TB - Chapter 24: Assessment of the Skin, Hair, and Nails Chapter 25: Care of Patients with Skin Problems

10. A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel

ANS: Hemoglobin and hematocrit Pallor conjunctivae signifies anemia. The nurse should assess the clients hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this clients potential anemia.

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

ANS: - Assess staff for a history of or vaccination for chickenpox. - Check the admission orders for analgesia. - Ensure that gloves are available in the room. Herpes zoster (shingles) is caused by reactivation of the same virus, varicella zoster, in clients who have previously had chickenpox. Anyone who has not had the disease or has not been vaccinated for it is at high risk for getting chickenpox. Herpes zoster is very painful and requires analgesia. Use of gloves and good handwashing are sufficient to prevent spread. It is best to put this client in a private room. Herpes zoster is a disease of immune suppression, so no one who is immune-suppressed should be in the same room.

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

ANS: - Client with a left heel ulcer with slight necrosis Whirlpool treatments - Client with an eschar-covered sacral ulcer Surgical debridement Necrotic tissue should be removed so that healing can take place. Whirlpool treatment can gently remove the necrosis. A wound covered with eschar most likely needs surgical dbridement. Warm water would not be recommended for a client with erythema. A wet-to-dry dressing and a transparent film dressing are not appropriate for urticaria or pressure ulcers, respectively.

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

ANS: - Cool, moist compresses - Tepid bath with cornstarch For a client with eczematous dermatitis, the goal of comfort measures is to decrease inflammation and help dbride crusts and scales. The nurse should implement cool, moist compresses and tepid baths with additives such as cornstarch. 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.

5. A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients 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?

ANS: - Have you been under a lot of stress lately? - Have you recently had any other health problems? - Have you changed any medications recently? Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.

2. A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results

ANS: - Height - Alcohol use - Prealbumin laboratory results Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status should include a high-protein, high-calorie diet. To determine the clients nutritional status, the nurse should assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and obesity. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing.

5. A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions? a. Two 2-cm hyperpigmented patches b. Two 1-inch erythematous plaques c. Two 2-mm pigmented papules d. Two 1-inch moles

ANS: Two 2-cm hyperpigmented patches Patches are larger flat areas of the skin. The information provided does not indicate a mole or the presence of erythema.

1. A nurse assesses an older adults skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Increased presence of fungal toenails d. Lesion with various colorse. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

ANS: - Lesion with various colorse. Spider veins on legs - Asymmetric 6-mm dark lesion on forehead The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the American Cancer Societys hallmark signs for cancer according to the ABCD method. Other manifestations are variants of normal seen in various age groups.

3. A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Look for asymmetry of shape and irregular borders. b. Assess for color variation within each lesion. c. Examine the distribution of lesions over a section of the body. d. Monitor for edema or swelling of tissues. e. Focus your assessment on skin areas that itch.

ANS: - Look for asymmetry of shape and irregular borders. - Assess for color variation within each lesion. Clients should be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

2. A nurse plans care for a client who is immobile. Which interventions should the nurse include in this clients 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 clients heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

ANS: - Place a small pillow between bony surfaces. - Use a lift sheet to assist with re-positioning. - Keep the clients heels off the bed surfaces. 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 should 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 should be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.

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

ANS: - Use a lift sheet when moving the client in bed. - Avoid tape when applying dressings. - Implement pressure-relieving devices. Using a lift sheet will prevent shearing forces from tearing skin. Tape should be avoided so that the skin wont tear. Using pressure-relieving devices for clients who are at risk for pressure ulcer formation, including older adults, is a proactive approach to prevent skin breakdown. No contraindication to using whirlpool therapy for the older client is known. Dressings should be applied as prescribed, not so loose that they do not provide required treatment, and not so tight that they decrease blood flow to tissues.

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

ANS: - Wash your hands before touching the client. - Wear gloves when bathing the client. All health care providers should follow Standard Precautions when caring for clients who have any open skin areas. This includes hand hygiene and wearing gloves when in contact with the lesions. The UAP is not qualified to assess the clients skin. The other statements are not appropriate for the care of open skin lesions.

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

ANS: A 65-year-old with hemi-paralysis and incontinence Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.

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

ANS: After you bathe, put lotion on before your skin is totally dry. The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.

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

ANS: Apply a different pressure-relieving device. Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.

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

ANS: Assess the IV site at least every 2 hours for thrombophlebitis. Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to red man syndrome), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy.

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

ANS: Assess the right leg for pulses, skin color, and temperature. A client with an ulcer on the foot should 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.

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

ANS: Change the dressing every 6 hours. Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum dbridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.

9. A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder?a. Clean hair and nails b. Poor eye contact c. Disheveled appearance d. Drapes a scarf over the face

ANS: Clean hair and nails The nurse should complete a psychosocial assessment to determine if the client is coping effectively. Signs of adequate coping include clean hair, skin, and nails; good eye contact; and being socially active. A disheveled appearance and draping a scarf over the face to hide the clients appearance demonstrate that the client may be having difficulty coping with his or her condition.

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

ANS: Client admitted from a nursing home with furuncles and folliculitis The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs are visible at present. The rash following participation in a sporting event could be caused by several different things. A client with an elevated white blood cell count has the potential for infection but should be at lower risk for MRSA than the client admitted from the communal environment.

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

ANS: Client with a white blood cell count of 23,000/mm3 A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.

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

ANS: Contact the provider and express concerns related to the wound treatment prescribed. A client on anticoagulants is not a candidate for VAC because of the incidence of bleeding complications. The health care provider needs this information quickly to plan other therapy for the clients wound. The nurse should contact the wound care nurse after alternative orders for wound care are prescribed. Vital signs and telemetry monitoring is appropriate for a client who has a history of atrial fibrillation and should 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.

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

ANS: Fungal infection Ketoconazole (Nizoral) Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.

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

ANS: High-protein diet with vitamins and mineral supplements The preferred diet is high in protein to assist in wound healing and prevention of new wounds. Fat is also needed to ensure formation of cell membranes, so any of the options with low fat would not be good choices. A vegetarian diet would not provide fat and high levels of protein.

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

ANS: How are you coping with providing this care? 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. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wifes feelings and provide support for coping with changes. Asking about the clients toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregivers support and coping mechanisms and ability to continue to care for her husband.

4. After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition? a. This rash is probably due to fluid overload. b. I need to wash this daily with antibacterial soap. c. I can use powder to keep this area dry. d. I will schedule a mammogram as soon as I can.

ANS: I can use powder to keep this area dry. Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds.

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

ANS: I have to make sure I keep my lesions covered, so I do not spread this to others. Psoriasis 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, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division.

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

ANS: If his tailbone is red and tender in the morning, I will massage it with baby oil. Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a client at home.

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

ANS: Ill cleanse the area prior to applying antibiotic cream. Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.

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

ANS: Irregular blue mole with white specks on the lower leg This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of 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.

11. During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients chest. Which descriptors should the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed

ANS: Linear and circinate Diffuse is used to describe lesions that are widespread. Serpiginous describes lesions with wavy borders. Clustered describes lesions grouped together. Linear describes lesions occurring in a straight line. Annular lesions are ringlike with raised borders, circinate lesions are circular, and circumscribed lesions have well-defined sharp borders. Coalesced describes lesions that merge with one another and appear confluent.

6. While assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next? a. Ask about a family history of skin disorders. b. Palpate the clients pedal pulses bilaterally. c. Check for the presence of Homans sign. d. Assess the clients skin for adequate skin turgor.

ANS: Palpate the clients pedal pulses bilaterally. Localized, decreased skin temperature and pallor indicate interference with vascular flow to the region. The nurse should assess bilateral pedal pulses to screen for vascular sufficiency. Without adequate blood flow, the clients limb could be threatened. Asking about a family history of skin problems would not take priority over assessing blood flow. Homans sign is a screening tool for deep vein thrombosis and is often inaccurate. Skin turgor gives information about hydration status. This assessment may be needed but certainly does not take priority over assessing for blood flow.

12. A nurse assesses an older adult client with the skin disorder shown below: How should the nurse document this finding? a. Petechiae b. Ecchymoses c. Actinic lentigo d. Senile angiomas

ANS: Petechiae Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure, are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising. Actinic lentigo presents as paper-thin, transparent skin. Senile angiomas, also known as cherry angiomas, are red raised lesions.

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

ANS: Place the client in a single room. The clients presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the clients infectious disorder.

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

ANS: Punch skin biopsy This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Woods lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates erythema, making skin lesions easier to examine.

8. A nurse assesses a client who has open lesions. Which action should the nurse take first? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the clients pain. d. Obtain vital signs.

ANS: Put on gloves. Nurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The other options should be completed after gloves are put on.

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

ANS: Recent wound assessment, including size and appearance The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.

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

ANS: Request a dietary consult. 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 should request a dietary consult. The other interventions do not address the information provided.

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

ANS: Shake the clients hand and introduce self. Clients with psoriatic lesions are often self-conscious of their skin. The nurse should 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 should be completed after establishing a report with the client.

7. A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond? a. I will consult the chaplain to provide you with spiritual support. b. You do not need to go to church; God is everywhere. c. Tell me more about your concerns related to your skin. d. Religious people are nonjudgmental and will accept you.

ANS: Tell me more about your concerns related to your skin. Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses should assess how the clients skin changes are affecting the clients body image and encourage the client to express his or her feelings about a change in appearance. The other responses are not appropriate.

1. While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the clients oxygen saturation. c. Auscultate the clients lung fields for adventitious sounds. d. Palpate the clients bilateral radial and pedal pulses.

ANS: Use pulse oximetry to assess the clients oxygen saturation. Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse should assess for systemic oxygenation before continuing with other assessments.

2. A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition? a. What do you do for a living? b. Are your nails professionally manicured? c. Do you have diabetes mellitus? d. Have you had a recent fungal infection?

ANS: What do you do for a living? The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.

3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? a. Are you using lotion on your skin? b. Do you have a family history of this? c. Do your arms itch? d. What medications are you taking?

ANS: What medications are you taking? Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.

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

ANS: Which method of contraception are you using? Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin.

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

ANS: You can use tap water instead of sterile saline to clean your wound. For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.