skin disorders
Which clients would the nurse understand are at risk for pressure injuries?
A middle-aged quadriplegic client who is alert and conversant a very thin client who sites for long periods in a chair and refuses food an obese client who must be assisted to move and turn in bed an older adult who is bedridden and in late stage of Alzheimer's disease
For which conditions, which could contribute to overall hygiene, would the nurse assess when a client presents with matted hair, body odor, and soiled clothes?
intact sensory functions (e.g. sight, smell) range of motion and strength access to shower and laundry client's currently prescribed drugs perception of his/her appearance knowledge (memory) of hygiene care
Which characteristics would the nurse expect to assess for a client with plaque psoriasis?
raised, red patches covered with silvery white scales affected area usually include scalp, knees, elbows, lower back may be itchy, painful, or bleeding
What is the BEST place for the nurse to examine a fair-skinned client for yellow discoloration when jaundice is suspected?
sclera
Which teaching points would the nurse be sure to share with a client scheduled for a punch biopsy?
A local anesthetic will be injected into the site a circular instrument will cut out a tissue sample antibiotic ointment may be prescribed to reduce the risk for infection
What is the MOST accurate method for the nurse to use when assessing cyanosis in a dark-skinned client admitted for pneumonia?
Check the conjuctivae and nail beds for a bluish tinge color.
Which client is most likely to be a candidate for Mobs surgery?
Client with squamous cell carcinoma on the nose
Which terms would the nurse use to document a client's rash that is red, raised, and itching over most of his/her body?
Erythematous, diffuse, pruritic
Which factors are included in the ABCDE features associates with skin cancer?
Evolving or changing of any feature color variation within a lesion asymmetry of shape
What is the BEST method for the nurse to complete a client's skin assessment while effectively using time management?
Examine the client's skin while bathing or assisting with hygiene.
What is the BEST site for the nurse to assess skin for dehydration in an older adult client?
Forehead
Which assessment technique would the nurse use to check the skin turgor of a client who is at risk for hypovolemia?
Gently pinch the skin on the back of the hand and observe for tenting.
Which question would the nurse ask when assessing a female client who reports an unusual increase in facial hair?
Have you noticed any deepening of your voice quality?
Which question would the nurse ask a client, who has nonspecific eczematous dermatitis, to determine if avoidance therapy is an appropriate intervention?
Have you used any new soaps, detergents, or personal care products?
What type of healing does the nurse assess when a client's surgical wound edges are approximated, closed with sutures, and there is no inflammation?
Healing by first intention
Which skin changes does the nurse expect to see in an older adult client as a result of a decreased number of active melanocytes?
Increased sensitivity to sun exposure
Which actions would the nurse take when a client has decreased eccrine and apocrine gland activity?
Instruct the client to use soap with a high fat content teach the client to avoid frequent bathing with hot water encourage the client to apply moisturizers after bathing
Which skin assessment finding in an older adult client is MOST IMPORTANT for the nurse to report to the primary health care provider (PHCP) for follow-up?
Irregular light-brown macule (6.5 cm) on the right scapula
What diagnostic test does the nurse prepare a client for when the PHCP prescribes a test to determine of the client has a fungal infection of the skin?
KOH test
Which skin disorder is most associated with a familial predisposition?
Psoriasis
Which ESSENTIAL teaching would the nurse provide for a younger female client with psoriasis who is prescribed tazarotene?
Tazarotene can cause birth defects even when applied topically
In addition to topical drugs for psoriasis, which therapies would the nurse teach a client to reduce symptoms?
Ultraviolet (UV) radiation photochemotherapy with psoralen excimer lasers systemic therapy
What would the nurse suspect when a client is admitted with a rash of white or red edematous papules or plaques that developed after the client ate seafood?
Urticaria
What is the BEST method for the nurse to collect a superficial specimen from a raised lesion for a suspected fungal infection in a client's groin?
Use a scalpel or razor blade and move it parallel to the skin surface to remove the tissue specimen
Which equipment would the nurse obtain to assist the PHCP in examining the light-skinned client for evaluation of skin pigment changes?
Wood's lamp
Which PRIORITY nursing interventions focus on increasing client comfort and preventing skin injury when the client has pruritus?
administering prescribed antihistamines or topic drugs keeping client's fingernails trimmed short applying mittens or gloves to client's hands at night maintaining daily fluid intake of 3000 mL unless contraindicated after bathing, patting skin dry rather than rubbing
Which finding, when assessing a client's would for signs of healing or infection, indicates to the nurse that healing is progressing as expected?
area appears pale pink, progressing to a spongy texture with a deep reddish-purple color
When the nurse takes a client's medication history after noting the presence of ecchymoses, which types of drugs are of concern?
aspirin products anticoagulants long-term corticosteroids
What would the nurse direct the home assistive personnel (AP) to do for an older client who wants to avoid dry skin?
assist with a complete bath or shower only every other day (wash face, axillae, perineum, and any soiled areas with soap daily).
Which ESSENTIAL teaching would the nurse provide for a client who is prescribed diphenhydramine to treat urticaria (hives)?
avoid alcohol consumption, which can potentiate the sedative effects of this drug.
What is the PRIORITY action for the nurse and other interprofessional team members when caring for a client with Stevens-Johnson syndrome?
identify the offending drug and discontinue it
Which condition would the nurse suspect when observing linear riders on the inner aspects of the wrists and the client reports intense itching especially at night?
scabies
Which are the priorities of care when providing care for a client with a burn injury during the emergent phase?
securing the airway supporting circulation and perfusion maintaining body temperature keeping client comfortable with analgesics
Which areas would the nurse give special attention when assessing an obese older adult?
skinfolds
Which factors increase the risk of complications from a burn injury in an older adult client?
slower healing time medical conditions such as diabetes
Which assessment finding would the emergency department (ED) nurse expect when a client has a smoke-related inhalation injury?
soot around nose or mouth singed nasal hairs hoarseness of speech shortness of breath cough
How will the nurse document assessment findings on a client's coccyx region that is reddened, is intact, and does not blanch when pressure is applied?
stage 1 pressure injury
What would the help-line nurse advise a client who states that a skin lesion's color has changed, its size has increased, and its border is irregular?
"Contact your primary health care provider immediately."
Which is the nurses' BEST response when a client diagnosed with bedbug bites states he or she is embarrassed, showers every day, and lives in a clean environment?
"Have you been traveling or staying in a hotel?"
When regulating body temperature, who much evaporative water can eccrine sweat glands lose in one day?
10-12 L/day
Which information would the nurse teach a client about treatment of pediculosis pubic?
abstain from sexual intercourse with any infected person
How long would the nurse expect a client's partial-thickness wound to heal by epithelialization?
5 to 7 days
Which preventive strategies for skin cancer would the nurse teach to clients and families?
Avoiding sun exposure between 11am and 3pm Wearing a heat, opaque clothing, and sunglasses when you are in the sun taking pictures of lesions and comparing them month by month keeping a "body map" of your skin spots, scars, and lesions
Which questions would the nurse ask to determine if a client with a rash is having a new allergic reaction?
Are you taking any new medications? Have you been using any different soaps, cosmetics, or lotions? Have you been exposed to any new cleaning solutions? Have you had any recent changes in your diet?
Age-related change in the integumentary system include DECREASES in which factors?
Rate of nail growth Thickness of epidermis Dermal blood flow Vitamin D production
Which is the BEST rationale for the nurse to use to encourage a client to seek treatment for dandruff?
Severe dandruff is caused by excessive oiliness and can cause hair loss
What would be the nurse's BEST action when a client with a burn injury develops a brassy cough, increased difficulty swallowing, and progressive hoarseness?
activate the Rapid Response Team
Which technique does the nurse use to assess the "...health of the nails of a client with very dark skin."
gently squeeze the end of the finger exerting downward pressure, then release it
which roles of a client's intact skin will the nurse consider most important? (select all)
body temperature regulation protection against infection maintaining fluid electrolyte balance sensory function to provide comfort
What COLLABORATIVE action would the nurse take to promote would healing for a thin, malnourished client who had emergency abdominal surgery?
consult wiht the registered dietitian nutritionist (RDN) about a high-protein diet
Which is the BEST action for the nurse to take prior to changing the dressing of a client with a burn injury?
give pain medication 30 minutes prior to dressing change
What PRIORITY complication would the nurse suspect when assessing a client with an electrical burn that has an entrance wound on the right shoulder and an exit wound through the left side ribs?
cardiac dysrhythmias
Which finding indicating infection in a client would the nurse report to the health care provider IMMEDIATELY?
changes in the quantity, color, or odor of exudate
Which instruction would the nurse give the assistive personnel (AP) about how to perform skin care on a client at risk for pressure injury because of immobility and incontinence?
clean the skin and moisturize with dimethazone, zinc oxide, lanoline, or petrolatum
Which client would the nurse monitor carefully when continuous negative-pressure wound therapy (NPWT) is used to facilitate healing?
client receiving anticoagulation
Which expected outcomes are appropriate for a client with a pressure injury?
client will remain free from local or systemic infections client will re-establish the skin tissue integrity and restore skin barrier function client's wound will show granulation and decrease in size
For which client would the nurse notify the primary health care providers when a Zostavax vaccine for shingles is prescribed?
client with immunosuppression
Which assessment techniques would the nurse use when checking a client with dark skin for inflammation?
compare the affected area with nonaffected area for increased warmth compare the skin color of affected area with the same area on the opposite side examine the skin of the affected area to see if it is shiny, taut, or pits with pressure
When caring for an older adult, what skin change would cause the nurse to keep the client's room warmer?
decreased layer of subcutaneous fat
Which term would the nurse use to document a client's skin lesion that are widespread involving most of the body?
diffuse
What does the nurse suspect when a client has skin that is tight and shiny over the lower extremities?
fluid retention and edema
Which client does the nurse consider to be HIGHEST risk for development of skin cancer?
light-skinned female who works as a lifeguard every summer
Which conditions will the nurse consider to be contributing factors for a client with chronic pressure injuries?
malnutrition peripheral vascular disease incontinence immobility prolonged bedrest
Which assessment finding does the nurse use a the BEST indicator of a client's healthy nails?
nail bed blanches with gentle pressure
Which teaching strategies would the nurse include when instructing clients about how to prevent burn injuries?
never add a flammable substance to an open flame use sunscreen and protective clothes to avoid sunburn avoid smoking when drinking alcohol or taking drugs that induce sleep when space heaters are used, keep flammable objects away from them if using home oxygen, do not smoke in the room where the oxygen is in use
How does the nurse determine which dressing is BEST for a client with a stage 3 pressure injury over the left trochanter area that has a thick exudate?
obtain a prescription to consult with the certified wound care specialist
What would the nurse be sure to do before documenting a client's pressure injury changes with a series of photographs?
obtain informed consent from the client
For which client will the nurse instruct the assistive personnel (AP) to use a life sheet when assisting with movement in bed?
older adult client on steroids with thin, fragile skin
Which clients with pressure injuries would the nurse asses as at HIGH risk for development of infection?
older client with low white blood cell (WBC) count client with type 1 diabetes mellitus client with chronic obstructive pulmonary disease (COPD) on steroids older client with large abdominal incision who needs help with reposititioning
What are of a dark-skinned client would the nurse assess for petechiae when the client is at risk for thrombocytopenia?
oral mucosa
Which intervention would the nurse use to reduce shearing force for an obese client who is on bedrest for the next 3 days?
place the client in aside-lying position at a 30-degree tilt
Which laboratory test would the nurse be sure to check when finding a large area of ecchymoses while assessing a client?
platelet count
What changes in color does the nurse expect when assessing a client polycythemia vera?
reddish blue generalized skin color dark red nail beds
Which finding when the nurse assesses a nevus on a client's back would be of concern and warrant further investigation?
report of itching and bleeding
Which preprocedural teaching will the nurse provide for a client suspected of a bacterial cellulitis?
the primary health care provider will inject bacteriostatic saline, withdraw it, and send the aspirate to the lab for culture
For a DECREASE in which integumentary factor would the nurse avoid taping the skin on an older client?
thickness of epidermis
Which medical-surgical concept would the nurse designate as the HIGHEST priority for a client with pressure injuries of both heels?
tissue integrity
what is the priority medical/ surgical concept when the nurse assesses a client and finds reddened scratch marks on the right forearm?
tissue integrity
Which technique would the nurse use to check for tunneling when assessing a large pressure injury on a client's hip with a small opening in the skin draining purulent material?
use a sterile cotton-tipped applicator to probe gently for the tunnel
Which interventions would the nurse use to PREVENT HARM from the development of a pressure injury in a client with a prolonged coma?
use pillows or padding devices to keep the client's heels free from pressure when positioning a client on his or her side, position at a 30-degree tilt turn and reposition the client at least every 2 hours during all shifts place pillows or foam wedges between two bony surfaces or between bony surfaces and the bed
Which speciment would the nurse instruct the assistive personnel (AP) to IMMEDIATELY place on ice and transport to the lab as soon as possible?
vesicle fluid taken by sterile technique and placed in a viral culture tube
Which actions would the nurse teach a client and family to use to stop the spread of methicillin-resistant Staphylococcus aureaus (MRSA)?
wash your hands with soap and warm water before and after touching the infected area of handling the bandages shower (rather than bathe) daily, using an antibacterial soap sleep in a separate bed from others until the infection is cleared do not share clothing, washcloths, towels, athletic equipment, shavers or razors, or any other personal items avoid close contact with others, including participation in group sports, until the infection has cleared wash all soiled clothing and linens with hot water and laundry detergent. Dry clothing either in a hot dryer or outside on a clothesline in the sun.
What PRIORITY instruction would the nurse provide the assistive personnel (AP) who is to bathe a client with skin that is not intact and draining?
wear clean gloves and use Standard Precautions
When would the nurse expect to culture a client's pressure injury wound?
when clinical or systemic signs of infection area present
What skin manifestations does the nurse expect to observe in a client during an impending shock?
white, pale, blue skin
