Chapter 23: Care for patients with skin problems

A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? a. Suspected deep tissue injury: nonblanchable deep purple or maroon. b. Stage 2: may have visible adipose tissue and slough. c. Stage 3: may have a pink or red wound bed. d. Stage 4: wound bed is obscured with eschar or slough.

a A suspected deep tissue injury is characterized by persistent, nonblanchable purple or maroon discoloration. A stage 2 wound may have a pink of red would bed with granulation tissue. The stage 3 wound may have visible adipose tissue and slough. A stage 4 wound is full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. An unstageable wound is obscured by eschar or slough making assessment impossible.

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 would the nurse take? a. Request a prescription for permethrin. b. Administer an antihistamine. c. Assess the client's airway. d. Apply gloves to minimize friction.

a The client's presentation is most likely to be scabies, a contagious mite infestation. The drugs used to treat this infestation are ivermectin and permethrin. The nurse would contact the primary care provider to request a prescription for one of the medications. Secondary interventions may include medication to decrease the itching. The client's airway is not at risk with this skin disorder. Applying gloves will help prevent transmission.

A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? a. Assess the client's airway. b. Irrigate the client's skin. c. Brush any visible dust off the skin. d. Call poison control for guidance

a With any burn client, assessing and maintaining the airway is paramount. Airway tissues can swell quickly, cutting off the airway. The fertilizer would then be brushed off before irrigation. Poison control may or may not need to be called.

The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.) a. Thinner skin b. Slower healing time c. Decreased mobility d. Hyperresponsive immune response e. Increased risk of unnoticed sepsis f. Pre-existing conditions

a b c e f Age-related differences that can increase the risk of burns and complications of burns include thinner skin, slower healing, decreased mobility, increased risk of infection that goes unnoticed, and pre-existing conditions that can complicate recovery. The older adult has decreased inflammatory and immune responses

A nurse cares for many clients with pressure injuries. What actions by the nurse are considered best practice? (Select all that apply.) a. Conduct ongoing assessments that include pain. b. Use normal saline to cleanse around the pressure injury. c. Soak eschar daily until it softens and can be removed. d. Consult with a registered dietitian nutritionist. e. Use antimicrobial agents to clean wounds that are infected. f. Consider the use of adjuvant therapies for nonhealing wounds.

a b d e f Best practice for pressure injury wound management includes ongoing assessments that include pain, using normal saline to clean gently around the wound, ensuring optimal nutrition by involving a registered dietitian nutritionist, using an antimicrobial agent to clean wounds that are anticipated to become infected, and considering the use of adjuvant therapies such as stimulation, negative-pressure wound therapy, ultrasound, hyperbaric oxygen, and topical growth factors. The nurse would not disturb stable eschar.

The nurse in the emergency department would arrange to transfer which burned clients to a burn center? (Select all that apply.) a. 15% partial-thickness burn b. Lightening injury c. 7% partial-thickness burn d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum

a b d e f Clients with major burns are transferred to a burn center for specialized care. These include any partial-thickness burn over 10% TBSA; any lightening injury; a burn injury in a client with a history of pre-existing conditions that could complicate care or prolong recovery; adults over the age of 60; and burns to the face, hands, feet, genitalia, perineum, or major joints. The client with a 7% partial-thickness burn could be cared for in a hospital or a burn center.

A nurse is working with a client who has a painful rash consisting of grouped weeping and crusting lesions in distinct lines. What actions by the nurse are most appropriate? (Select all that apply.) a. Instruct the client to report lesions near the eyes. b. Have the client take long, hot baths to soak the lesions. c. Show the client how to make a baking soda compress. d. Advise the client to avoid exposure to UV light rays. e. Demonstrate proper use of antifungal medications. f. Review appropriate hygiene measures.

a c This client has herpes zoster (shingles). Eye infection is possible, so the client should be taught to report any lesions erupting near the eyes. Comfort measures can include compresses, calamine lotions, and baking soda. Long hot baths are not recommended. Avoiding UV lighting is important for herpes simplex. Herpes zoster is a viral disorder, so antifungal medications are not used. Hygiene is not an issue causing an outbreak.

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

a d For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help débride crusts and scales. The nurse would implement cool, moist compresses and tepid baths with additives such as colloidal oatmeal. Topical corticosteroids are a pharmacologic intervention. A heating pad and a back rub with baby oil are not appropriate for this client and could increase inflammation and discomfort.

A nurse plans care for a client who is immobile. Which interventions would 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 d f A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they would be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Clients would be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

A nurse evaluates the following data in a client's chart: Admission Note: A 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Prescription: Warfarin sodium (Coumadin) Sotalol (Betapace) Wound care: Negative-pressure wound therapy (NPWT) to leg wound Based on this information, which action would the nurse take first? a. Assess the client's vital signs and initiate continuous telemetry monitoring. b. Contact the primary health care provider to discuss the treatment 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 A client on anticoagulants is not a candidate for NPWT because of the incidence of bleeding complications. The health care primary health care provider needs this information quickly to plan other therapy for the client's wound. The nurse would contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring are appropriate for a client who has a history of atrial fibrillation and would be implemented as routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide the client with necessary nutrients for wound healing but can be implemented after wound care, vital signs, and telemetry monitoring.

A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge? a. Requests a referral to a registered dietitian nutritionist. b. Raises the head of the bed no more than 45 degrees. c. Performs perineal cleansing every 2 hours. d. Assesses the client's entire skin surface daily.

b A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. The nurse needs to keep the head of the bed elevated to no more than 30 degrees to prevent shearing. An RDN consultation, frequent perineal cleaning, and assessing the client's entire skin surface are all appropriate actions.

A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? a. The client may have memory and cognitive issues postburn. b. Everything between the entry and exit wounds can be damaged. c. The respiratory system requires close monitoring for signs of swelling. d. Electrical burns increase the risk of developing future cancers.

b As the electricity enters the body, travels through various tissues, and exits, it damages all the tissue it flows through. There may be severe internal injury that is not yet apparent. The client may have cognitive issues postburn but this is not as important as vigilant monitoring for complications. Respiratory system swelling is associated with thermal burns and smoke inhalation. Exposure to radiation increases cancer risk.

A nurse assesses a client who has psoriasis. Which action would 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 Clients with psoriatic lesions are often self-conscious of their skin. The nurse would first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy would be completed after establishing a report with the client.

A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of treatment choices. What statement by the client indicates good understanding of the information? a. "Dermabrasion or chemical peels can be done in the office." b. "I may need lymph node resection during Mohs surgery." c. "This needs only a small excision with local anesthetic." d. "After surgery I will need 8 weeks of radiation therapy."

b Melanoma is usually treated with Mohs micrographic surgery, in which tissue is sectioned horizontally in layers and examined histologically, layer by layer, to assess for cancer cells. Dermabrasion and chemical peels can be used on actinic keratoses. Local anesthetic for small excisions is generally used on basal or squamous cell carcinomas. Radiation is usually not used with melanoma.

After teaching a client who has a stage 2 pressure injury, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Green salad, a banana, whole wheat dinner roll, coffee b. Chicken breast, broccoli, baked potato, ice water c. Vegetable lasagna and green salad, iced tea d. Hamburger, fruit cup, cookie, diet pop

b Successful healing of pressure injuries depends on adequate intake of calories, protein, vitamins, minerals, and water. The dinner with the chicken breast meets all these criteria. The other dinners while having some healthy items each, are not as nutritious.

A nurse evaluates the following data in a client's chart: Admission Note: A 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis Lab Results: White blood cell count: 8000/mm3 (8 × 109/L) Prealbumin: 15.2 mg/dL (152 mg/L) Albumin: 4.2 mg/dL (42 mg/L) Lymphocyte count: 2000/mm3 (2 × 109/L) Wound care note: Sacral ulcer: 4 × 2 × 1.5 cm Based on this information, which action would 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 The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse would request a dietary consult. The other interventions do not address the information provided.

A nurse is teaching a client who has itchy, raised red patches covered with a silvery white scale how to care for this disorder. What statement by the client shows a need for further information? a. "At the next family reunion, I'm going to ask my relatives if they have anything similar." b. "I have to make sure I keep my lesions covered, so I do not spread this to others." c. "I must avoid large crowds and sick people while I am taking adalimumab." d. "I will buy a good quality emollient to put on my skin each day."

b This client has plaque psoriasis which is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links so it would be correct for the client to inquire about other family members who are affects. Adalimumab is a drug used to treat psoriasis and it has a black box warning about serious infection risk and cancer risk, so the client needs to take precautions to avoid infectious individuals. Emollients help keep the plaques soft and reduce itching.

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 mole with multiple colors on the leg. c. Large cluster of pustules in the right axilla. d. Thick, reddened papules covered by white scales.

b This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Freckles are a benign condition. Pustules could mean an infection, but it is more important to assess the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority

A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection? a. WBC 9200 mm/L3 (9.2 × 109 ) b. Boggy feel to granulation tissue c. Increased size after debridement d. Requesting pain medication

b Wound infection may or may not occur in the presence of signs of systemic infection, but a change in the appearance, texture, color, drainage, or size of a wound (except after debridement) is indicative of possible infection. The nurse would assess the client with boggy granulation tissue further. The WBC is normal. After debridement, the wound may look larger. If the client needs a sudden increase in the amount or frequency of pain medication that would be another indicator, but there is no evidence this client has more pain than usual.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would 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 e f Outbreaks of psoriasis can be induced by stress, environmental triggers, certain medications, skin injuries, infections, smoking, alcohol use, and obesity. Psoriatic lesions are not triggered by chocolate, public showers, or international travel

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure injury 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 hemiparesis and incontinence d. A 78 year old requiring assistance to ambulate with a walker

c Risk factors for development of a pressure injury include lack of mobility, exposure of skin to excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. The client with hemiparesis and incontinence has two risk factors. The client with pneumonia has no identified risk factors. The other two are at lower risk if they are not very mobile, but having two risk factors is a higher risk.

A nurse assesses a young female client who is prescribed tazarotene. 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 Tazarotene has many side effects. It is a known teratogen and can cause severe birth defects. Strict birth control measures must be used during therapy. The other questions are not directly related to this medication.

A nurse is teaching a client and family about self-care at home for the client's wound infected with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a need to review the information? a. "I will keep dry bandages on the wound and change them when drainage appears." b. "I will shower instead of taking a bath in the bathtub each day." c. "If the dressing is dry, I can sit or sleep anywhere in the house." d. "I will clean exposed household surfaces with a bleach and water mixture."

c The client should not sit on upholstered furniture or sleep in the same bed as another person until the infection has cleared. The other statements show good understanding.

A new nurse reads a client has a wound "healing by second intention" and asks what that means. Which description by the charge nurse is most accurate? a. "The wound edges have been approximated and stitched together." b. "The wound was stapled together after an infection was cleared up." c. "The wound is an open cavity that will fill in with granulation tissue." d. "The wound was contaminated by debris and can't be closed at all."

c Wounds healing by second intention are deeper wounds that leave open cavities. These wounds heal as connective tissue fills in the dead space. A wound that has its edges brought together (approximated) and sutured or stapled together is said to be healing by first intention. A wound that was left open while an infection healed and then is closed is an example of healing by third intention. A wound that cannot be closed at all would be left to heal by second intention.

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

d A client with an ulcer on the foot would be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

A client contacts the clinic to report a life-long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate? a. "Take monthly photographs of it so you can document any changes." b. "Wash daily with warm water and gentle soap to prevent infection." c. "Keep the lesion covered with a bandage and triple antibiotic ointment." d. "Please make an appointment to be seen here as soon as possible."

d A lesion demonstrating a change in characteristics, such as oozing, crusting, bleeding, or scaling, is suspicious for skin cancer. The nurse would instruct the client to come in for evaluation. Monthly photographs are a good way to document skin changes, but the client needs an assessment for skin cancer. The lesion can be washed and covered with a bandage and ointment, but again, the client needs an evaluation for skin cancer.

A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information? a. "I will shower daily using a super-fatted soap." b. "I can try taking a bath with colloidal oatmeal." c. "I will pat my skin dry instead of rubbing it with a towel." d. "I will be careful to keep my nails filed smoothly."

d The client with pruritus should shower only every other day, although super-fatted soap is an appropriate choice. Colloidal oatmeal baths are very soothing. Patting the skin dry avoids trauma and injury. Keeping nails filed smoothly also prevents injury.

A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound? a. Wet-to-damp saline moistened gauze b. None, the wound is left open to the air c. A transparent film d. Multi-fiber superabsorbent dressing

d This pressure injury requires a superabsorbent dressing that will collect the exudate but not stick to the wound itself. A wet-to-damp gauze dressing provides mechanical removal of necrotic tissue. A draining wound would not be left open. A transparent film is a good choice for a noninfected stage 2 pressure injury.