Chapter 14: Promoting Healthy Skin
The nurse monitors for which clinical indicator when the older adult complains of pruritus? a. Coarse skin b. Brown macule c. Brownish skin d. Regional edema
ANS: A The nurse is alert for rough, dry, flaky skin when an older adult complains of pruritus to be able to prevent linear excoriation leading to skin breaks, excoriation, inflammation, and infection. A brown macule is a freckle or a liver spot, an indication of sun exposure. Brownish skin is a clinical indicator of venous insufficiency. Regional edema is a sign of fluid overload and venous insufficiency; localized edema is a sign of infection.
An older person is admitted to the hospital with an exacerbation of congestive heart failure. The nurse notes that the patient complains of severe itching at night and has a red rash on her torso. The patient is diagnosed with scabies. The patient asks the nurse, "How did I get something like this?" The best response by the nurse is: a. "Scabies is highly contagious and spreads easily through physical contact." b. "Scabies is commonly seen in older adults due to normal age-related changes in the skin." c. "Scabies is only seen in older adults who have multiple chronic illnesses." d. "Certain medications can make you more susceptible to contracting scabies."
ANS: A Scabies is caused by a tiny burrowing mite and is highly contagious and easily passed by an infected person to family members and others in close contact by direct physical content. It is not limited to older adults, and age-related changes in the skin do not cause it or make a person more susceptible. Individuals with multiple chronic conditions are not more likely to develop scabies than other individuals. There is no evidence that medications can make an individual more susceptible.
A nurse will be conducting an educational session on preventing skin cancer at a local senior citizen's center. Which should the nurse include in the session? a. Squamous cell cancer may appear similar to a wart. b. Basal cell carcinoma is more common in women. c. Actinic keratosis begins as a pearly papule. d. Melanoma is characterized by rough, scaly patches.
ANS: A Squamous cell lesion may appear like a wart and be hard with defined borders. Basal cell carcinoma is more prevalent in fair-skinned older men and begins as a pearly papule. A multicolored, raised lesion with asymmetrical borders characterizes melanoma.
6. The nurse plans care to protect the skin covering an older adult's greater trochanter. Which of the following interventions is the nurse's priority when the older adult is positioned on the side? a. Implement a turning schedule. b. Place a cushion between the knees. c. Keep the skin clean and dry. d. Use the Sims' position.
ANS: A The most important nursing intervention when an older adult is positioned on the side is to relieve pressure on the head of the femur and the greater trochanter; the greater trochanter is the most prominent bony projection on the side of a body. By turning the older adult at intervals, the nurse helps maintain tissue perfusion, thus providing oxygenation to tissues and allowing the removal of waste from vulnerable skin. The nurse places a pillow between the knees to help maintain physiological body alignment and to prevent strain on the hips and spine; if positioned properly, the pillow can help maintain tissue integrity of the medial malleolus and ankle by elevating them off the mattress. However, because the nurse's priority is to maintain tissue oxygenation, preventing muscle and joint strain is not as important. The nurse keeps the skin clean and dry to help maintain skin integrity, but this intervention is not as important as maintaining tissue oxygenation. The nurse uses the Sims' position to supplement turning; when in the Sims' position, the patient is on the side but rotated slightly forward, allowing the chest and abdomen to fall forward to relieve some of the pressure on the patient's side.
Although intact skin effectively protects an individual, it functions within physiological limits. Which qualities of healthy skin work synergistically within these limits to absorb, cushion against, deflect, or neutralize potentially harmful forces, as well as protect against potentially harmful substances that might impair skin integrity? (Select all that apply.) a. Strength b. Pliability c. Location d. Durability e. Moistness f. Pigmentation
ANS: A, B, D Skin must be strong enough to withstand forces that can impair its integrity. If skin is not supple, then it is unable to withstand directional forces and will tear. Skin must be sturdy enough to act as an effective protective mechanism. All skin must be able to absorb, cushion, and withstand forces. Skin in a moist environment is subject to bacterial and fungal overgrowth. Skin pigmentation is unrelated to its ability to cushion, absorb, and withstand potentially harmful substances and forces.
The nurse identifies which of the following interventions in the treatment of fungal infections? (Select all that apply.) a. Eliminate the conditions that created the problem. b. Lubricate the affected area daily with moisturizing lotion. c. Thoroughly clean and dry the skin daily. d. Use an antibacterial cleanser daily. e. Apply miconazole (Micatin) as directed.
ANS: A, C, E Eliminating the conditions that created the problem will decrease the occurrences. The skin should be cleaned with a mild soap or cleansing agent daily, and the skin should be thoroughly dried. Lotion should not be used because it traps moisture. Antifungal medications should be used 7 to 14 days or until the fungal infection is completely cleared.
. For which of the following conditions does the nurse identify the patient as at risk for developing fungal infections? (Select all that apply.) a. Obesity b. Multiple sclerosis c. Impaired mental status d. Incontinent e. Bedridden
ANS: A, D, E Prevention is prioritized for persons who are obese, bedridden, incontinent, or diaphoretic. Patients with multiple sclerosis may develop skin infections but are not at high risk. Patients with an impaired mental status can often be incontinent, but this condition in itself does not predispose the patient to fungal infections.
An older patient complains of dry skin and asks for advice. Which advice should the nurse offer for improving dry skin? a. Add oil to the bath water to keep skin soft. b. Use tepid bath water. c. Move to a climate with lower humidity. d. Vigorously dry skin with a rough towel after bathing.
ANS: B Tepid bath water minimizes moisture loss from skin. Oil added to the bathtub increases the risk of slipping and falling, which can result in a catastrophic injury. Oils should be applied directly to moist skin after bathing. Humidity should be maintained at approximately 60%; the person may not be able to move. Vigorous, rough towel drying increases skin irritation
A dermatologist should promptly evaluate which one of the following skin lesions? a. Circumscribed, raised area resembling a blob of brown wax b. Multicolored raised lesion with a fuzzy border c. Bright red, glazed area with satellite lesions around it d. Brown spot on the skin with no raised area
ANS: B A multicolored raised lesion with a fuzzy border must be promptly evaluated; this lesion is a malignant melanoma. A circumscribed, raised area resembling a blob of brown wax reflects seborrheic keratosis. A bright red, glazed area with satellite lesions around it is a Candida infection. A brown spot on the skin with no raised area, such as a freckle, is lentigo.
A nurse is providing an educational session on vaccines to a group of older adults. The nurse is discussing the zoster vaccine (Zostavax). Which of the following information should the nurse include in the education? a. Zostavax should only be given to individuals who have never had an episode of herpes zoster (HZ). b. Zostavax is recommended for all individuals older than 60 years of age that have no contraindications to the vaccine. c. Zostavax should not be given to anyone with a chronic cardiac or respiratory condition. d. Zostavax will always prevent an individual from developing herpes zoster
ANS: B Zostavax is recommended for all persons 60 years of age and older who have no contraindications to the vaccine including persons with a previous episode of herpes zoster (HZ) and those with chronic conditions. The vaccine does not guarantee that an individual will not get HZ; however, individuals who get the vac
The nurse determines the risk for a pressure ulcer in an older adult who is 6 feet tall and weighs 155 lb. Which patient information should the nurse use in planning care to reduce this individual's risk for a pressure ulcer? (Select all that apply.) a. Osteoarthritis of the neck b. Dry mucous membranes c. Prealbumin level of 7 mg/dL d. Fasting glucose of 140 mg/dL e. Serum sodium of 135 mEq/dL f. Uses food stamps to get food
ANS: B, C, D, F One area of concern the nurse should address is the potential for skin breakdown related to possible pain or immobility caused by arthritic changes. The nurse also plans care to address dehydration as a significant risk factor for pressure ulcers because this man is underweight, malnourished, and dehydrated as evidenced by dry mucous membranes. Dehydration increases the risk for pressure ulcers because water is essential for intracellular functioning and cell durability. The nurse plans care based on the assessment of hypoproteinemia because this man is underweight and malnourished, significantly increasing his risk for pressure ulcers. A fasting glucose level showing hyperglycemia is a clinical indicator of diabetes mellitus; therefore, the nurse plans care to manage the hyperglycemia. Diabetes mellitus increases the risk of pressure ulcers as a result of the greater likelihood of impaired tissue perfusion, impaired wound healing, and a greater occurrence of peripheral neuropathies. In addition, impaired tissue sensation as a result of nerve damage from hyperglycemia increases the risk of injury and infection for individuals with diabetes mellitus. A characteristic of type 1 diabetes mellitus is a low weight-for-height ratio. This man has limited resources for obtaining food, considering that he uses food stamps, and is therefore at risk for malnutrition, which increases the risk for pressure ulcers. Osteoarthritis in the neck is not related to the nursing care planned to reduce the risk for pressure ulcers; it should not impair this older adult's mobility or ability to obtain and prepare food. His sodium level is within normal limits.
Which of the following is a true statement about impaired skin integrity? a. Stage III pressure ulcer cannot regress to stage II because the subcutaneous tissues regenerate . b. Stasis ulcer is another term for pressure ulcer. c. Muscle and fat cannot regenerate. d. Weight reduction is recommended to help prevent pressure ulcers.
ANS: C Because subcutaneous tissues such as muscle and fat are not regenerated but simply replaced by granular tissue, the staging of pressure ulcers is never reversed. Stasis ulcers are the result of the leakage of blood from veins beneath the skin. Pressure ulcers are caused when perfusion to the tissue is impaired by external pressure that causes tissue injury and death. Sufficient nutrition is essential in maintaining skin integrity
Which of the following is a true statement about skin care for older adults? a. A licensed practical nurse is qualified to care for the feet of a patient with diabetes. b. Onychomycosis is quickly eradicated with antifungal creams or powders. c. A ram's-horn nail should be cut to give a smooth, rounded edge. d. Maintaining oral hydration may reduce the incidence of xerosis.
ANS: C Because subcutaneous tissues such as muscle and fat are not regenerated but simply replaced by granular tissue, the staging of pressure ulcers is never reversed. Stasis ulcers are the result of the leakage of blood from veins beneath the skin. Pressure ulcers are caused when perfusion to the tissue is impaired by external pressure that causes tissue injury and death. Sufficient nutrition is essential in maintaining skin integrity
Which nursing intervention is most likely to prevent the creation of an environment conducive to fungal growth? a. Provide oral care with soft-bristled brush. b. Apply nystatin powder to reddened tissue. c. Use mild skin cleansing agents and blot dry. d. Apply gauze soaked with antifungal lotion.
ANS: C Fungal infections are most likely to begin in moist, dark areas of the body such as under the breasts and at the perineum; thus, the nurse works to keep the skin of these areas, as well as all skin, clean and dry and to prevent tissue irritation from harsh drying. Providing oral care with a soft-bristled brush is ineffective therapy for preventing an oral Candida infection (thrush). Besides, thrush is usually an opportunistic infection caused by immunosuppression. Reddened tissue can be already infected; nonetheless, applying an antifungal agent is an indicated treatment for a fungal infection. Applying antifungal lotion and keeping an area moist can contribute to fungal overgrowth.
An older adult is vitamin deficient. Which of the following does the nurse offer to the older adult to provide the important missing vitamin for maintaining healthy skin and enhancing tissue repair? a. Carrot sticks b. Nonfat milk c. Orange slices d. Unsalted nuts
ANS: C Orange slices provide vitamin C, which is important for healthy tissues and gums, tissue repair and healing, and the maintenance of blood vessels. Although carrots sticks are a good source of beta carotene, fiber, and vitamin A and important in the formation of epithelial tissue and although milk provides calcium for bone strength and protein for tissue repair, neither carrots nor milk addresses vitamin deficiency. Unsalted nuts provide healthy fats, fiber, and other nutrients but not vitamin C.
The nurse is conducting an admission assessment on an older adult and notes a small lesion with a multicolor appearance. Which assessment approach should the nurse use? a. Braden scale b. Wound staging c. ABCD (asymmetry, border, color, diameter) rule d. Pressure ulcer scale for healing (PUSH) tool
ANS: C The ABCD rule is used to assess potential cancerous lesions for asymmetry, border irregularity, color, and diameter. The Braden scale is used for predicting pressure ulcers. Wound staging is used during the assessment of pressure ulcers. The PUSH tool provides a detailed form that covers all aspects of an assessment.
Which of the following is an important consideration about the skin of older adults? a. Generous amounts of soap should be used for cleansing. b. Sweat gland activity increases. c. Skin becomes more vulnerable to damage. d. Skin becomes darker in unexposed areas.
ANS: C Thin skin-reduced sebaceous protection, vascular insufficiency, and longer periods in stationary positions promote skin damage for older adults. Because moisture is lost more rapidly from the skin of older adults, excessive use of soap tends to dehydrate the skin more severely than it does in younger people. Sweat gland activity does not increase in older age, but moisture is lost more rapidly because the skin is thinner and sebum secretion is reduced. Changes of skin color in areas exposed to the sun are of greater concern than those in unexposed areas.
Which infection-control practice should the nurse implement when caring for an older adult who has active herpes zoster? a. Wear a face shield and gown for all patient contact. b. Instruct the staff and visitors to wear a type of respirator mask. c. Use a hospital room that has negative airflow circulation. d. Cover ruptured skin lesions with a nonabsorbent dressing.
ANS: D Herpes zoster in an adult is spread through contact; therefore, the nurse applies the principles of contact precautions when caring for an older adult with active herpes zoster. To reduce the transmission of the virus through contact, the nurse keeps the ruptured lesions covered. A face shield is not necessary when caring for an adult with herpes zoster; however, a gown can be necessary during dressing changes or any time that splashing can occur. Airborne precautions and a respirator-type mask are indicated for infections transmitted through the air. Because active herpes zoster in an older adult is transmitted through contact, negative airflow is not indicated.
The nurse cares for an older man who has a malignant melanoma. Which intervention should the nurse implement for this man to prevent a recurrence or advancement of this condition in the future? a. Place posters about sunscreen in the halls of his apartment building. b. Promote the application of a sunscreen at his neighborhood health fair. c. Tell him to schedule all outdoor activities after 4 PM daily. d. Instruct him to wear sun-protective clothing and a hat at all times
ANS: D The nurse caring for an older adult in acute care instructs him to wear sun-protective garments at all times to help prevent additional skin cancers, as well as apply an effective sunscreen to protect his skin against ultraviolet light. Placing posters and promoting sunscreen at a health fair are interventions for a community nurse. Scheduling activities after a specific time can be impractical or impossible.