Chapter 61: Management of Patients with Dermatologic Disorders

What should the nurse assess for to determine if a patient using corticosteroids for a dermatologic condition is having local side effects? Select all that apply.

- Skin atrophy - Striae - Telangiectasia Local side effects of topical corticosteroids may include skin atrophy and thinning, striae (bandlike streaks), and telangiectasias (small, red lesions caused by dilation of blood vessels).

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?

Antiviral Oral acyclovir (Zovirax), when taken within 48 hours of the appearance of symptoms, reduces their severity, and prevents the development of additional lesions. Corticosteroids, analgesics,, and antipyretics are not used for this purpose.

A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

Behind the ears Adult lice usually bite the scalp behind the ears and along the back of the neck. Because such lice are tiny (1 to 2 mm) with grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions. Although lice may bite any part of the scalp, bites are less common on the temporal area, top of the head, and middle area.

The nurse is conducting an admission history and physical examination of a client with a history of contact dermatitis. The nurse assesses whether the client uses which medication classification?

Corticosteroids Corticosteroids are used for contact dermatitis. Antifungals, antivirals, and saline irrigations are not used in the treatment of contact dermatitis.

Which of the following aggravates the condition caused by acne vulgaris?

Cosmetics Acne vulgaris is aggravated by cosmetics. Any correlation with specific food items such as chocolate is more myth than fact. Sunlight does not aggravate the condition caused by acne vulgaris.

A dermatologist recommends an over-the-counter suspension to relieve pruritus. The nurse advises the patient that the lotion should be applied:

Every 3 to 4 hours for sustained effectiveness. Lotions are frequently used to replenish lost skin oils or to relieve pruritus. They are usually applied directly to the skin, but a dressing soaked in the lotion can be placed on the affected area. Lotions must be applied every 3 or 4 hours for sustained therapeutic effect because if left in place for a long period, they may crust and cake on the skin.

Which of the following nonsedating antihistamines is appropriate for daytime pruritus?

Fexofenadine (Allegra) Nonsedating antihistamine medications such as Allegra are more appropriate to relieve daytime pruritus. Benadryl or Atarax, when prescribed in a sedative dose at bedtime, may be beneficial in producing a restful and comfortable sleep. Ativan has sedating properties and is used as an antianxiety medication.

Which drug is an oral retinoid used to treat acne?

Isotretinoin Isotretinoin, an oral retinoid, is used in clients diagnosed with nodular cystic acne that does not respond to conventional therapy. Estrogen, tetracycline, and benzoyl peroxide are not oral retinoids.

A patient is being evaluated for nodular cystic acne. What systemic pharmacologic agent may be prescribed for the treatment of this disorder?

Isotretinoin (Accutane) Synthetic vitamin A compounds (i.e., retinoids) are used with dramatic results in patients with nodular cystic acne unresponsive to conventional therapy. One compound is isotretinoin, which is used for active inflammatory popular pustular acne that has a tendency to scar. Isotretinoin reduces sebaceous gland size and inhibits sebum production. It also causes the epidermis to shed (epidermal desquamation), thereby unseating and expelling existing comedones.

Which of the following information regarding the transmission of lice would the nurse identify as a myth?

Lice can jump from one individual to another. The nurse is correct to identify that lice cannot jump from one individual to another. Direct contact is needed for transmission. The other options are correct.

Photochemotherapy has been used as a treatment for which of the following skin disorders?

Psoriasis Photochemotherapy is used for severe, disabling psoriasis that does not respond to other methods of treatments.

A patient is scheduled for Mohs microscopic surgery for removal of a skin cancer lesion on his forehead. The nurse knows to prepare the patient by explaining that this type of surgery requires:

Removal of the tumor, layer by layer. Mohs micrographic surgery removes the tumor layer by layer. The first layer excised includes all evident tumor and a small margin of normal-appearing tissue. The specimen is frozen and analyzed by section to determine if all the tumor has been removed. If not, additional layers of tissue are shaved and examined until all tissue margins are tumor-free.

The school nurse is instructing a parent in the care and elimination of lice from their child's hair. The parent brings all of the products for care in a bag. Which contents are not appropriate for use?

Shampoo and conditioner The nurse is correct to instruct the parent to avoid shampoo and conditioner because this coats the hair and protects the nits. Nix and a fine-toothed comb are recommended. New hair clips may be used once the infestation is gone.

To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application?

Tretinoin (retinoic acid [Retin-A]) Tretinoin is a topical agent applied nightly to treat acne vulgaris. Minoxidil promotes hair growth. Zinc oxide gelatin treats stasis dermatitis on the lower legs. Fluorouracil is an antineoplastic topical agent that treats superficial basal cell carcinoma.

A client is being treated for acne vulgaris. What contributes to follicular irritation?

overproduction of sebum The overproduction of sebum provides an ideal environment for bacterial growth within the irritated follicle. The follicle becomes further distended and irritated, causing a raised papule in the skin.

Which medication classification may be used for contact dermatitis?

Corticosteroids Corticosteroids are used for contact dermatitis. Antifungals, antivirals, and saline irrigations are not used in the treatment of contact dermatitis.

The nurse teaches the client who demonstrates herpes zoster (shingles) that

the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of the latent varicella (chickenpox) virus and reflects lowered immunity. It is believed that the varicella zoster virus lies dormant inside nerve cells near the brain and spinal cord and is reactivated with weakened immune systems and cancers. A person who has had chickenpox is immune and therefore not at risk of infection after exposure to clients with herpes zoster. Some evidence shows that infection is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

"All family members need to be treated." When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

The nurse is caring for a patient with extensive bullous lesions on the trunk and back. Prior to initiating skin care, what is a priority for the nurse to do?

Administer analgesic pain medication. The patient with painful and extensive lesions should be premedicated with analgesic agents before skin care is initiated.

A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?

"To prevent evaporation of water from the hydrated epidermis." The nurse should tell the client that applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer. Although emollients make the skin feel soft, this effect occurs whether or not the client has just bathed or showered. An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). An emollient doesn't prevent skin inflammation.

A nurse is assessing a client with a new skin disorder. Which questions would the nurse include when asking the client about the change in skin condition? Select all that apply.

- When did the disorder first begin, and where did it first appear? - Where are the lesions located? - Has the problem spread? - Have you tried to treat the lesions? The nurse would ask the client when and where the disorder started, where the lesions are located and if they have spread, and if the client has attempted to treat them. The client's exercise habits would not affect the skin disorder.

A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination can be used to determine if the rash is a fungal rash using ultraviolet light?

A Wood's light examination A Wood's light is also known as a black light and is a handheld device that can identify certain fungal infections that fluoresce under long-wave ultraviolet light. In a darkened room, when a physician or nurse aims the light at a lesion caused by a fungus that fluoresces, the lesion emits a blue-green color. It is the only test that uses a light, the others use skin scrapings.

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria?

Impetigo Impetigo is seen at all ages but is particularly common among children living under poor hygienic conditions. Scabies is caused by the itch mite. Pediculosis capitis is caused by head lice. Poison ivy is a contact dermatitis caused by the oleoresin given off by a particular form of ivy.

A nurse is admitting a client with toxic epidermal necrolysis. What is the nursing priority in preventing sepsis?

Preventing infection The major cause of death from toxic epidermal necrolysis is from sepsis. Monitoring vital signs closely and noticing changes in respiratory, kidney, and gastrointestinal function may help the nurse to quickly detect the beginning of an infection. Strict asepsis is always maintained during routine skin care measures. Hand hygiene and wearing sterile gloves when carrying out procedures are essential. Visitors should wear protective garments and wash their hands before and after coming into contact with the patient. People with any infections or infectious disease should not visit the patient until they are no longer a danger to the patient. The nurse is critical in identifying early signs and symptoms of infection and notifying the primary provider. Antibiotic agents are not generally begun until there is an indication for the use. Hemorrhage, renal failure, and liver failure are not the major causes of toxic epidermal necrolysis.

A nurse assesses a client with dry, rough, scaly skin without lesions and the presence of itching on the legs. What skin assessment would the nurse document?

Pruritus Pruritus (itching) is one of the most common symptoms of patients with dermatologic disorders. Itch receptors are unmyelinated, penicillate (brush-like) nerve endings that are found exclusively in the skin, mucous membranes, and cornea. Shingles is a skin condition with lesions. Candidiasis is a red condition often found in the folds of skin. Seborrhea refers to dry scaly patches usually located on the scalp.

A patient is diagnosed with psoriasis after developing scales on the scalp, elbows, and behind the knees. The patient asks the nurse where this was "caught." What is the best response by the nurse?

Psoriasis is an inflammatory dermatosis that results from an overproduction of keratin. Current evidence supports an autoimmune basis for psoriasis (Porth & Matfin, 2009). Periods of emotional stress and anxiety aggravate the condition, and trauma, infections, and seasonal and hormonal changes may also serve as triggers. In this disease, the epidermis becomes infiltrated by activated T cells and cytokines, resulting in both vascular engorgement and proliferation of keratinocytes. Epidermal hyperplasia results.

What advice should the nurse give a client with dermatitis until the etiology of the dermatitis is identified?

Wear rubber gloves when in contact with soaps. The nurse should advise the client to wear rubber gloves when coming in contact with any substance such as soap or solvents. The client should avoid wool, synthetics, and other dense fibers. The client should use tepid bath water and should pat rather than rub the skin dry.

The classic lesions of impetigo manifest as

honey-yellow crusted lesions on an erythematous base. The classic lesions of impetigo are honey-yellow crusted lesions on an erythematous base. Comedones in the facial area are representative of acne. A carbuncle is an abscess of skin and subcutaneous tissue. Herpes zoster is exhibited by patches of grouped vesicles on red and swollen skin.

The nurse notes that the client's lower extremities are covered with very dry skin and that the horny layer of the skin has become thickened. The nurse notes the finding as

lichenification. The nurse should note this as being lichenification, also called scaling. Dermatitis is an inflammation of the skin. Acantholysis is a separation of the epidermal cells from each other, and pyodermas is a bacterial skin infection.

A client is undergoing photochemotherapy involving a combination of a photosensitizing chemical and ultraviolet light. What health problem does this client most likely have?

psoriasis Photochemotherapy is used to treat psoriasis.