Chap 52 Disorders of Skin Integrity and Function
What would be the best response to the mother of two teens who have been diagnosed with scabies?
"One of your children probably had direct contact with an infected person." Explanation: Scabies is spread through direct person-to-person contact; the teens could have contacted with someone who has scabies. Scabies does not occur only with sexual contact. This condition does not involve unaffected carriers. Poor hygiene is not the trigger for this condition.
What should the nurse teach the client about the diagnosis of "primary skin disorder"?
"This disorder is caused by a virus, bacteria, or fungus that invades the skin." Explanation: The client who has a primary skin disorder should understand that this is caused by something that invades the skin and causes the inflammatory response. It is not secondary to any other diagnosis or medication reaction.
A client with new-onset herpes zoster (shingles) asks the nurse, "Why is this rash just on my face?" Which response by the nurse is most accurate?
"This virus was reactivated and travels from the gangila to the skin of the corresponding single spinal nerve like your face." Explanation: Herpes zoster (shingles) lesions appear as an eruption of vesicles. Eruptions are usually unilateral in the thoracic region, trunk, or face. New groups of vesicles erupt for 3 to 5 days along the nerve pathway. The lesions usually clear in 2 to 3 weeks, although they can persist up to 6 weeks in some older adults.
A nurse is caring for four clients. Select the client most at risk for the development of a pressure ulcer.
A 72-year-old undernourished female who recently underwent thigh surgery Explanation: Populations at risk for pressure ulcers include persons with quadriplegia and older adults with restricted activity and hip fractures in a critical care setting. An undernourished postsurgical client is at risk for ulcer development.
A 30-year-old woman who just found out that she is pregnant seeks treatment for her severe acne. Which treatment for her skin condition is most appropriate?
A benzoyl peroxide agent Explanation: Benzoyl peroxide is a topical agent that has both antibacterial and comedolytic properties. It is the topical agent most effective in reducing the Cutibacterium acnes (formerly known as Propionibacterium acnes) population. Bacterial resistance does not develop to benzoyl peroxide. The irritant effect of the drug also causes vasodilation and increased blood flow, which may hasten resolution of the inflammatory lesions. Although isotretinoin, low-dose tetracycline, and tretinoin are often used to treat severe acne, these drugs should not be given to those who are pregnant because they can affect the development of the fetus.
A client has been diagnosed with lentigo. Which is the most accurate description of lentigo?
A small lesion of melanocytes Explanation: Lentigo maligna (i.e., Hutchinson freckle) is a small, slowly progressive neoplastic disorder of melanocytes. The lesion is a pigmented macule with a well-defined border and grows to 5 cm or sometimes larger.
A client presents with a skin infection in which the health care provider uses a potassium hydroxide (KOH) preparation and the Wood (UV) light to determine the cause. Which type of infection does this client most likely have?
A superficial fungal infection Explanation: Diagnosis of superficial fungal infections is primarily done by microscopic examination of skin scrapings for fungal spores, the reproducing bodies of fungi. Potassium hydroxide (KOH) preparations are used to prepare slides of skin scrapings. KOH disintegrates human tissue and leaves behind the threadlike filaments, or hyphae, that grow from the fungal spores, as some types of fungi fluoresce yellow-green when the light is directed onto the affected area. The other options would not be diagnosed with these methods.
The parents of an 18-month-old child noticed a small vesicle on her face that ruptured a few days later and left a straw-colored crust on the child's face. New vesicles have prompted them to bring the child to the health care provider. Which treatment for the child's skin problem is most likely?
A topical antibiotic Explanation: The course and symptomatology of the child's skin disorder is characteristic of impetigo, which is bacterial in etiology and would likely be treated with a topical antibiotic such as mupirocin.
An adult man has been brought to the emergency department with severe electrical burns. Which assessment finding leads the providers to suspect the brain has been damaged with this burn?
Confusion, memory loss, and lethargy Explanation: The most immediate threat to this client is hemodynamic instability. If the brain or spine is directly injured from the burn, the client will have neurologic signs/symptoms like confusion, memory loss, insomnia, lethargy, and combativeness. Infection would develop later if at all. Pain control is essential, but inadequate pain control does not pose a direct threat to survival. Impaired hearing and double-vision may occur if the client has had a head injury but wheezing is usually caused by smoke inhalation.
Which factor is most protective against squamous cell carcinomas?
Dark skin color Explanation: Dark-skinned people are rarely affected. Males are twice as likely as females to have squamous cell carcinoma. Age and history are not protective, as the increase in the incidence of squamous cell carcinomas is consistent with increased exposure to ultraviolet radiation.
A nurse is assessing the skin of an aging adult. Which findings does the nurse note as being a normal part of the aging process? Select all that apply.
Dry skin Scaly Explanation: As the skin ages, it becomes wrinkled, thin, dry, rough, scaly, and itchy. Although unevenly pigmented skin is a normal finding in the aging adult, unevenly pigmented moles can be a sign of skin cancer and is therefore not a normal part of the aging process. Lentigo maligna is a slowly progressive preneoplastic disorder of melanocytes. It occurs on sun-expoised areas, particularly the face. The lesion is a pigmented macule with well-defined border and grows to 5 cm.
Nevi are benign tumors of the skin. There is one type of nevus that is important because of its capacity to transform to malignant melanoma. What type of nevus is this?
Dysplastic Explanation: One form of nevus, the dysplastic nevus, is important because of its capacity to transform to malignant melanoma.
A client has been diagnosed with a superficial fungal infection. Which assessment technique is most likely assisted with this diagnosis?
Examination of the area with a Wood's light Explanation: When a Wood's light (or Wood's lamp) shines on the area, some types of fungi fluoresces yellow green.
Which cause of pressure injuries (decubitus injuries or bedsores) impairs the flow of blood in the capillary beds?
External pressure Explanation: Factors contributing to the development of pressure injuries include external pressure that compresses blood vessels and friction and shearing forces that tear and injure blood vessels. External pressure that exceeds capillary pressure interrupts blood flow in the capillary beds. Shearing forces are caused by the sliding of one tissue layer over another with stretching and angulation of blood vessels, causing injury and thrombosis. As a result of the ischemia and shearing forces, the injured tissues become edematous.
A client comes in with a mild sunburn. Which term best describes the sunburn?
First-degree burn Explanation: First-degree burns (superficial partial-thickness burns) involve only the outer layers of the epidermis. They are red or pink, dry, and painful. There usually is no blister formation. A mild sunburn is an example.
Which process accounts for the damaging effects of the sun's radiation?
Generation of reactive oxygen species and damage to melanin Explanation: Ultraviolet (UV) B radiation is primarily responsible for sunburns, and it acts mainly on the cells in the basal layer of the epidermis, causing the generation of reactive oxygen species and damage to melanin. It also provokes free radical production and induces a significant reduction in skin antioxidants, impairing the ability of the skin to protect itself against the free radicals that are generated. UV radiation does not provoke an autoimmune response or hyperkeratinization, although there is an inflammatory response. Increased melanin production is a protective mechanism and does not participate in the deleterious effects of UV radiation.
Which process accounts for the damaging effects of the sun's radiation? You Selected:
Generation of reactive oxygen species and damage to melanin Explanation: Ultraviolet (UV) B radiation is primarily responsible for sunburns, and it acts mainly on the cells in the basal layer of the epidermis, causing the generation of reactive oxygen species and damage to melanin. It also provokes free radical production and induces a significant reduction in skin antioxidants, impairing the ability of the skin to protect itself against the free radicals that are generated. UV radiation does not provoke an autoimmune response or hyperkeratinization, although there is an inflammatory response. Increased melanin production is a protective mechanism and does not participate in the deleterious effects of UV radiation.
An older adult client presents with noted burning pain along the thoracic region with a tingling sensation and extreme sensitivity of the skin to touch, but there is no rash present at this time. Which skin problem will the health care provider interpret for this client?
Herpes zoster Explanation: The lesions of herpes zoster (shingles) typically are preceded by a prodrome (may be present for 1 to 3 days or longer before the appearance of the rash) consisting of a burning pain, a tingling sensation, extreme sensitivity of the skin to touch, and pruritus along the affected dermatome. The dermatomes' most frequently involved areas are thoracic, cervical, trigeminal, and the lumbosacral. Shingles is caused by the same herpesvirus, varicella zoster, that causes chickenpox. The other conditions do not have these symptoms. Impetigo is caused by beta-hemolytic streptococci, a common bacterial infection; it is and common in infants and young children and is primarily located on the face. Psoriasis is a chronic inflammatory skin disease characterized by red, thickened plaques with overlying silvery-white scales.
A client has been diagnosed with nevus with architectural disorder with cytologic atypia (former known as dysplastic nevus). Because of the large size of the nevi, the nurse will educate this client on which priority topic?
Increased risk for melanoma Explanation: Nevus with architectural disorder with cytologic atypia (dysplastic nevi) is a precursor of malignant melanoma. The nevi are larger than other nevi (often >5 mm in diameter), have a flat, slightly raised plaque and pebbly surface or a target-like lesion with a darker, raised center and irregular border. Nevocellular nevi are tan to deep brown, uniformly pigmented, small papules with well-defined and rounded borders that grow in nests or clusters along the dermal-epidermal junction. Eventually, most junctional nevi grow into the surrounding dermis as nests or cords of cells. They are not transmitted to others by contact. They may bleed as the cancer grows within the nevi but not by just being touched by fabric. Because this is not an infection, there should be no pustules forming.
An 81-year-old resident of an elder care facility is immobile and has been restricted to her bed for the past 6 weeks. Her physician recently discovered a decubitus ulcer on her left buttock. Which etiology is most likely?
Ischemia from prolonged pressure Explanation: The resident has been in bed, in the same position for a long period of time. The pressure of her pelvis on the tissue caused ischemia and necrosis. Following ulcer formation, viral and bacterial infections are likely, but these are not probably initial causes. Ulcers do not usually result from lacerations.
Scabies infections are caused by mites that burrow under the skin. They are usually easily treated by bathing with a mite-killing agent and leaving it on for 12 hours. When scabies are resistant to the mite-killing agent, what oral drug is prescribed?
Ivermectin Explanation: Oral ivermectin, a broad-spectrum antiparasitic agent, has been used for treatment-resistant scabies. The other drugs are not used for treatment-resistant scabies.
What skin disease manifests with lesions on the skin and oral lesions that look like milky white lacework?
Lichen planus Explanation: Most persons with lichen planus who have skin lesions also have oral lesions, appearing as milky white lacework on the buccal mucosa or tongue.
The nurse is assessing an Asian client who presents with pigmented birthmarks on the buttocks and sacral area. The nurse would document this assessment as:
Mongolian spots Explanation: Mongolian spots are caused by selective pigmentation. They usually occur on the buttocks or sacral area and are seen commonly in Asian and black persons. Hemangiomas are small, red lesions; nevi are moles. Rosacea is a chronic skin disorder causing papules and pustules.
The clinic health care worker notices that a client has a fungal infection on her nails that looks like the fungus is digesting the nail keratin. The nail appears opaque and white in color. The client states she has had this for years. The health care worker suspects the client has:
Onychomycosis Explanation: Onychomycosis often begins at the tip of the nail, where the fungus digests the nail keratin. Initially, the nail appears opaque, white, or silvery. The nail then turns yellow or brown and remains unchanged for years. Gradually, the nail thickens and cracks as the infection spreads. Candidiasis (moniliasis) is a fungal infection caused by C. albicans. This yeast-like fungus is a normal inhabitant of the gastrointestinal tract, mouth, and vagina. Cellulitis is a deeper infection affecting the dermis and subcutaneous tissues. The lesion consists of an expanding red, swollen, tender plaque with an indefinite border, covering a variety of widths. Cellulitis is frequently accompanied by fever, erythema, heat, edema, and pain. Tinea corporis (ringworm of the body) are oval or circular patches on exposed skin surfaces and the trunk, back, or buttocks.
A client is being seen in the dermatology clinic for a follow-up appointment for a second-degree full-thickness burn. What are characteristics of second-degree burns? Select all that apply.
Painful Blistered Mottled, pink red Explanation: These burns appear as mottled pink, red,or waxy white areas with blisters and edema. The blisters resemble flat, dry tissue paper rather than the bullous blisters seen with superficial partial-thickness injury.
A client has a stage III pressure ulcer in the sacral area. What factors can contribute to the development of pressure ulcers? Select all that apply.
Pressure Shearing force Friction Explanation: Four factors contribute to the development of pressure ulcers: (1) pressure, (2) shearing forces, (3) friction, and (4) moisture
What disease has primary lesions that have a silvery scale over thick red plaques?
Psoriasis vulgaris Explanation: In psoriasis vulgaris, the primary lesions are sharply demarcated, thick, red plaques with a silvery scale that vary in size and shape.
Which nursing intervention involves the greatest risk of skin shearing?
Pulling the client up in bed Explanation: Shear occurs when the skeleton moves but the skin remains fixed to an external surface, such as occurs with transfer from a stretcher to a bed or pulling a person up in bed. Rolling a client, starting an IV catheter, or assisting with mobilization does not pose a risk of skin shearing.
A client is admitted to the hospital with first- and second-degree burns. Which assessment findings are associated with first-degree burns? Select all that apply.
Red or pink Painful Explanation: First-degree burns (superficial partial thickness burns) involve only the outer layers of the epidermis. They are red or pink, dry, and painful.
The nurse is assessing a client's skin and notices a few papules. What is the best description to include in the assessment about papules?
Small, raised superficial lesions Explanation: Papules are small, raised superficial lesions. Plaque is a flat-topped solid lesion. Cyst is a closed, rounded space containing fluid.
Which microorganism is responsible for the development of bullous impetigo?
Staphylococcus aureus Explanation: Staphylococcus aureus is the microorganism that causes bullous impetigo. Group A beta-hemolytic Streptococcus is the common organism in superficial bacterial infection of impetigo. Tinea capitis is a fungal infection involving the scalp and head. Propionibacterium acnes is the organism responsible for acne.
A nurse comes upon a automobile accident where smoke and flames are coming from the car's engine. What would be the nurse's first priority in this situation?
Stop the fire or remove the person from the vehicle Explanation: Regardless of the type of burn, it is first priority to stop the fire and provide a safe environment for the people affected. The heat source should be removed, and flames should be doused with water or smothered with a blanket. The people should be removed from the vehicle, especially if the fire cannot be contained. After moving them to a safe distance, their airways should be assessed next. If cellular phone is working, the nurse should call 911 and report the findings. That way, help will be on the way
A young adult is going on vacation to a sunny climate and plans on using a tanning booth to build up a protective tan. Which instructions should the nurse provide to the young adult?
Tanning booths should be avoided under all circumstances. Explanation: There is no known safe use of tanning booths, and they should be wholly avoided. Sunscreen would defeat the purpose of a tanning booth.
A child is sent home from school following a check for head lice by the nurse. The parents call to ask, "How do you know it is head lice? We thought our child just had dry skin and dandruff." Which manifestation(s) will the school nurse share with these parents? Select all that apply.
The child is scratching at the head. There are firmly attached nits on the hair shaft. The child has red, excoriated scalp lesions. Explanation: A positive diagnosis depends on the presence of firmly attached nits or live adult lice on hair shafts. Pruritus and scratching of the head are the primary indicators that head lice may be present. The scalp may appear red and excoriated from scratching. Swimming is a great exercise but the chlorine used to keep out harmful bacteria from the pool water can also strip your hair and skin of its natural oils. This can cause dry skin, brittle hair. Alopecia areata is a noncontagious condition of hair loss thought to be caused by the body's immune system attacking the hair follicles. It is characterized by the sudden appearance of round or oval patches of hair loss.
Which client would the nurse be most concerned about?
The client with herpes zoster affecting the trigeminal nerve Explanation: The nurse would be most concerned about the client with herpes zoster affecting the trigeminal nerve, as an episode affecting the face can affect hearing or vision. Blindness or deafness could result. Prodromal episodes are very common, as is postherpetic neuralgia.
An adult client has a large number of nevi on her neck and back. How should the nurse best interpret this assessment finding?
The nevi are likely benign, unless they are undergoing changes Explanation: Nevi are generally benign, though those that undergo changes in size or character are suggestive of skin cancer. It is not necessary to biopsy all nevi in most cases and the number of nevi is not the main determinant of cancer risk.
A 4-year-old male child has several small pustules with honey-colored crusted drainage on his face but in no other location. The child is diagnosed with impetigo. The most appropriate treatment would be:
Topical mupirocin and limiting exposure, as it is transmitted easily Explanation: The condition should be treated with topical mupirocin with limited exposure due to risk of transmission with direct contact. Oral antibiotics would not be the first-line treatment as it is isolated in one area. Antifungals would not be effective for a bacterial infection. Due to the risk of further transmission to self and others, impetigo is treated with either topical or systemic antibiotics (decision based on location of impetigo).