Chapter 25: Care of Patients with Skin Problems

2. A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the client's heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

a. Place a small pillow between bony surfaces. d. Use a lift sheet to assist with re-positioning. f. Keep the client's heels off the bed surfaces.

11. A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a. Place the client in a single room. b. Administer an antihistamine. c. Assess the client's airway. d. Apply gloves to minimize friction.

a. Place the client in a single room.

6. A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a. "Wash your hands before touching the client." b. "Wear gloves when bathing the client." c. "Assess skin for breakdown during the bath." d. "Apply lotion to lesions while the skin is wet." e. "Use a damp cloth to scrub the lesions."

a. "Wash your hands before touching the client." b. "Wear gloves when bathing the client."

12. A nurse assesses a client who has a chronic wound. The client states, "I do not clean the wound and change the dressing every day because it costs too much for supplies." How should the nurse respond? a. "You can use tap water instead of sterile saline to clean your wound." b. "If you don't clean the wound properly, you could end up in the hospital." c. "Sterile procedure is necessary to keep this wound from getting infected." d. "Good hand hygiene is the only thing that really matters with wound care."

a. "You can use tap water instead of sterile saline to clean your wound."

4. A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care? a. Change the dressing every 6 hours. b. Assess the wound bed once a day. c. Change the dressing when it is saturated. d. Contact the provider when the dressing leaks.

a. Change the dressing every 6 hours.

9. A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a. Client admitted from a nursing home with furuncles and folliculitis b. Client with a leg cut and other trauma from a motorcycle crash c. Client with a rash noticed after participating in sporting events d. Client transferred from intensive care with an elevated white blood cell count

a. Client admitted from a nursing home with furuncles and folliculitis

1. A nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? (Select all that apply.) a. Client with a left heel ulcer with slight necrosis - Whirlpool treatments b. Client with an eschar-covered sacral ulcer - Surgical débridement c. Client with a sunburn and erythema - Soaking in warm water for 20 minutes d. Client with urticaria - Wet-to-dry dressing changes every 6 hours e. Client with a sacral ulcer with purulent drainage - Transparent film dressing

a. Client with a left heel ulcer with slight necrosis - Whirlpool treatments b. Client with an eschar-covered sacral ulcer - Surgical débridement

7. A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a. Cool, moist compresses b. Topical corticosteroids c. Heating pad d. Tepid bath with cornstarch e. Back rub with baby oil

a. Cool, moist compresses c. Heating pad

21. A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below: Which diagnostic test should the nurse anticipate being ordered for this client? a. Punch skin biopsy b. Viral cultures c. Wood's lamp examination d. Diascopy

a. Punch skin biopsy

18. A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a. Recent wound assessment, including size and appearance b. Insurance information for billing and coding purposes c. Complete health history and physical assessment findings d. Resources available to the client for wound care supplies

a. Recent wound assessment, including size and appearance

4. A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.) a. Use a lift sheet when moving the client in bed. b. Avoid tape when applying dressings. c. Avoid whirlpool therapy. d. Use loose dressing on all wounds. e. Implement pressure-relieving devices.

a. Use a lift sheet when moving the client in bed. b. Avoid tape when applying dressings. e. Implement pressure-relieving devices.

5. A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a. "Have you eaten a large amount of chocolate lately?" b. "Have you been under a lot of stress lately?" c. "Have you recently used a public shower?" d. "Have you been out of the country recently?" e. "Have you recently had any other health problems?" f. "Have you changed any medications recently?"

b. "Have you been under a lot of stress lately?" e. "Have you recently had any other health problems?" f. "Have you changed any medications recently?"

20. A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a. "Do you have a bedpan at home?" b. "How are you coping with providing this care?" c. "What are you doing to prevent pediculosis?" d. "Are you sharing a bed with your husband?"

b. "How are you coping with providing this care?"

13. After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a. "At the next family reunion, I'm going to ask my relatives if they have psoriasis." b. "I have to make sure I keep my lesions covered, so I do not spread this to others." c. "I expect that these patches will get smaller when I lie out in the sun." d. "I should continue to use the cortisone ointment as the patches shrink and dry out."

b. "I have to make sure I keep my lesions covered, so I do not spread this to others."

6. After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? a. "I can help him shift his position every hour when he sits in the chair." b. "If his tailbone is red and tender in the morning, I will massage it with baby oil." c. "Applying lotion to his arms and legs every evening will decrease dryness." d. "Drinking a nutritional supplement between meals will help maintain his weight."

b. "If his tailbone is red and tender in the morning, I will massage it with baby oil."

3. A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.) a. Prepare a room for reverse isolation. b. Assess staff for a history of or vaccination for chickenpox. c. Check the admission orders for analgesia. d. Choose a roommate who also is immune suppressed. e. Ensure that gloves are available in the room.

b. Assess staff for a history of or vaccination for chickenpox. c. Check the admission orders for analgesia. e. Ensure that gloves are available in the room.

23. A nurse evaluates the following data in a client's chart: Admission Note Prescriptions Wound Care 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) Sotalol (Betapace) Vacuum-assisted wound closure (VAC) treatment to leg wound Based on this information, which action should the nurse take first? a. Assess the client's vital signs and initiate continuous telemetry monitoring. b. Contact the provider and express concerns related to the wound treatment prescribed. c. Consult the wound care nurse to apply the VAC device. d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.

b. Contact the provider and express concerns related to the wound treatment prescribed.

7. After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Low-fat diet with whole grains and cereals and vitamin supplements b. High-protein diet with vitamins and mineral supplements c. Vegetarian diet with nutritional supplements and fish oil capsules d. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

b. High-protein diet with vitamins and mineral supplements

14. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands b. Irregular blue mole with white specks on the lower leg c. Large cluster of pustules in the right axilla d. Thick, reddened papules covered by white scales

b. Irregular blue mole with white specks on the lower leg

22. A nurse evaluates the following data in a client's chart: Admission Note Laboratory Results Wound Care Note 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL Albumin: 4.2 mg/dL Lymphocyte count: 2000/mm3 Sacral ulcer - 4 cm ´ 2 cm ´ 1.5 cm Based on this information, which action should the nurse take? a. Perform a neuromuscular assessment. b. Request a dietary consult. c. Initiate Contact Precautions. d. Assess the client's vital signs.

b. Request a dietary consult.

19. A nurse assesses a client who has psoriasis. Which action should the nurse take first? a. Don gloves and an isolation gown. b. Shake the client's hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

b. Shake the client's hand and introduce self.

16. A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a. "Do you spend a great deal of time in the sun?" b. "Have you or any family members ever had skin cancer?" c. "Which method of contraception are you using?" d. "Do you drink alcoholic beverages?"

c. "Which method of contraception are you using?"

2. A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a. A 44-year-old prescribed IV antibiotics for pneumonia b. A 26-year-old who is bedridden with a fractured leg c. A 65-year-old with hemi-paralysis and incontinence d. A 78-year-old requiring assistance to ambulate with a walker

c. A 65-year-old with hemi-paralysis and incontinence

3. When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? a. Turn the mattress overlay to the opposite side. b. Do nothing because this is an expected occurrence. c. Apply a different pressure-relieving device. d. Reinforce the overlay with extra cushions.

c. Apply a different pressure-relieving device.

15. A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? a. Administer it over 30 minutes using an IV pump. b. Give the client diphenhydramine (Benadryl) before the drug. c. Assess the IV site at least every 2 hours for thrombophlebitis. d. Ensure that the client has increased oral intake during therapy.

c. Assess the IV site at least every 2 hours for thrombophlebitis.

8. A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a. Client with blood cultures pending b. Client who has thin, serous wound drainage c. Client with a white blood cell count of 23,000/mm3 d. Client whose wound has decreased in size

c. Client with a white blood cell count of 23,000/mm3

1. A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education? a. "Use lots of moisturizer several times a day to minimize dryness." b. "Take a cold shower instead of soaking in the bathtub." c. "Use antimicrobial soap to avoid infection of cracked skin." d. "After you bathe, put lotion on before your skin is totally dry."

d. "After you bathe, put lotion on before your skin is totally dry."

10. After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? a. "I'll apply cortisone cream to reduce the inflammation." b. "I'll apply a clean dressing after squeezing out the pus." c. "I'll keep my arm down at my side to prevent spread." d. "I'll cleanse the area prior to applying antibiotic cream."

d. "I'll cleanse the area prior to applying antibiotic cream."

5. A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Place the client in bed and instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

d. Assess the right leg for pulses, skin color, and temperature.

17. A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a. Viral infection - Clindamycin (Cleocin) b. Bacterial infection - Acyclovir (Zovirax) c. Yeast infection - Linezolid (Zyvox) d. Fungal infection - Ketoconazole (Nizoral)

d. Fungal infection - Ketoconazole (Nizoral)