Tissue Integrity Nclex
The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which of the following locations should the nurse inspect for cyanosis (select all that apply)? 1. Patient's sclera 2. Patient's nail beds 3. Soles of the patient's feet 4. Palms of the patient's hands 5. Conjunctiva of the patient's eyes
2,5. In patients with darkly pigmented skin, the conjunctiva and nail beds are often examined to assess for cyanosis. Palms of the hands, soles of the feet, and the sclera are not the focus when assessing for cyanosis
During skin inspection the nurse observes three lesions on the client's right knee. The lesions are round, have a raised border, and are grouped in a "smiley face" pattern. Which descriptors does the nurse use to document these observations? A. Annular, circinate, clustered B. Linear, confluent, vesicular C. Circumscribed, universal, pustular D. Serpiginous, coalesced, wheal-like
A Rationale: Annular lesions have a raised border with flat, clear centers. Circinate lesions are round. The grouping is not linear and they are not touching, which makes them clustered rather than confluent. The information given is not enough to determine whether they are circumscribed.
Which intervention does the nurse use to promote "take" of a graft placed on the client's right heel? A. Elevate the client's right foot by placing pillows under the leg from the knee to the ankles. B. Position the client on the abdomen with the right foot hyperextended for at least 4 hours daily. C. Ensure that the grafted area is pressed tightly to the bed to promote adherence to the wound bed. D. Assess the circulation distal to the graft every hour and compare the findings with those from the left foot.
A Rationale: No pressure should be placed on the graft, and care must be taken to ensure it does not move over the wound so the blood vessels can connect the graft with the wound bed. Elevating the area allows better circulation and no pressure. Pressing the graft tightly against the bed would disturb the graft location and compromise circulation. Although placing the client on the abdomen would eliminate pressure on the heel, having the foot hyperextended would move the graft. Assessing circulation is a good thing to do but does not promote graft take.
In which position does the nurse place the client immediately after a rhytidectomy to promote venous return and prevent swelling? A. Fowler's B. Lithotomy C. Lateral Sims' D. Trendelenburg
A Rationale: Only Fowler's position would make the face less dependent, thus promoting venous return and decreasing swelling.
Which technique for obtaining a specimen for bacterial culture is most correct for the nurse to use with a client who has crusted skin lesions on the upper back? A. Remove several crusts, and swab the underlying exudate. B. Dampen the culture swab with sterile water, and then roll the swab over the central crusts. C. Apply a gauze bandage to the area, remove it after 1 hour, and send the entire gauze to the laboratory. D. Clean the area with an antibacterial solution, remove a crust from the center of the cluster of lesions, and send it to the laboratory.
A Rationale: The infecting agent is present in the material underneath the crusts, not on the outer surface of the crusts. Cleaning the area first with an antibacterial solution could compromise or delay culture results.
Which of the following safe sun practices would the RN include in the teaching care plan for a pt who has photosensitivity? (select all) A. wear protective clothing B. apply sunscreen liberally and often C. tanning booths decrease the likelihood of sunburn D. avoid exposure to the sun, esp during midday E. wear any sunscreen as long as it is purchased in a drugstore
A, B, D. Patients should recognize that sun safety guidelines include sun avoidance, especially during the midday hours; protective clothing; and broad-spectrum sunscreen (e.g., SPF 15, SPF 30 if a history of skin cancer or sun sensitivity). Sunscreens should be applied 20 to 30 minutes before going outdoors and be reapplied every 2 hours and after swimming. Patients should avoid tanning booths and sun lamps.
Dermatologic manifestation(s) of Cushing syndrome can include (select all that apply) A. acne B. telangiectasia C. increased sweating D. generalized hyperpigmentation E. brown pigmentation in the legs
A, B. Dermatologic manifestations of glucocorticoid excess (as in Cushing syndrome) include atrophy; striae; epidermal thinning; telangiectasia; acne, decreased subcutaneous fat over extremities; thin, loose dermis; impaired wound healing; increased vascular fragility; mild hirsutism; and excessive collection of fat over clavicles, back of neck, abdomen, and face.
The RN assessed the skin lesions as circumscribed, superficial, elevated, solid, and greater than 0.5 cm in diameter. They would be called: A. plaques B. papules C. pustules D. wheals
A. A plaque is a circumscribed, elevated, superficial, solid lesion; it is > 0.5 cm in diameter.
The staff mix available for the medical-surgical unit includes RNs, LPNs/LVNs, and nursing assistants. Which of these clients does the nurse plan to assign to an experienced LPN/LVN? A. Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road B.Adult client who needs to be admitted for a grafting of a second-degree burn on the right leg C.Middle-aged adult client who needs discharge teaching before going home after receiving steroids for Stevens-Johnson syndrome D. Older adult client with stage I pressure ulcers who needs to be turned every 2 hours
A. An LPN/LVN would be familiar with wound monitoring for potentially contaminated wounds and would recognize manifestations of infection.
The nurse is teaching the client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include? A. Avoiding or reducing skin exposure to sunlight B. Avoiding tanning beds C. Being aware of skin markings and performing skin self-examination D. Wearing SPF 40 sunscreen
A. Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats).
In a patient admitted with cellulitis of the left foot, which of the following clinical manifestations would you expect to find on assessment of the left foot? A. Redness and swelling B. Pallor and poor turgor C. Cyanosis and coolness D. Edema and brown skin discoloration
A. Cellulitis is a diffuse, acute inflammation of the skin. It is characterized by redness, swelling, and heat in the affected area. These changes accompany the processes of inflammation and infection.
When the nurse is assessing the skin of an older adult client, which of these data will be most important to report to the physician? A. A multicolored lesion is present on the client's thigh. B. Liver spots are present on both hands. C. Cherry hemangiomas are scattered on the client's back. D. The skin on the extremities is paper thin.
A. Color variation within a lesion is associated with skin cancer; the physician should be informed, so that the lesion can be further assessed.
The client with a foot ulcer says, "I feel helpless." What is the nurse's best response? A. Encourages participation in care of the wound B. Encourages visitors C. Says, "I know how you feel" D. Assures the client that it will be all right
A. Encouraging participation in wound care gives the client a sense of autonomy.
Individuals with dark skin are more likely to develop: A. keloids B. wrinkles C. skin rashes D. skin cancer
A. Individuals with dark skin are predisposed to certain skin and hair conditions such as keloids, which are overgrowths of collagenous tissue at the site of a skin injury.
While providing teaching to the client undergoing excisional biopsy, which statement will the nurse include? A. "Administration of local anesthetic agents may cause burning." B. "The biopsy results will be available within 2 hours of the procedure." C. "The dressing must remain in place for the first 48 hours." D. "Redness and swelling at the puncture site are expected."
A. Local anesthetic agents may cause a burning sensation for the client.
The nursing instructor reviews instructions with the nursing student on caring for the older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client? A. Massages bony prominences B. Avoids reddened areas C. Repositions the client every 1 to 2 hours D. Uses a moisturizing lotion
A. Massaging bony prominences should be avoided in older adult clients.
The nurse would assess a patient admitted with cellulitis for which of the following localized signs? A. pain B. fever C. chills D. malaise
A. Pain, redness, heat, and swelling are all localized signs of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection.
Important pt teaching after a chemical peel includes: A. avoidance of sun exposure B. application of firm bandages C. limitations of vigorous exercise D. use of ice to relieve discomfort
A. Patient teaching after a chemical peel should include instructions to use sunscreen and to avoid sun exposure for 6 months to prevent hyperpigmentation.
A mother and her two children have been diagnosed with pediculosis corporis. an appropriate measure in treating this condition is: A. applying pyrethrins to the body B. topical application of griseofulvin C. moist compresses applied frequently D. administration of systemic antibiotics
A. Pediculosis corporis (i.e., body lice) is treated with γ-benzene hexachloride or pyrethrins.
During change-of-shift report, the outgoing nurse reports a new finding of petechiae in a new patient admitted with a yet-to-be diagnosed hematologic disorder. On assessment of this patient, the incoming nurse may expect to find: A. Tiny, purple spots on skin. B. Large ecchymotic areas on skin. C. Hyperkeratotic papules and plaques. D. Small, raised red areas on the soles of the feet.
A. Petechiae present as tiny, purple spots on the skin. Large ecchymotic areas are purpura; hyperkeratotic papules and plaques represent actinic keratosis; and small raised red areas on the soles of the feet signify Osler's nodes
Which of the following patients would be more likely to have the highest risk of developing malignant melanoma? A. A fair-skinned woman who uses a tanning booth regularly B. An African American patient with a family history of cancer C. A Hispanic male with a history of psoriasis and eczema that responded poorly to treatment D. An adult who required phototherapy as an infant for the treatment of hyperbilirubinemia
A. Risk factors for malignant melanoma include a fair complexion and exposure to ultraviolet light. Psoriasis, eczema, short-duration phototherapy and a family history of other cancers are less likely to be linked to malignant melanoma.
The nurse should teach a patient who is taking which of the following drugs to avoid prolonged sun exposure? A. Tetracycline B. Ipratropium C. Morphine sulfate D. Oral contraceptives
A. Several antibiotics, including tetracycline, may cause photosensitivity. This is not the case with ipratropium, morphine, or oral contraceptives.
Which of the following interventions would be most helpful in managing a patient newly admitted with cellulitis of the right foot? A. Applying warm, moist heat B. Limiting ambulation to three times daily C. Keeping the foot at or below heart level D. Wrapping the foot snugly in warm blankets
A. The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris.
The nurse is teaching the client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client? A. Body image counseling B.Respiratory protection C. Self-suctioning D. Tobacco cessation education
A. The epidermis is the outer layer of the skin. Damage to the epidermis can cause body image disturbance with clients.
in teaching a pt with malignant melanoma about this disorder, the RN recognizes that the prognosis of the pt is most dependent on: A. the thickness of the lesion B. the degree of color change in the lesion C. how much the lesion has spread superficially D. the amount of ulceration present in the lesion
A. The most important prognostic factor is tumor thickness at the time of diagnosis. Two methods are used to determine thickness. The Breslow measurement indicates the depth of the tumor in millimeters, and the Clark level indicates the depth of invasion of the tumor. The higher the number, the deeper the melanoma.
Which of the following laboratory results is the best indicator that a patient with cellulitis is recovering from this infection? A. WBC of 8200/μl B. WBC of 2900/μl C. WBC of 16,300/μl D. WBC of 12,700/μl
A. The normal white blood cell count is generally 4000 to 11,000/μl. For this reason, the patient's level would be returning to normal if it was 8200/μl, indicating recovery from cellulitis.
In teaching the client about skin cancer prevention, which instruction will the nurse include? A. "Avoid sun exposure between 11 AM and 3 PM." B. "Examine skin quarterly for possible cancerous or precancerous lesions." C. "Wear transparent clothing to protect the skin from the sun." D. "It is safe to use a tanning bed."
A. The sun's rays are strongest between 11 AM and 3 PM and can cause more damage during this time.
A client with bacteremia associated with a bacterial skin infection is receiving clindamycin (Cleocin) intravenously (IV). Which assessment finding indicates the need for immediate action by the nurse? A. Blood pressure is 88/40 mm Hg. B. White blood cell count is 15,000/mm3. C. Oral temperature is 101° F (38.3° C). D. Heart rate is 102 beats/min.
A. Too-rapid administration of clindamycin (Cleocin) can cause shock and cardiac arrest; the client's low blood pressure indicates a need to slow the rate and reassess the client.
Which statement by the client with psoriasis indicates to the nurse that additional teaching about his condition is required? A. "A tanning bed will supply the ultraviolet light I need." B. "Medicine can prevent the growth of new skin cells." C. "I can never be cured." D. "Stress can cause my flare-ups."
A. Ultraviolet (UV) radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients. This statement indicates that the client requires further teaching.
To assess the skin for temperature and moisture, the most appropriate technique for the RN is to use is: A. palpation B. inspection C. percussion D. auscultation
A. Using the back of your hand on the patient's skin best assesses its temperature.
When assessing the activity-exercise pattern in relation to the skin, the RN questions the pt regarding: A. protection against sun exposure B. the use of moisturizing shampoo C. self-care habits related to daily hygiene D. the presence of dark circles under the eyes
A. When assessing the activity-exercise pattern, the nurse asks the following questions: Do your leisure or work activities involve the use of any chemicals that are irritating to your skin? Do you do anything to protect yourself from the sun?
The client has an odorous purulent wound. How does the nurse best support this client? A. Changes the dressing frequently B. Encourages a diet high in protein C. Suggests whirlpool therapy D. Places room deodorizers in the room
A> Frequent dressing changes help the client feel clean.
The nurse anticipates that the client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy? A. Hyperbaric oxygen B. Nutrition therapy C. Topical growth factors D. Vacuum-assisted wound closure
A> Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers.
The nurse is teaching the client with loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy will the nurse include in the client's teaching plan? A. Lift hips off the chair at least every 30 minutes. B. Eat a low-fat diet. C. Massage reddened areas. D. Complete a pressure map.
A> Lifting hips off the chair at least every 30 minutes relieves pressure and can prevent pressure ulcers.
A female business professional has extremely dry skin on her legs. In addition to using lotions after bathing, she asks the nurse about other measures to help reduce the dryness. What is the nurse's best response? A. "Wear long-legged pajamas to sleep in rather than nightgowns." B. "Avoid wearing pantyhose or nylon stockings for more than 2 hours at a time." C. "Leave the fat-containing soap on your skin when bathing rather than rinsing it off." D. "Bathe in water that is as warm as you can stand to stimulate the release of body oils from your sebaceous glands."
B Rationale: Clothing that fits tightly and rubs can dry the skin. Prolonged contact with nylon stockings or pantyhose causes or exacerbates dry skin on the legs. Avoiding these clothing items can reduce this dryness. Wearing pajamas to sleep in, leaving soap on the skin, and bathing in very warm water can contribute to dry skin.
Age-related changes in the skin include (select all that apply) A. oily scalp B. a loss of collagen C. thicker, brittle nails D. thinner, fragile nails E. improved blood supply
B, C. Decreased subcutaneous fat, muscle laxity, degeneration of elastic fibers, and collagen stiffening lead to increased wrinkling, sagging breasts and abdomen, redundant flesh around eyes, and slowness of skin to flatten when pinched together (i.e., tenting). Decreased oil leads to dry, coarse hair and a scaly scalp. Diminished blood supply leads to the following changes: decrease in rosy appearance of the skin and mucous membranes, skin that is cool to the touch, and diminished awareness of pain, touch, temperature, and peripheral vibration. Decreased peripheral blood supply leads to thick, brittle nails with diminished growth. The dermis loses volume and has fewer blood vessels.
in teaching a pt who is using topical corticosteroids to treat acute dermatitis, the RN should tell the pt that: (select all that apply) A. the cream form is the most efficient system of delivery B. short term use of topical corticoisteroids usually does not cause systemic side effects C. creams and ointments should be applied with a glove in small amounts to prevent further infection D. abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the dermatitis E. systemic side effects may be experienced from topical corticosteroids if the person is malnourished
B, D. Systemic corticosteroids often have undesirable systemic effects. Topical corticosteroids for short-term therapy have fewer systemic effects. Rebound dermatitis is common when therapy is stopped abruptly; this effect can be reduced by tapering the use of topical corticosteroids.
The nurse is aware that which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon? A.1-mm ecchymotic area on the upper extremity B. Presence of one of the ABCD features C. Dark red color D. Round and raised appearance
B. A lesion with one or more of the ABCDE features should be evaluated by a dermatologist or a surgeon.
Which of the following assessment findings of a 70-year-old male patient's skin should the nurse prioritize? A. The patient's complaint of dry skin that is frequently itchy. B. The presence of an irregularly shaped mole that the patient states is new. C. The presence of veins on the back of the patient's leg that are blue and tortuous. D. The presence of a rash on the patient's hand and forearm to which the patient applies a corticosteroid ointment.
B. Although all of the noted assessment findings are significant, the presence of an irregular mole that is new is suggestive of a neoplasm and warrants immediate follow-up.
The older adult female client asks the nurse, "Why is my hair thinning?" After assuring the client that this is a normal sign of aging, what is the nurse's best follow-up response? A. "How does this make you feel?" B. "How is this affecting you?" C. "Wear a hat outside to stay warm." D. "You could wear a wig."
B. Asking the client how she is affected assesses the need for direct additional counseling.
Diagnostic testing is recommended for skin lesions when: A. a health history cannot be obtained B. a more definitive diagnosis is needed C. percussion reveals an abnormal finding D. treatment with prescribed medication has failed
B. Biopsy is one of the most common diagnostic tests used in the evaluation of a skin lesion. A biopsy is indicated in all conditions in which a malignancy is suspected or a specific diagnosis is questionable.
Which of the following medications are the most likely to have an effect on the patient's integumentary system? A. Diuretic B. Corticosteroid C. Benzodiazepine D. Calcium channel blocker
B. Corticosteroids can have unwanted integumentary side effects. Integumentary effects are less likely to occur with benzodiazepines, calcium channel blockers, and diuretics.
The nurse working in the same-day surgery unit has just received report and plans to assess which client first? A. Adult with a basal cell carcinoma excised who needs discharge teaching about wound care B. Young adult who has had rhinoplasty and is swallowing frequently C. Middle-aged adult who reports 7/10 pain after removal of a cyst D. Older adult ready to be transferred to the long-term care facility after débridement of a pressure ulcer
B. Frequent swallowing after rhinoplasty may indicate bleeding, which requires immediate action by the nurse.
the RN identifies that a pt with a diagnosis of which of the following disorders is most at risk for spreading the disease? A. tinea pedis B. impetigo on the face C. candidiasis D. psoriasis on the palms and soles
B. Impetigo is caused by a bacterial infection (group A β-hemolytic streptococci or staphylococci) and is highly contagious. Good skin hygiene and infection control practices are necessary to prevent the spread of this infection. Tinea pedis and candidiasis are fungal infections. Psoriasis is an autoimmune chronic dermatitis and is not contagious.
On inspection of the pt's skin, the RN notes hypertrophied scarring at the site of a prior injry to the skin. this assessment abnormality is called: A. vitiligo B. keloid C. telangiectasia D.
B. Keloid is an overgrowth of collagenous tissue at the site of a skin injury.
Which activity for the long-term care client does the nurse plan to assign to the LPN/LVN? A. Develop a care plan for a client who has blisters caused by herpes zoster. B. Administer an antihistamine to a client who is describing pruritus. C. Teach a client how to self-assess for changes in skin lesions. D. Perform a baseline skin assessment for a newly admitted client.
B. LPNs/LVNs are familiar with safe administration of medications, including monitoring for medication effectiveness and adverse effects.
The nurse would recognize which of the following patients as likely to have the poorest prognosis? A. A 60-year-old diagnosed with nodular ulcerative basal cell carcinoma B. A 59-year-old man who is being treated for stage IV malignant melanoma C. A 70-year-old woman who has been diagnosed with late squamous cell carcinoma D. A 51-year-old woman whose biopsy has revealed superficial squamous cell carcinoma
B. Late detection of malignant melanoma is associated with a poor outcome. Basal cell carcinomas often have very effective treatment success rates. Although late SCC has worse outcomes than superficial SCC, these are both exceeded in mortality by late-stage malignant melanoma.
Which skin condition will the emergency department nurse assess first? A. Localized redness to the surgical site B. Pitting edema C. Poor skin turgor D. Red bony prominences
B. Pitting edema indicates an electrolyte, cardiac, or renal insufficiency.
The nurse understands that deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? A. First B. Second C. Third D. Mixed
B. Second intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss.
The nurse in the outpatient clinic is caring for four clients who require cultures of skin lesions. Which action will the nurse take first? A. Add potassium hydroxide to the specimen to check for a possible fungal infection, and inspect it under the microscope. B. Soak the crust of a possible bacterial lesion with normal saline. C. Instruct the client who has had a punch biopsy about wound care. D. Place the viral culture tubes for a client with possible herpes zoster
B. Soaking the crust of a possible bacterial lesion with normal saline does not require immediate action.
The older adult immobile client has "sunk" to the bottom of the bed. What will the nurse do first? A. Gently pull the client up. B. Get help and lift the client. C. Look for broken skin areas. D. Pad the bony prominences.
B. The client should be gently lifted with a sheet. Pulling or dragging the client should be avoided.
The primary function of the skin is: A. insulation B. protection C. sensation D. absorption
B. The primary function of the skin is to protect the underlying tissues of the body by serving as a surface barrier to the external environment.
Which nursing documentation is correct in describing multiple lesions with well-defined borders that are located in one area? A. Clustered round lesions to the chest B. Five clustered circumscribed lesions on the chest C. Five diffuse circinate lesions on the chest D. Several lesions in one area that have well-defined borders
B. This entry is specific, with correct terminology.
Inspection of an obese, female patient reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. The nurse would suspect that the odor is most likely caused by A. Ecchymosis. B. Colonization by yeast or bacteria. C. Age-related integumentary changes. D. Atrophy of the skin under the abdominal folds.
B. Unusual foul odors, especially those found in intertriginous areas, are often the result of colonization by yeast or bacteria. Ecchymosis is the presence of bruising whereas an unusual odor would not normally be attributed to age-related changes or skin atrophy.
During assessment of a pt, the RN notes an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the pt's knees and elbows, this is known as: A. lentigo B. psoriasis C. actinic keratosis D. seborrheic keratosis
B.Clinical manifestations of psoriasis include sharply demarcated, silvery scaling plaques on reddish skin, commonly on the scalp, elbows, knees; palms, soles, and fingernails; itching, burning, and pain; localized or general, intermittent or continuous pattern; and symptoms that vary in intensity from mild to severe.
Which method will the nurse use to assess skin lesions for cancer? A. American Cancer Society Skin Assessment B. Asymmetry, border, color, diameter, evolving C. Dermatologist skin review D. Size, location, and inflammation
B> The ABCDE method is the accepted technique for assessing skin lesions.
The nurse is developing a teaching a plan for a client diagnosed with (MRSA) infection. The nurse plans to include which instruction in the client's teaching plan? A. Take daily tub baths using a mild soap. B. The infected area should be covered with a clean, dry bandage. C. Wash the infected areas first, then wash the uninfected areas. D. Use bath sponges or puffs when bathing.
B> The infected area should be covered with a clean, dry bandage to prevent the spread of infection.
The nurse notices yellowing at the corners of the sclera in the African-American client admitted for hepatitis. What does the nurse do next? A. Palpates the liver B. Checks the oral mucosa C. Examines the client's hair D. Monitors pulse oximetry
B> To assess dark-skinned clients for jaundice, check for a yellow tinge to the oral mucous membranes, especially the hard palate, and examine the sclera nearest to the iris rather than the corners of the eye.
Which precaution is most important for the nurse to teach a client prescribed adalimumab (Humira)? A. Drinking a full glass of water when taking each drug dose B. Reducing the drug dosage when psoriasis symptoms decrease C. Reporting symptoms of infection to the prescriber immediately D. Avoiding sunlight and tanning beds for the duration of drug therapy
C Rationale: Humira suppresses inflammatory and immune responses to some degree. This makes the client more susceptible to infection and may suppress some of the usual manifestations of infection. Together, these actions can allow a minor infection to become more severe very quickly. Any potential infection, no matter how minor, should receive immediate medical attention.
During morning rounds, the nurse discovers that the older adult client has been incontinent during the night. To protect the skin, what will the nurse do first? A. Apply a barrier cream. B. Assess the area for skin breakdown. C. Clean the client. D. Place the client in a side-lying position.
C. Cleaning and drying the client is the first priority for skin protection.
Which statement by the client with psoriasis indicates that teaching about the condition has been effective? A. "I know that I need to avoid warm climates." B. "I need to cover up the affected areas to prevent spread to my family." C. "I should practice good handwashing technique." D. "Psoriasis can be cured with steroids."
C. Infections such as strep throat can exacerbate psoriatic flare-ups. Handwashing can help prevent infection.
The nurse is caring for a client prescribed linezolid (Zyvox) for treatment of methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans to monitor the client for which adverse effect of linezolid? A. Depression B. Hyperglycemia C. Hypertension D. Incontinence
C. Linezolid (Zyvox) constricts blood vessels and may trigger hypertensive crisis.
Which of the following laboratory tests would be most important to check in a patient presenting with purpura? A. Urinalysis B. Serum electrolytes C. Coagulation studies D. White blood cell count
C. Purpura are areas of ecchymoses that may signify a bleeding disorder. Therefore it is most important for the nurse to assess the patient's coagulation studies.
A common site for the lesions associated with atopic dermatitis is the: A. buttocks B. temporal area C. antecubital space D. plantar surfaces of the feet
C. The most common location for atopic dermatitis in adults is the antecubital or popliteal space.
During the physical examination of a pt's skin, the RN would: A. use a flashlight if the room is poorly lit B. note cool, moist skin as a normal finding C. pinch up a fold of skin to assess for turgor D. perform a lesion-specific examination first and then a general inspection
C. Turgor refers to the elasticity of the skin. The nurse should assess turgor by gently pinching an area of skin under the clavicle or on the back of the hand. Skin with good turgor should move easily when lifted and should immediately return to its original position when released.
The discharged obese client will require frequent dressing changes for a skin condition on the left foot. How will the nurse assess whether the client is able to perform this task at home? A. Asks the client if he is squeamish B. Demonstrates how to change the dressing C. Determines whether the client can reach the affected area D. Provides all the necessary dressing materials
C. Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to perform frequent dressing changes at home.
A client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity will the nurse assign to an LPN/LVN working with this client? A. Teach the client about signs of incisional infection. B. Instruct the client about how to do dressing changes. C. Apply an antibiotic ointment and place a sterile dressing on the incision. D. Complete the written discharge instructions for the long-term care facility.
C. Wound care is included in practical nursing education.
What is the best way for the nurse to prevent the client's stage I pressure ulcer from advancing to stage II? A. Massage the reddened areas. B. Pad the ulcer. C. Promote mobility and/or frequent repositioning. D. Suggest an egg crate mattress.
C> Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer.
The young client has been diagnosed with ringworm, but the mother would like the child to return to school. To avoid spreading the infection, what will the nurse suggest to the mother? A. "Wash your hands frequently." B. "Your child may return to school but must be isolated from the rest of the class." C. "Keep the site covered with a bandage." D. "Keep your child out of school until the infection has cleared."
C> Keeping the site covered prevents spread of the infection.
The nurse is instructing the client on skin and sun protection. Which statement by the client indicates the need for further teaching? A. "My skin is better protected from the sun because I am dark skinned." B. "Sunscreen should be applied liberally." C. "I use a tanning bed to avoid the sun's harmful rays." D. "My sunglasses are UVA and UVB protected."
C> Tanning beds are just as damaging to the skin as the sun's rays; this statement indicates that the client needs further teaching.
Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? A. Use the Braden scale to determine pressure ulcer risk for a newly admitted client. B. Complete daily sterile dressing changes for a client with a venous leg ulcer. C. Reposition every 2 hours a client who has had a stroke and is incontinent. D. Admit a newly transferred client who had pedicle flap surgery 1 week ago.
C> The nursing assistant has the education and scope of practice to reposition a client.
The older adult client who is bedridden has a documented history of protein deficiency. What will the nurse plan to monitor for? A. Anemia B. Decreased wound healing C. Pressure ulcer development D. Weight gain
C> This client is at risk for pressure ulcer if he or she remains bedridden.
The nurse prepares to administer vancomycin (Lyphocin, Vancocin) to a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. How will the nurse administer this medication? A. Administer by bolus. B. Give IV push. C. Infuse over 60 minutes. D. Mix vancomycin with primary intravenous (IV) bag.
C> Vancomycin (Lyphocin, Vancocin) is irritating to the veins and can trigger thrombophlebitis; it should be given over at least 60 minutes.
The newly admitted client has all of the following laboratory test values. Which value suggests to the nurse that the client may be at an increased risk for pressure ulcer formation? A. International normalized ratio (INR) of 1.5 B. White blood cell (WBC) count of 5200/mm3 C. Serum sodium concentration of 134 mEq/L D. Serum prealbumin concentration of 15.2 mg/dL
D Rationale: Adequate nutrition, especially protein intake, helps promote healthy skin and prevent tissue breakdown. A serum prealbumin concentration less than 19.5 mg/dL indicates inadequate nutrition and a severe protein deficiency. With so little protein, the skin cannot repair itself and is at great risk for injury even with minor trauma.
The client reports that a previously sensitive area of skin no longer responds to temperature changes or painful stimuli. This finding indicates a functional abnormality for which skin layer? A. Stratum corneum B. Adipose layer C. Epidermis D. Dermis
D Rationale: The dermis or dermal layer of skin contains sensory nerves that transmit the sensations of touch, pressure, temperature, pain, and itch. The stratum corneum, epidermis, and adipose tissue do not transmit sensation. Because this client's skin area was once sensitive and now is not suggests an abnormality in the function of the dermis.
During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response? A. Clubbing of the nail beds B. Cool extremities C. Café au lait spots D. Warm red area on the calf
D. A warm red area on the calf is indicative of a thrombus and requires urgent attention.
The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration? A. Calcium B. Hematocrit C. Numbers of immature white blood cells (WBCs) D. Serum albumin
D. Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.
The nurse identifies the priority problem of skin breakdown related to poor hygiene in a long-term care client who has areas of skin breakdown in the skin folds and the perineal area. Which intervention will be best for the RN to delegate to the nursing assistant? A. Check the client's skin weekly for areas of redness or breakdown. B. Teach the client and family about the importance of good hygiene in skin folds. C. Evaluate the client's ability to provide skin hygiene independently. D. Bathe the client, and apply a protective barrier to skin folds and perineum.
D. Assisting clients with personal hygiene is included in nursing assistant education.
The home health nurse is doing an intake assessment on a client who had a recent shave biopsy of a basal cell carcinoma located on the client's cheek. Which statement by the client may indicate the greatest need for client teaching? A. "Every morning, I check the biopsy site for signs of infection." B. "I have been cleaning my face with soap and water." C. "My appetite is improving lately." D. "I have been working in my garden for several hours every day."
D. Basal cell carcinomas of the skin are associated with sun exposure. The nurse should further assess the client for knowledge about the association between sun exposure and skin cancers and for use of sunscreens.
Which of the following practices should the nurse teach a patient to follow when the patient is applying topical medication? A. Avoid applying medications directly on to dressings B. Use a tongue blade whenever the patient's skin integrity allows C. Avoid covering skin regions that have topical medication in place D. Apply a layer of medication that is just thick enough to ensure coverage
D. Patients should be directed to avoid applying topical medications too thickly. Medications may be applied directly on to dressings, and regions with medications may be covered. A tongue blade is not normally necessary for application.
The nurse is assessing a client and observes multiple small pits in all of the client's fingernails. The nurse suspects that the client may have which condition? A. Cystic fibrosis B. Iron deficiency anemia C. Isolated periods of severe malnutrition D. Psoriasis
D. Pitting of the nails may be associated with plate thickening and onycholysis and most often involves several or all of the fingernails; it is seen in clients with psoriasis and alopecia areata.
A pt with psoriasis tells the Rn that she has quit her job as a receptionist because she feels her appearance is disgusting to customers. the nursing diagnosis that best describes this pt response is: A. ineffective coping r/t lack of social support B. impaired skin integrity r/t presence of lesions C. anxiety r/t lack of knowledge of the disease process D. social isolation r/t decreased activities secondary to fear of rejection
D. Psoriasis can be severe and disabling, and people withdraw from social contacts because of visible lesions.
A 14-year-old female and her mother have presented to their nurse practitioner seeking treatment for the daughter's acne. The nurse would recognize that acne is characterized by the presence of multiple: A. Ulcers. B. Wheals. C. Vesicles. D. Pustules.
D. Pustules are elevated, superficial lesions filled with purulent fluid, such as those commonly associated with acne. Wheals, ulcers, and vesicles are not common manifestations of acne.
The client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client? A. Ensure that all lesions are reviewed by a dermatologist or a surgeon. B. Avoid sun exposure. C. Perform a total skin self-examination monthly. D. Perform a total skin self-examination monthly with a partner.
D> Performing a monthly total skin self-examination with another person is the best secondary preventive measure.
The nurse admits a client to the clinic who is reporting severe itching to the arms and legs caused by exposure to poison ivy. The nurse anticipates that the health care provider will prescribe which medication? A. Anthralin (Anthaforte, Drithocreme, Lasan) B. Benzyl benzoate (Ascabiol) C. Calcipotriene (Dovonex) D. Diphenhydramine (Benadryl)
D> Treatment is aimed at removal of the triggering substance and relief of symptoms. Because the skin reaction is caused by histamine release, antihistamines such as diphenhydramine (Benadryl) are helpful.
