate the client's discomfort?

2 :
A client presents with a painful rash on one side of the torso. The nurse suspects herpes zoster. Which nursing management strategy is most important in this scenario?

3 :
Are sexually transmitted diseases a common cause of male genitourinary tract infections?

4 :
What is a Tzanck smear used for in clinical practice?

5 :
Which of the following is the most appropriate nursing diagnosis for a patient with a pressure injury?

6 :
Why is resting in a dark room recommended for patients with meningitis?

7 :
A 24-year-old client assigned female at birth identifies as non-binary and prefers the pronouns 'they/them.' They are also in a same-sex relationship. As a nurse, what is the most appropriate way to address the client during the initial assessment?

8 :
A client in a long-term care facility has developed a localized area of non-blanchable erythema on their sacrum. Which of the following is the most appropriate nursing intervention for a Stage 1 pressure injury?

9 :
What is a primary nursing goal for a client diagnosed with a blistering disease such as pemphigus vulgaris?

10 :
Which of the following are characteristics of aging skin? (Select All that Apply.)