ch 15 Integumentary problems

Which assessment finding calls for the most immediate further assessment or intervention? 1. Bluish color around the lips and earlobes 2. Yellow color of the skin and sclera 3. Bilateral erythema of the face and neck 4. Dark brown spotting on the chest and back

Ans: 1 A blue color or cyanosis may indicate that the client has significant problems with circulation or ventilation. More detailed assessments are needed immediately. The other data may also indicate health problems in major body systems, but potential respiratory or circulatory abnormalities are the priority. Focus: Prioritization

A 22-year-old woman who has been taking isotretinoin (Claravis) to treat severe cystic acne makes all these statements while being seen for a follow-up examination. Which statement is of most concern? 1. "My husband and I are thinking of starting a family soon." 2. "I don't think there has been much improvement in my skin." 3. "Sometimes I get nauseated after taking the medication." 4. "I have been having problems driving when it gets dark."

Ans: 1 Because isotretinoin is associated with a high incidence of birth defects, it is important that the client stop using the medication at least a month before attempting to become pregnant. Nausea and poor night vision are possible adverse effects of isotretinoin that would require further assessment but are not as urgent as discussing the fetal risks associated with this medication. The client's concern about whether treatment is effective should be addressed, but this is a lower-priority intervention. Focus: Prioritization

You are the charge nurse in an LTC facility that employs RNs, LPNs/LVNs, and UAPs as staff members. An 80-year-old client has candidiasis in the skinfolds of the abdomen and groin. Which intervention is best to delegate to an LPN/LVN? 1. Applying nystatin (Mycostatin) powder to the area three times daily 2. Cleaning the skinfolds every 8 hours with mild soap and drying thoroughly 3. Evaluating the need for further antifungal treatment at least weekly 4. Assessing for ongoing risk factors for skin breakdown and infection

Ans: 1 Medication administration is included in LPN/LVN education and scope of practice. Bathing and cleaning clients require the least education and would be better delegated to a UAP. Assessment and evaluation of outcomes of care are more complex skills best performed by RNs. Focus: Delegation

You are preparing to discharge four clients from the hospital and are planning their discharge teaching. Which client will it be most important to instruct about the need to use sunscreen? 1. 32-year-old with a urinary tract infection who is being discharged with a prescription for tetracycline (Sumycin) 2. Fair-skinned 55-year-old who has just had neck surgery and who plans to walk in the yard for 15 minutes twice daily 3. Dark-skinned 62-year-old who has had keloids injected with hydrocortisone (Solu-Cortef) 4. 78-year-old with a red, pruritic rash caused by an allergic reaction to penicillin (Bicillin)

Ans: 1 Systemic use of tetracycline is associated with severe photosensitivity reactions to ultraviolet light. All individuals should be taught about the potential risks of overexposure to sunlight or other ultraviolet light, but the client taking tetracycline is at the most immediate risk for severe adverse effects. Focus: Prioritization

As charge nurse, you are providing orientation for a newly-hired RN. Which action by the new RN requires the most immediate action? 1. Obtaining an anaerobic culture specimen from a superficial burn wound 2. Giving doxycycline (Vibramycin) with a glass of milk to a client with cellulitis 3. Discussing the use of herpes zoster vaccine with a 25-year-old client 4. Teaching a newly admitted burn client about the use of pressure garments

Ans: 2 Dairy products inhibit the absorption of doxycycline, so this action would decrease the effectiveness of the antibiotic. The other activities are not appropriate but would not cause as much potential harm as the administration of doxycycline with milk. Anaerobic bacteria would not be likely to grow in a superficial wound. The herpes zoster vaccine is recommended for clients who are 60 years or older. Pressure garments may be used after graft wounds heal and during the rehabilitation period after a burn injury, but this should be discussed when the client is ready for rehabilitation, not when the client is admitted. Focus: Prioritization

You have just received a change-of-shift report for the burn unit. Which client should you assess first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

Ans: 2 Facial burns are frequently associated with airway inflammation and swelling, so this client requires the most immediate assessment. The other clients also require rapid assessment or interventions, but not as urgently as the client with facial burns. Focus: Prioritization

A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is admitted to the ED. Which ordered intervention will you implement first? 1. Infuse lactated Ringer's solution at 250 mL/hr. 2. Rinse the back and legs with 4 L of sterile normal saline. 3. Obtain blood for a complete blood count and electrolyte levels. 4. Document the percentage of total body surface area burned.

Ans: 2 With chemical injuries, it is important to remove the chemical from contact with the skin to prevent ongoing damage. The other actions also should be accomplished rapidly; however, rinsing the chemical off is the priority for this client. Focus: Prioritization

You are the charge nurse on a medical-surgical unit and are working with a newly-graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? 1. 34-year-old who was just admitted to the unit with periorbital cellulitis 2. 40-year-old who needs discharge instructions after having skin grafts to the thigh 3. 67-year-old who requires a dressing change after hydrotherapy for a pressure ulcer 4. 78-year-old who needs teaching before a punch biopsy of a facial lesion

Ans: 3 A new graduate would be familiar with the procedure for a sterile dressing change, especially after working for 3 weeks on the unit. Clients whose care requires more complex skills such as admission assessments, preprocedure teaching, and discharge teaching should be assigned to more experienced RN staff members. Focus: Assignment

You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? 1. 23-year-old who has just been admitted with burns over 30% of the body after a warehouse fire 2. 36-year-old who requires discharge teaching about nutrition and wound care after having skin grafts 3. 45-year-old with infected partial-thickness back and chest burns who has a dressing change scheduled 4. 57-year-old with full-thickness burns on both arms who needs assistance in positioning hand splints

Ans: 3 A nurse from the oncology unit would be familiar with dressing changes and sterile technique. The charge RN in the burn unit would work closely with the float RN to provide partners to assist in providing care and to answer any questions. Admission assessment and development of the initial care plan, discharge teaching, and splint positioning in burn clients all require expertise in caring for clients with burns. These clients should be assigned to RNs who regularly work on the burn unit. Focus: Assignment

As a home health nurse, you are caring for a 72-year-old client who has a nursing diagnosis of Impaired Skin Integrity related to poor nutrition, bladder incontinence, and immobility. Which nursing actions should you delegate to the UAP? 1. Telling the client and family to apply the skin barrier cream in a smooth, even layer 2. Completing a diet assessment and suggesting changes in diet to improve the client's nutrition 3. Reminding the family to help the client to the commode every 2 hours during the day 4. Evaluating the client for improvement in documented areas of skin breakdown or damage

Ans: 3 Although it is not appropriate for UAPs to plan or implement initial client or family teaching, reinforcement of previous teaching is an important function of UAPs (who are likely to be in the home on a daily basis). Teaching about medication use, nutritional assessment and planning, and evaluation for improvement are included in the RN scope of practice. Focus: Delegation

You are caring for a client who has just had a squamous cell carcinoma removed from the face. Which activity can you delegate to an experienced LPN/LVN? 1. Teaching the client about risk factors for squamous cell carcinoma 2. Showing the client how to care for the surgical site at home 3. Monitoring the surgical site for swelling, bleeding, or pain 4. Discussing the reasons for avoiding aspirin use for a week after surgery

Ans: 3 An LPN/LVN who is experienced in working with postoperative clients will know how to monitor for pain, bleeding, or swelling and will notify the supervising RN. Client teaching requires more education and a broader scope of practice and is appropriate for RN staff members. Focus: Delegation

When you are evaluating a client who has been taking prednisone (Deltasone) 30 mg daily to treat contact dermatitis, which finding is most important to report to the health care provider? 1. The blood glucose level is 136 mg/dL. 2. The client states, "I am eating all the time." 3. The client reports epigastric pain. 4. The blood pressure is 148/84 mm Hg.

Ans: 3 Epigastric pain may indicate that the client is developing peptic ulcers, which require collaborative interventions such as the use of antacids, histamine2 receptor blockers (e.g., famotidine [Pepcid]), or proton pump inhibitors (e.g., esomeprazole [Nexium]). The elevation in blood glucose level, increased appetite, and slight elevation in blood pressure may be related to prednisone use but are not clinically significant when steroids are used for limited periods and do not require treatment. Focus: Prioritization

A client is scheduled for patch testing to determine allergies to several substances. Which action associated with this test should you delegate to a medical assistant working in the allergy clinic? 1. Explaining the purpose of the testing to the client 2. Examining the patch area for evidence of a reaction 3. Scheduling a follow-up appointment for the client in 2 days 4. Monitoring the client for anaphylactic reactions to the testing

Ans: 3 Scheduling a follow-up appointment for the client is within the legal scope of practice and training for the medical assistant role. Client teaching, assessment for positive skin reactions to the test, and monitoring for serious allergic reactions are appropriate to the education and practice role of licensed nursing staff. Focus: Delegation

You have just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention? 1. 22-year-old admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left 2. 34-year-old who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0 to 10) 3. 45-year-old with partial-thickness leg burns who has a temperature of 102.6° F (39.2° C) and a blood pressure of 98/46 mm Hg 4. 57-year-old who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L

Ans: 3 This client's vital signs indicate that the life-threatening complications of sepsis and septic shock may be developing. The other clients also need rapid assessment and/or nursing interventions, but their symptoms do not indicate that they need care as urgently as the febrile and hypotensive client. Focus: Prioritization

You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished. 1. Apply silver sulfadiazine (Silvadene) ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. Débride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing. _____, _____, _____, _____, _____

Ans: 3, 4, 2, 1, 5 Pain medication should be administered before changing the dressing, because changing dressings for partial-thickness burns is painful, especially if the dressing change involves removal of eschar. The wound should be débrided before obtaining wound specimens for culture to avoid including bacteria that are skin contaminants rather than causes of the wound infection. Culture specimens should be obtained prior to the application of antibacterial creams. The antibacterial cream should then be applied to the area after débridement to gain the maximum effect. Finally, the wound should be covered with a sterile dressing. Focus: Prioritization

You take the health history of a 60-year-old client who has been admitted to the same-day surgery unit for elective facial dermabrasion. Which information is most important to convey to the plastic surgeon? 1. The client does not routinely use sunscreen. 2. The client has a family history of melanoma. 3. The client has not eaten anything for 8 hours. 4. The client takes 325 mg of aspirin daily.

Ans: 4 Because aspirin affects platelet aggregation, the client is at increased risk for postprocedure bleeding, and the surgeon may need to reschedule the procedure. The other information is also pertinent but will not affect the scheduling of the procedure. Focus: Prioritization

You perform a skin assessment on a 70-year-old new resident in an LTC facility. Which finding is of most concern? 1. Numerous striae are noted across the abdomen and buttocks. 2. All the toenails are thickened and yellow. 3. Silver scaling is present on the elbows and knees. 4. An irregular border is seen on a black mole on the scalp.

Ans: 4 Irregular borders and a black or variegated color are characteristics associated with malignant skin lesions. Striae and toenail thickening or yellowing are common in elderly individuals. Silver scaling is associated with psoriasis, which may need treatment but is not as urgent a concern as the appearance of the mole. Focus: Prioritization

You are employed as the charge nurse in a long-term care (LTC) facility that employs RNs, LPNs/LVNs, and UAPs. When you are planning care for a resident with a stage III sacral pressure ulcer, which nursing intervention is best to delegate to an LPN/LVN? 1. Choosing the type of dressing to be used on the ulcer 2. Using the Norton scale to assess for pressure ulcer risk factors 3. Assisting the client in changing position at frequent intervals 4. Cleaning and changing the dressing on the ulcer every morning

Ans: 4 LPN/LVN education and scope of practice includes sterile and nonsterile wound care. LPNs/LVNs do function as wound care nurses in some LTC facilities, but the choice of dressing type and assessment for risk factors are more complex skills that are appropriate to the RN level of practice. Assisting the client to change position is a task included in UAP education and would be more appropriate to delegate to the UAP. Focus: Delegation

A client admitted to the emergency department (ED) reports itching of the trunk and groin. You note multiple reddened wheals on the chest, back, and groin. Which question is most appropriate to ask next? 1. "Do you have a family history of eczema?" 2. "Have you been using sunscreen regularly?" 3. "How do you usually manage stress?" 4. "Are you taking any new medications?"

Ans: 4 Wheals are frequently associated with allergic reactions, so asking about exposure to new medications is the most appropriate question for this client. The other questions would be useful in assessing the skin health history but do not directly relate to the client's symptoms. Focus: Prioritization