Chapter 25

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required?

"A tanning bed will supply the ultraviolet light I need." Ultraviolet radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients. This statement indicates that the client requires further teaching. Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis.

In teaching a client about primary prevention of skin cancer, which instruction does the nurse include?

"Avoid sun exposure between 11 a.m. and 3 p.m." The nurse teaches the client that the sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time. Skin should be examined at least monthly. A total body spot and lesion map is used for secondary prevention. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

A client with a bacterial skin infection is being taught home care for treatment of this infection. Which statement by the client indicates a need for further teaching?

"I may stop using the topical antibiotic when the lesions disappear." The statement by the client that, "I may stop using the topical antibiotic when the lesions disappear," indicates the need for further teaching. The antibiotic should be used for the time prescribed and not just until the lesions seem to be resolved. Clients should be taught to remove crusts before applying the medication to improve absorption. If signs of systemic disease occur, the client should contact the provider since oral antibiotics may be necessary. Covering the lesions will help prevent spread to others.

Which statement by a client with psoriasis indicates that teaching about the condition has been effective?

"I should practice good handwashing technique." Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection. Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.

A young client has been diagnosed with tinea corporis (ringworm), but the mother would like the child to return to school. To avoid spreading the infection, what does the nurse suggest to the mother?

"Keep the site covered with a bandage." Keeping the site covered with a bandage prevents spread of the infection. Frequent handwashing is not the best suggestion in this case. Keeping the child isolated from the other children in school or keeping the child out of school is not necessary.

The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include?

Avoiding or reducing skin exposure to sunlight Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily. Avoiding tanning beds is significant, but is not the most important technique. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important.

A client has an odorous, purulent wound. How does the nurse best support this client?

Changes the dressing frequently The nurse knows that frequent dressing changes help with healing and help the client feel clean. This is the best method of support for this client. A diet high in protein would not be directly helpful for this client. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first?

Clean and dry the client's skin. Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection. Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus infection. The nurse plans to include which instruction in the client's teaching plan?

Cover the infected area with a clean, dry bandage. The nurse includes the instruction that the infected area should be covered with a clean, dry bandage to prevent the spread of infection. The client should shower rather than take a tub bath, using an antibacterial soap. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. Bath sponges or puffs should be avoided because they cannot be laundered. Washcloths should be used only once before laundering.

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home?

Determines whether the client can reach the affected area Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to independently perform frequent dressing changes at home. The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. A demonstration of how to change the dressing and providing the dressing materials are a good start, but they do not assess the client's ability to perform the task himself.

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response?

Encourages participation in care of the wound The nurse's best response is to encourage client participation in wound care. This gives the client a sense of autonomy. Encouraging visitors is not the best suggestion for this client. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing. Assuring the client that everything will be all right not only fails to address the underlying issue, but also may be untrue.

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant?

Every 2 hours, reposition a client who has had a stroke and is incontinent. The nurse can delegate repositioning a client to a nursing assistant. A nursing assistant has the education and scope of practice to perform such a task. Using the Braden Scale, changing a sterile dressing, and client admissions are actions that should be done by licensed nursing staff who have broader education and scope of practice.

The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy?

Hyperbaric oxygen Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers. Nutrition therapy can be implemented for all types of wound healing. Topical growth factors are typically used for clean, surgically débrided chronic wounds. Vacuum-assisted wound closure is typically used with chronic ulcers.

The nurse is teaching a client who has loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy does the nurse include in the client's teaching plan?

Lift hips off the chair at least every hour. The daily prevention strategy the nurse includes in the client's teaching plan is that the client will lift the hips off the chair at least every hour to relieve pressure and help prevent pressure ulcers. Eating a low-fat diet is not a daily prevention strategy for skin integrity. Reddened areas should never be massaged. Pressure mapping is not a daily activity and is not performed by the client.

The nursing instructor reviews instructions with the nursing student about caring for an older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client?

Massages bony prominences Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears. The nursing instructor needs to make sure that the student is aware of this fact. Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The client should be repositioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. Using a moisturizing lotion is appropriate.

A client has had a melanoma lesion removed. For secondary prevention, what is most important for the nurse to teach the client?

Perform a total skin self-examination monthly with a partner. The nurse teaches the client that performing a monthly total skin self-examination with another person is the best secondary preventive measure.If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. Genetic testing of lesions is performed to determine whether targeted therapy will be effective.

An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for?

Pressure ulcer development This client is at risk for developing pressure ulcers related to protein deficiency if he or she remains bedridden. Anemia and weight gain have no correlation with this client's protein deficiency. The client does not have an indicated wound.

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II?

Promote mobility and/or frequent repositioning. Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer. Reddened areas should never be massaged. Padding the ulcer may not be appropriate. An egg crate mattress may be suggested but is not the best option.

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention?

Second Second-intention healing is characterized by a cavity like defect frequently found in chronic pressure ulcers. This involves gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss. First-intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third-intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is débrided and inflammation subsides. There is no such thing as mixed-intention healing.

The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration?

Serum albumin Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian. Calcium, hematocrit, and WBC readings do not relate to successful pressure ulcer management.

The nurse is caring for a client who has several infected lesions on both arms. The client is afebrile and does not have enlarged regional lymph nodes. The nurse notifies the provider who will most likely order which medication?

Topical mupirocin Topical mupirocin is an antibiotic that is most likely to be ordered for a client with a mild bacterial skin infection without fever or lymphadenopathy. Recurrent or severe infections may be treated with oral amoxicillin. Clients with methicillin-resistant Staphylococcus aureus infections should be treated with oral linezolid or clindamycin or intravenous vancomycin if the infection is severe.

The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. What precaution will the nurse take while performing this dressing change?

Wearing disposable gloves The nurse will wear disposable gloves. Disposable gloves are necessary when changing a dressing on a wound infected with MRSA to prevent transmission to others. It is not necessary to wear a mask, since the infection is spread by direct contact with the infected material. Sterile technique is not indicated. Soiled dressings should be placed in a sealed plastic bag before discarding, and according to agency policy.