Chp 25- Skin Problems

The nurse is teaching a client with 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? A) Lift hips off the chair at least every hour. B) Eat a low-fat diet. C) Massage reddened areas. D) Complete a pressure map.

A Lifting the hips off the chair at least every hour relieves pressure and can 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 on 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? A) Massages bony prominences B) Avoids reddened areas C) Re-positions the client every 1 to 2 hours D) Uses a moisturizing lotion

A Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears. Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The client should be re-positioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. Using a moisturizing lotion is appropriate.

In teaching a client about skin cancer prevention, which instruction does the nurse include? A) "Avoid sun exposure between 11 a.m. and 3 p.m." B) "Examine your skin quarterly for possible cancerous or precancerous lesions." C) "Wear transparent clothing to protect your skin from the sun." D) "If you feel you must tan, use a tanning bed."

A 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. Opaque clothing should be worn to protect the skin from the sun. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

A client with bacteremia associated with a bacterial skin infection is receiving clindamycin (Cleocin) intravenously. Which assessment finding indicates the need for immediate action by the nurse? A)Blood pressure of 88/40 mm Hg B) White blood cell count of 15,000/mm3 C)Oral temperature of 101° F (38.3° C) D) Heart rate of 102 beats/min

A Too-rapid administration of clindamycin can cause shock and cardiac arrest; the client's low blood pressure indicates a need to slow the rate and re-assess the client. An elevated white blood cell count, an elevated temperature, and an elevated heart rate are expected findings in a client with bacteremia.

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? A) "A tanning bed will supply the ultraviolet light I need." B) "Medicine can prevent the growth of new skin cells." C) "I can never be cured." D) "Stress can cause my flare-ups."

A) 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.

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? A) "Wash your hands frequently." B) "Your child may return to school, but must be isolated from the rest of the class." C) "Keep the site covered with a bandage." D) "Keep your child out of school until the infection has cleared."

C Keeping the site covered 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.

An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for? A) Anemia B) Decreased wound healing C) Pressure ulcer development D) Weight gain

C This client is at risk for pressure ulcer 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.

The nurse prepares to administer vancomycin (Vancocin) to a client diagnosed with methicillin-resistant Staphylococcus aureus infection. How does the nurse administer this medication? A By bolus B IV push C Infused over 60 minutes D Mix with the primary IV bag

C Vancomycin is irritating to the veins and can trigger thrombophlebitis; it should be given over at least 60 minutes. Vancomycin should not be given by bolus or by IV push, and it should not be mixed with the primary IV bag. It is administered IV piggyback or through a saline or heparin lock.

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? A) Use the Braden Scale to determine pressure ulcer risk for a newly admitted client. B) Complete daily sterile dressing changes for a client with a venous leg ulcer. C) Every 2 hours, re-position a client who has had a stroke and is incontinent. D) Admit a newly transferred client who had pedicle flap surgery 1 week ago.

C) The nursing assistant has the education and scope of practice to re-position a client. 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.

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II? A) Massage the reddened areas. B) Pad the ulcer. C) Promote mobility and/or frequent re-positioning. D) Suggest an egg crate mattress.

C) Frequent re-positioning 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.

A client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client? A) Ensure that all lesions are reviewed by a dermatologist or a surgeon. B) Avoid sun exposure. C) Perform a total skin self-examination monthly. D) Perform a total skin self-examination monthly with a partner.

D 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. It is difficult for a person to assess all of the skin surfaces of his or her body by him- or herself, even with the use of mirrors. It is better to involve a partner with the assessment.

The nurse admits a client to the clinic who is reporting severe itching of the arms and legs caused by exposure to poison ivy. The nurse anticipates that the health care provider will prescribe which medication? A) Anthralin (Drithocreme) B) Benzyl benzoate (Ascabiol) C) Calcipotriene (Dovonex) D) Diphenhydramine (Benadryl)

D) Treatment for inflammations such as poison ivy is aimed at removal of the triggering substance and relief of symptoms. Because the skin reaction is caused by histamine release, antihistamines such as diphenhydramine are helpful. Anthralin is indicated for treatment of psoriasis. Benzyl benzoate is a scabicide indicated for treatment of scabies. Calcipotriene is a synthetic form of vitamin D that is used to treat psoriasis.

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? A) Avoiding or reducing skin exposure to sunlight B) Avoiding tanning beds C) Being aware of skin markings and performing skin self-examination D) Wearing SPF 40 sunscreen

A 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). Avoiding tanning beds is significant, but is not the most important technique. It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important.

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response? A) Encourages participation in care of the wound Correct B) Encourages visitors C) Says, "I know how you feel" D) Assures the client that it will be all right

A Encouraging participation in wound care 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.

A client has an odorous, purulent wound. How does the nurse best support this client? A Changes the dressing frequently B Encourages a diet high in protein C Suggests whirlpool therapy D Places room deodorizers in the room

A Frequent dressing changes help the client feel clean. 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.

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? A Hyperbaric oxygen B Nutrition therapy C Topical growth factors D Vacuum-assisted wound closure

A 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 working in the same-day-surgery unit has just received report and plans to assess which client first? A) Adult with a basal cell carcinoma excised who needs discharge teaching about wound care B) Young adult who has had rhinoplasty and is swallowing frequently C) Middle-aged adult who reports 7/10 pain after removal of a cyst D) Older adult ready to be transferred to a long-term-care facility after débridement of a pressure ulcer

B Frequent swallowing after rhinoplasty may indicate bleeding, which requires immediate action by the nurse. Discharge teaching, controlling pain, and client transfers are all important, but are not priorities because each of these clients is stable and not experiencing a postoperative complication that requires immediate attention.

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? A First B Second Correct C Third D Mixed

B Second-intention healing is characterized by a cavity-like defect. This requires 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 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? A) Take daily tub baths using a mild soap. B) The infected area should be covered with a clean, dry bandage. C) Wash the infected areas first, then wash the uninfected areas. D) Use bath sponges or puffs when bathing.

B 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.

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? A) Apply a barrier cream. B) Assess the area for skin breakdown. C) Clean the client. D) Place the client in a side-lying position.

C 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.

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? A) Asks the client if he is squeamish B) Demonstrates how to change the dressing C) Determines whether the client can reach the affected area D) Provides all of the necessary dressing materials

C 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 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.

Which statement by a client with psoriasis indicates that teaching about the condition has been effective? A) "I know that I need to avoid warm climates." B) "I must cover up the affected areas to prevent spread to my family." C) "I should practice good handwashing technique." D) "Psoriasis can be cured with steroids."

C) 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.

The nurse is caring for a client prescribed linezolid (Zyvox) for treatment of methicillin-resistant Staphylococcus aureus infection. The nurse plans to monitor the client for which adverse effect of linezolid? A) Depression B) Hyperglycemia C) Hypertension Correct D) Incontinence

C) Linezolid constricts blood vessels and may trigger hypertensive crisis. Depression, hyperglycemia, and incontinence are not adverse effects of linezolid.

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? A) Calcium B) Hematocrit C) Numbers of immature white blood cells (WBCs) D) Serum albumin

D) 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.