Chapter 61
An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this residents plan of care?
Avoid using hot water during the patients baths.
A nurse is planning the care of a patient with herpes zoster. What medication, if administered within the first 24 hours of the initial eruption, can arrest herpes zoster?
Acyclovir (Zovirax)
A nurse educator is teaching a group of medical nurses about Kaposis sarcoma. What would the educator identify as characteristics of endemic Kaposis sarcoma? Select all that apply.
Affects people predominantly in the eastern half of Africa Affects men more than women Can progress to lymphadenopathic forms
A patient requires a full-thickness graft to cover a chronic wound. How is the donor site selected?
An area matching the color and texture of the skin at the surgical site is selected.
A patient has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?
Anticipate the need for, and administer, appropriate analgesic medications.
A nurse is caring for a patient who has a diagnosis of bullous pemphigoid and who is being treated on the medical unit. When providing hygiene for this patient, the nurse should perform which of the following actions?
Apply cornstarch to the patients skin after bathing to facilitate mobility.
A nurse is providing care for a patient who has psoriasis. The nurse is aware of the sequelae that can result from this health problem. Following the appearance of skin lesions, the nurse should prioritize what assessment?
Assessment of the patients joints for pain and decreased range of motion
When writing a plan of care for a patient with psoriasis, the nurse would know that an appropriate nursing diagnosis for this patient would be what?
Impaired Skin Integrity Related to Scaly Lesions
A patient comes to the dermatology clinic requesting the removal of a port-wine stain on his right cheek. The nurse knows that the procedure especially useful in treating cutaneous vascular lesions such as port-wine stains is what?
Laser treatment
While performing an initial assessment of a patient admitted with appendicitis, the nurse observes an elevated blue-black lesion on the patients ear. The nurse knows that this lesion is consistent with what type of skin cancer?
Malignant melanoma
A nurse practitioner is seeing a 16-year-old male patient who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?
Benzoyl peroxide and erythromycin (Benzamycin)
A patient has just been diagnosed with psoriasis and frequently has lesions around his right eye. What should the nurse teach the patient about topical corticosteroid use on these lesions?
Cataract development is possible.
A 65-year-old man presents at the clinic complaining of nodules on both legs. The man tells the nurse that his son, who is in medical school, encouraged him to seek prompt care and told him that the nodules are related to the fact that he is Jewish. What health problem should the nurse suspect?
Classic Kaposis sarcoma
A patient comes to the clinic complaining of a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with herpes zoster?
Grouped vesicles in linear patches along a dermatome
A patient has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the patients subsequent care?
Helping the patient identify and avoid the offending agent
A 35-year-old kidney transplant patient comes to the clinic exhibiting new skin lesions. The diagnosis is Kaposis sarcoma. The nurse caring for this patient recognizes that this is what type of Kaposis sarcoma?
Immunosuppression-related
A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?
Nits may have to be manually removed from the childs hair shafts.
A patient diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?
Perform hand hygiene.
A patient with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction should the nurse include in home care instructions?
Protect the graft from direct sunlight and temperature extremes.
A patients blistering disorder has resulted in the formation of multiple lesions in the patients mouth. What intervention should be included in the patients plan of care?
Provide chlorhexidine solution for rinsing the patients mouth.
A patient is admitted to the intensive care unit with what is thought to be toxic epidermal necrolysis (TEN). When assessing the health history of the patient, the nurse would be alert to what precipitating factor?
Recent administration of new medications
A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond?
Remind the patient of the need to immobilize the graft to facilitate healing.
A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply.
Risk for Infection Related to Lesions Impaired Skin Integrity Related to Epidermal Blisters Disturbed Body Image Related to Presence of Skin Lesions Acute Pain Related to Disruption in Skin Integrity
A patient with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse should anticipate that treatment for this type of cancer will primarily consist of what intervention?
Surgical excision
A nurse is caring for a patient whose skin cancer will soon be removed by excision. Which of the following actions should the nurse perform?
Teach the patient about self-care after treatment.
A nurse is working with a family whose 5 year-old daughter has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care?
Teaching about the importance of maintaining high standards of hygiene
A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants risks of basal cell carcinoma (BCC)?
Teaching participants to limit their sun exposure
A patient who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Disturbed Body Image Related to Disfigurement. What would be an appropriate nursing intervention related to this diagnosis?
Teaching the patient how to use and care for the prosthesis
A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient?
Wash your face with water and gentle soap each morning and evening.
A patient has just been told that he has malignant melanoma. The nurse caring for this patient should anticipate that the patient will undergo what treatment?
Wide excision
A 55-year-old woman is scheduled to have a chemical face peel. The nurse is aware that the patient is likely seeking treatment for which of the following?
Wrinkles near the lips and eyes
When caring for a patient with toxic epidermal necrolysis (TEN), the critical care nurse assesses frequently for high fever, tachycardia, and extreme weakness and fatigue. The nurse is aware that these findings are potential indicators of what? Select all that apply.
Epidermal necrosis Increased metabolic needs Possible gastrointestinal mucosal sloughing
A patient has recently been diagnosed with advanced malignant melanoma and is scheduled for a wide excision of the tumor on her chest. In writing the plan of care for this patient, what major nursing diagnosis should the nurse include?
Deficient Knowledge about Early Signs of Melanoma
A nurse is assessing a teenage patient with acne vulgaris. The patients mother states, I keep telling him that this is what happens when you eat as much chocolate as he does. What aspect of the pathophysiology of acne should inform the nurses response?
Diet is thought to play a minimal role in the development of acne.
A patient has a diagnosis of seborrhea and has been referred to the dermatology clinic, where the nurse contributes to care. When planning this patients care, the nurse should include which of the following nursing diagnoses?
Disturbed Body Image Related to Excess Sebum Production
A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?
Educating participants about the early signs and symptoms of skin cancer
A nurse is providing care for a patient who has developed Kaposis sarcoma secondary to HIV infection. The nurse should be aware that this form of malignancy originates in what part of the body?
Endothelial cells lining small blood vessels
A 30-year-old male patient has just returned from the operating room after having a flap done following a motorcycle accident. The patients wife asks the nurse about the major complications following this type of surgery. What would be the nurses best response?
The major complication is when the blood supply fails and the tissue in the flap dies.
A patient presents at the free clinic with a black, wart-like lesion on his face, stating, Ive done some research, and Im pretty sure I have malignant melanoma. Subsequent diagnostic testing results in a diagnosis of seborrheic keratosis. The nurse should recognize what significance of this diagnosis?
The patient requires no treatment unless he finds the lesion to be cosmetically unacceptable.
A nurse is caring for a patient who has been diagnosed with psoriasis. The nurse is creating an education plan for the patient. What information should be included in this plan?
Use caution when taking nonprescription medications.
